By Thomas Goldsmith

In January, an 89-year-old woman who lived in a Lillington nursing home went into the hospital for treatment of a large, foul-smelling necrotic bed sore with an underlying infection. It had been almost four weeks since staff first made written notice of the spot as a much less severe pressure sore.

Grim details of the woman’s perhaps unnecessary ordeal emerged in a March 25 state report on Universal Health Care of Lillington, a 129-bed facility that was recently named one of eight North Carolina candidates for status as a federal “special focus facility.”

Federal “special focus facility program” status means that “the facility is subjected to more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid,” according to the federal website Nursing Home Compare.

State inspection reports are available at

North Carolina long-term care centers designated as special focus facility participants as of April, the most recent report available:

  • Macon Valley Nursing and Rehabilitation Center, Franklin
  • Richmond Pines Healthcare and Rehabilitation Center, Hamlet

Special focus facility candidates, all rated one star, or the lowest category, by the Centers for Medicare and Medicaid Services:

  • Person Memorial Hospital, Roxboro
  • Tsali Care Center, Cherokee
  • Accordius Health at Salisbury
  • Randolph Health and Rehabilitation Center, Asheboro
  • Universal Health Care, Lillington
  • Pinehurst Healthcare and Rehabilitation Center, Pinehurst
  • Pine Ridge Health and Rehabilitation Center, Thomasville
  • Sanford Health and Rehabilitation, Sanford

Although the term has an anodyne sound to it, a special focus facility in the language of the federal Centers for Medicare and Medicaid Services (CMS) means a center that “has a history of persistent poor quality of care, as indicated by the findings of state or Federal inspection teams.”

“You can think about the special focus facility program as sports team drafts,” said Charles Phillips, of Pittsboro, board chair for the nonprofit advocacy group Friends of Residents in Long Term Care. “CMS only has resources to deal with 88 facilities across the country — SFF programs get twice as many surveys as the average facility. But there are about 435 that are candidates for the list.”

“CMS reports the fact that there are special focus facilities and now they are reporting the candidates, because that’s what they have been forced to do by Congress.”

This month, at the urging of Pennsylvania U.S Senators Bob Casey (D-Pa.) and Pat Toomey (R-Pa.) CMS reversed a longstanding practice of listing only two special focus facilities “participants” per state. With the change, all the candidates for the status are also being made public.

Previously hundreds of other facilities known internally as candidates weren’t publicly identified for inadequate performance even though they had the same deficiencies as participants.

“Despite being indistinguishable from participants in terms of their qualifications for enhanced oversight, candidates are not publicly disclosed,” the senators said in a recently released report. “As a result, individuals and families making decisions about nursing home care for themselves or for a loved one are unlikely to be aware of these candidates.”

Putting consumers on notice

That status is where, in the convoluted scheme of federal oversight, Universal Health Care of Lillington comes in. The center is listed as a special focus facility candidate in public documents. Along with other statewide candidates, the Lillington center now will likely get higher levels of scrutiny from those seeking long-term care.

If the candidates fare as badly in surveys as those already listed, why doesn’t CMS move them all to the status in which they’d be more frequently inspected? According to the Casey-Toomey report, CMS can’t afford to perform the heightened oversight required by the special focus facility program.

“At least it puts the consumer on notice that the facility has a history of problems,” said Steve Gugenheim, a Raleigh attorney involved in plaintiffs’ litigation against nursing homes.

“The consumers are going to have to discover the record by going to Nursing Home Compare,” the federal website that details federal nursing home quality measures, he said. “Most consumers don’t know to do that.”

Universal Health Care of Lillington declined comment on its status as a candidate during a telephone call last week.

According to state listings of nursing home deficiencies, failed communications at Universal Health Care appear in part responsible for the marked decline of the resident with the bed sore, known in medical terms as a pressure ulcer. A state survey found that the nursing home failed overall to meet a requirement for services to treat and/or heal a pressure ulcer.

More information needed

The state report reported that the resident was readmitted to Universal Health Care of Lillington on Dec. 23 after a hospital stay for a broken hip. A nursing note five days later detailed the presence of a Stage 2 pressure ulcer, meaning that the upper skin layer was damaged. The facility dealt with it by means including a pressure mattress, wound cleaning, and topical medication.

But no one made sure that she was seen by a specialized wound physician. By Jan. 14, she had stopped eating entirely and was losing weight. On Jan. 16 and 17, a wound doctor visited the facility, but the record is muddy. The wound specialist came and went without seeing the patient, and there’s some ambiguity about whether or not there was an order to see her.

According to the incident report, the woman’s usual physician “stated a consult should have been initiated on 1/14/19 when the resident’s wound showed eschar and the wound physician should have been involved in the resident’s wound care thereafter.

According to the physician he thought an order for a referral had been given on 1/14/19 when he gave the order for the change in wound care.”

On Jan. 24, the wound doctor finally saw the resident and had her admitted to the hospital. An examination showed her pressure ulcer had reached Stage 4 and that she had an underlying infection.

A National Center for Biological Information overview describes Stage 4 pressure ulcers:  “The skin and much of the surrounding tissue is damaged and has died. The muscles, tendons and bones may be damaged as well. The wound often has slough on it or is covered by a scab.”

On April 6, a revisit report showed that the deficiencies connected with the February violations had been corrected.

Would the news that this nursing home was a candidate for special focus status have stopped this incident from occurring? It’s impossible to say, but more information is better, say both advocates for older people and representatives of the nursing home industry in North Carolina.

“We think that’s it important that information be transparent and it be accessible to everyone,” said Polly Welsh, executive vice president at the North Carolina Health Care Facilities Association. “It’s still important that they go in and see how the facility feels. The most important thing is to talk to the people that live and work there.”

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Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...