Fayetteville Center for Nursing & Healing LLC

Inspectors wroteBased on record reviews, family and staff interviews, and review of the facility policy titled Notification of Changes, the facility failed to notify the physician and Responsible Party (RP)/family of a fall of one of seven Residents (R) (R7) reviewed for notification of change.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility policies titled Resident and Family Grievances, and Resident Personal Belongings, the facility failed to make a prompt effort to file a grievance for one of nineteen sampled residents (R) (R8) who's family/responsible party (RP) reported both a written and verbal grievance. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner.

Inspectors wroteBased on family and staff interviews, record reviews, observations, and the facility policies titled Abuse, Neglect and Exploitation, and Safe Resident Handling/Transfer, the facility failed to protect two out of five Residents (R) (R7 and R16) by neglecting to use the designated mechanical lift to transfer the residents. Specifically, Licensed Practical Nurse (LPN) III and Certified Nursing Assistant (CNA) DDDD attempted to transfer R7 from the floor to the bed by his legs and his neck. During this improper transfer from the floor to the bed CNA DDDD lost control and dropped R7, causing his head to hit the floor. The facility allowed the LPN III and CNA DDDD to continue working with the vulnerable residents for an additional 15 days. CNA EEEE transferred R16 from the bed to the chair without using the required mechanical lift, causing a laceration to R16's right great toe. [...]

Inspectors wroteBased on record reviews, family and staff interviews, text messages, and the facility policies titled Bed Hold Prior To Transfer, EXHIBIT B Bed Hold Policy, and the Immediate Discharge Notice the facility failed to permit one of three Residents (R) (R7) to return to the facility after being sent to the hospital emergency room. The facility also denied R7's family from entering the building to obtain the resident's personal belongings. This deficient practice had the potential to place the residents who are sent to the hospital in an unsafe and unsuitable situation and cause stress and harm to the residents.

Inspectors wroteBased on staff interviews, record reviews, the facility policy titled Comprehensive Care Plans, and the Charge Nurse Job Description, the facility failed to implement the care plan interventions for mechanical lift with two staff assistants for transfers for two Residents (R) (R7 and R16). In addition, the facility failed to implement fall mats and update R7's care plan after an incident and an accident.

Inspectors wroteBased on family and staff interviews, record reviews, observations, and the facility policy titled Safe Resident Handling/Transfer, the facility failed to provide appropriate interventions while transferring two of five residents (R) (R7 and R16), reviewed for mechanical lift transfers.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Oxygen Administration, the facility failed to obtain a physician's order for oxygen use, including the frequency of use and flow rate, and an order for a continuous positive airway pressure (CPAP) for one of four sampled resident (R) (R8) of four sampled residents. This deficient practice had the potential to place R8 at increased risk for respiratory complications.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy titled Medication Administration, the facility failed to assess three of 73 sampled residents (R) (R51, R482, and R456) for self-administration of medication. This deficient practice had the potential to place R51, R482, and R456 at risk of unsafe medication use and unauthorized medication access by other residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive, person-centered care plan for one of 73 sampled residents (R) (R101). The deficient practice had the potential to place R101 at risk of unmet needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policies titled Medication Administration and Unavailable Medications, the facility failed to ensure that two of five residents (R) (R452 and R580) reviewed for medication administration received medications as ordered by the physician. Specifically, the facility failed to ensure R452 received ordered intravenous (I.V.) antibiotics, oral antibiotics, insulin injections, and oral diabetic medications after admission to the facility, and failed to ensure that R580's anti-hypertensive medications were administered as ordered by the physician.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure medications were not available for use past their expiration date and were stored in the original container on two of seven medication carts (Hall 900 and Hall 800). These deficient practices created the potential for residents to receive medications with altered effectiveness.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Handwashing/Hand Hygiene and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently perform hand hygiene during two of four medication pass observations and failed to sanitize shared medical equipment between residents during one of four medication pass observations. This failure had the potential to increase the risk of infection transmission among staff and residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to assess for the ability to self-administer medications prior to leaving medications at the bedside for one of 42 sampled residents (R) (R118). The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the Medication Administration Record (MAR) documentation was completed for one of 42 sampled residents (R) (R31).

Inspectors wroteAMENDED 11/30/2023 Based on staff interviews, record review, and review of the facility policy titled, Pressure Injury Prevention and Management the facility failed to identify and treat a pressure wound for one of five sampled residents (R) (R1) reviewed for pressure ulcer prevention and treatment. Harm was identified to occur on 7/29/2023 when the facility failed to identify and treat the wound resulting in the resident being sent out to the hospital for diagnosis of septic shock due to an infected sacral decubitus wound with bacteremia and requiring surgical debridement of the wound.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to complete a thorough investigation for one of three sampled residents (R) (R25) reviewed for misappropriation of personal property.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Notification of Changes the facility failed to provide care and treatment according to professional standards for two of 33 sampled residents related to (1) failing to notify the physician when a resident's blood pressure was out of range for R10; and (2) failing to follow physician's orders to obtain a urinalysis for R32.

Inspectors wroteBased on staff interviews, record review and review of the facility pharmacy manual titled, Medication Ordering and Receiving from Pharmacy the facility failed to follow the procedure for medications received from the pharmacy for one of three residents (R) (R25) reviewed for misappropriation of personal property.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medication Errors the facility failed to maintain a medication error rate of less than five percent (%). There were three errors made in 25 opportunities, resulting in a medication error rate of 12.0 %. These errors affected three out of four residents (Resident 31, Resident 32, and Resident 33) observed during medications pass.

Inspectors wroteBased on interview, record review, and review of the facility policy Change in a Resident's Condition or Status, the facility failed to notify the physician of an accident sustained by one resident (R) (R#78) of three residents investigated for accidents.

Inspectors wroteBased on interview, record review, and review of facility policy Policy: Baseline Care Plan, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one resident (R) (R#135) of three residents reviewed for a closed record review.

Inspectors wroteBased on interviews, record review, and review of the facility Medication Orders policy, the facility failed to follow physician's orders for over the counter (OTC) moisturizer for one resident (R) (R#29) of 44 residents reviewed for physician's orders.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to weigh a resident upon admission or weekly for one resident (R) (R#140) from a total of five residents reviewed for nutrition.