Alamance Health Care Center

Inspectors wroteBased on record review, observation, resident interviews, significant other interview, and staff interviews, the facility failed to ensure the provision and availability of linens to meet the hygiene and comfort needs for 9 of 9 residents representing three of four halls and interviewed regarding linen availability (Residents #4, #12, #10, #13, #14, #15, #16's significant other, #17, and #18).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure staff implemented the facility's abuse reporting and protection policy and procedures by failing to immediately report to the Administrator leading to a lack of protection after an allegation of staff to resident physical abuse involving Nurse #1 and Resident #3. This failure affected one of three residents that were reviewed for implementation of abuse policies and procedures (Resident #3).

Inspectors wroteBased on record review, family interview, nurse practitioner interviews, and staff interviews, the facility failed to ensure accurate documentation of a medical diagnosis for one of three residents reviewed for the accuracy of medical record documentation (Resident #4).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policy for Enhanced Barrier Precautions (EPB) when nurse aides failed to wear a gown while providing incontinence care for Resident #59 who was on EPB. The deficient practice was observed for 3 of 9 staff observed for infection control practices (Nurse Aide #1, Nurse Aide #2, and Nurse Aide #3).

Inspectors wroteBased on record review and interviews with family, facility staff, and Support Representative from the money transfer application company, the facility failed to protect the resident's right to be free from misappropriation of Resident #186's cell phone and an unauthorized transfer of funds from the resident's money transfer application (a financial platform that allows users to send, receive, and manage money directly from their smartphone) on his cell phone. This deficient practice affected 1 of 1 resident reviewed for misappropriation of property (Resident #186).

Inspectors wroteBased on record review, and staff and Ombudsman interviews, the facility failed to send a copy of the Notice of Transfer/Discharge to the Ombudsman for 3 of 3 residents reviewed for discharge process (Resident #117, Resident #182 and Resident # 179).

Inspectors wroteBased on observation, record review, and staff, Wound Nurse Practitioner (NP), and Medical Director interviews, the facility failed to keep the resident's pressure ulcer wound vacuum device off the floor. The resident had sacral pressure ulcer and osteomyelitis (infection of the bone) of the sacral bone. The deficient practice affected 1 of 6 residents reviewed for pressure ulcer (Resident #14).

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to have an effective system in place for communicating a therapy order for a resting left hand splint to nursing staff for 1 of 1 resident reviewed for a contracture and limited range of motion (Resident #36).

Inspectors wroteBased on observation, record review, and staff and Medical Director interviews, the facility failed to keep a dependent resident positioned in the center of his bed so when the air mattress rotated for offload it did not cause the resident to fall out of his bed. The resident sustained a laceration above his right eye and was sent to the Emergency Department (ED). The deficient practice affected 1 of 9 residents reviewed for accidents (Resident #14).

Inspectors wroteBased on record review, and resident, staff, and Quality Assurance Pharmacist interviews, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medication to meet the resident's needs for 1 of 1 resident reviewed for medication administration (Resident #89).

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to maintain an effective pest control program for 7 of 94 resident rooms (Rooms #11, # 12, #57, #50, #89, #88 and #74). The deficient practice occurred on 4 of 4 halls (Mauve 1, Mauve 2, Teal 1 and Teal 2 halls).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to clean sticky floors with debris, repair base boards and clean and maintain air conditioning units in resident rooms for 13 of 94 (Rooms #11, # 12, 14, 18, 20, 25, 46, 50, 52, 56, 70, 74 and 90) observed for cleanliness. The deficient practice occurred on 4 of 4 halls (Mauve 1, Mauve 2, Teal 1 and Teal 2 halls).

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to schedule an an opthamologist consultation for cataract extraction surgery when ordered by the Medical Director for 1 of 2 residents (Resident #81) reviewed for vision.

Inspectors wroteBased on record review, observations and staff interviews the facility failed to maintain clean nourishment refrigerators, failed to record the nourishment refrigerator and freezer temperatures from 4/24/25 to 4/28/25, and failed to label and date residents' food stored in the nourishment refrigerators for 2 of 3 nourishment refrigerators (on Teal and Mauve 1 hallway). These practices had the potential to affect food being served to residents.

Inspectors wroteBased on observation, record review, and interviews with the resident and staff, the facility failed to treat one of six residents (Resident #4) reviewed for respect in a dignified manner when Nurse Aide (NA) #3 pulled Resident #4's geriatric wheelchair (a padded chair with a wheeled base) backwards down the hall. Resident #4 said she felt like she was being treated as if she was a crazy person and she thought that the NA did not like her because she pulled the wheelchair in that manner.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure resident's fingernails were trimmed for 1 of 4 residents dependent on staff for Activity of Daily Living (ADL) care (Resident # 124).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to protect a resident's right to be free from abuse when Resident #3 struck Resident #4 with a 15 ounce can of peaches. This affected 1 of 3 residents reviewed for abuse.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to: 1) Store medications in accordance with the manufacturer's storage instructions on 2 of 4 med carts (Teal South Med Cart and Mauve 2 South Med Cart); 2) Dispose of loose, unidentified tablets observed in the drawer of 1 of 4 medication carts (Teal South Med Cart); 3) Label a medication stored in 2 of 4 med carts with the minimum information required, including the resident's name (Teal South Med Cart and Mauve 2 South Med Cart); 4) Discard expired medication stored on 1 of 4 medication (med) carts (Teal South Med Cart); and 5) Date a vial of injectable medication as to when it was opened to allow for the determination of its shortened expiration date in 1 of 2 medication storage rooms observed (Teal Med Room).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification/complaint investigation surveys dated 11/2/23 and 5/27/21; and for the complaint investigation surveys dated 7/6/23, 1/17/23, 3/31/22, and 12/13/21 in order to achieve and sustain compliance. These were for recited deficiencies on a recertification and compliant survey on 4/23/24. The deficiencies were in the following areas: Quality of Care, Bowel/Bladder Incontinence, Catheter, UTI, and label/ store drugs and biologicals. The continued failure during federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on records review, and staff interviews, the facility failed to have Advance Directives (code status) in the residents' record for 1 of 1 resident reviewed for Advance Directives (Resident #44).

Inspectors wroteBased on record review and interviews with the staff, family member, physician, and nurse practitioners the facility failed to ensure effective communication occurred amongst staff and providers when a resident, who had chronic diarrhea, also began to have multiple episodes of nausea and vomiting in addition to the diarrhea. This was for one (Resident # 1) of one sampled resident reviewed for acute medical changes.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #129) reviewed with urinary catheters.

Inspectors wroteBased on record review and interviews of the staff, Nurse Practitioner #2, facility Physician, and Pharmacist, the facility failed to determine or assess the need to continue daily bedside blood sugar monitoring for an insulin dependent resident with numerous comorbidities for 1 of 3 residents reviewed for diabetic blood glucose monitoring.

Inspectors wroteBased on record review, staff, Nurse Practitioner (NP) and Medical Director's interviews, the facility failed to prevent a significant medication error by failing to administer prescribed extra dose of diuretic medication to a resident resulting in two doses of medication being missed for 1 of 1 resident (Resident #128) reviewed for medication errors.