Harborview Lumberton

Inspectors wroteBased on record review, staff, and Physician interviews, the facility failed to ensure that a resident received wound care and treatment to a new surgical site following admission for a left below knee amputation. This occurred for 1 of 1 resident reviewed for non-pressure related wound care (Resident #112).

Inspectors wroteBased on record review, and staff, Registered Dietitian, Wound Care Physician, and the Medical Director's interviews the facility failed to 1a.) implement treatment orders on admission and provide daily wound treatments as ordered for a resident (Resident#17) with a chronic venous wound on the left lower extremity. b.) obtain daily weights as ordered for Resident #17 who had a diagnosis of congestive heart failure and on fluid restrictions. 2a.) provide treatments as ordered for a resident with arterial ulcers (Resident #24). [...]

Inspectors wroteBased on record review, and staff, Physician, and the Consultant Pharmacist interviews, the facility failed to hold the medication Midodrine when Resident #95 's systolic blood pressure was above 120 mm Hg (millimeters of mercury) or give the medication when the systolic blood pressure was less than 120 mm Hg. Resident #95 experienced no significant outcome. This occurred for 1 of 1 resident reviewed for medication administration.

Inspectors wroteBased on observations and staff interviews the facility failed to discard expired medications, record an opened date on a multi-dose oral inhaler that had a shortened expiration date, and refrigerate unopened ophthalmic drops according to the manufacturer's guidelines on 2 of 5 medication carts (400 hall, 800 hall) and in 2 of 2 medication storage rooms (300 hall, 400 hall) that were reviewed for medication storage.

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date an opened food item in 1 of 1 walk-in refrigerator and failed to remove expired containers of milk from 2 of 3 nourishment rooms (Secured Unit and East Wing). These practices had the potential to affect food service for the residents.

Inspectors wroteBased on record review, and staff and the Wound Care Physicians interviews, the facility failed to notify the Wound Care Physician for evaluation and treatment of a Stage IV (full thickness skin and tissue loss with exposed muscle, tendon, ligament or bone)pressure wound on the left trochanter (boney protrusion on the femur bone) that was present on admission. This occurred for 1 of 1 resident reviewed for wound care (Resident #1).

Inspectors wroteBased on observation, record review, and staff, Wound Care Physician, and the Medical Director's interviews the facility failed to 1.) conduct an initial wound assessment on admission for a Stage IV (fullthickness skin and tissue loss with exposed muscle, tendon, ligament or bone) left trochanter (bony protrusion on the femur bone) wound to include the wound description with measurements and perform daily wound care treatments according to the physicians orders for a resident (Resident #1) admitted with a stage IV pressure wound and who developed a stage II (partial thickness skin loss involving the dermis) pressure wound on the sacrum and lower back following admission. 2.) provide daily wound care to a stage IV pressure wound (Resident #71). This occurred for 2 of 2 residents (Resident #1, Resident #71) reviewed for pressure wound care.

Inspectors wroteBased on observations, record review, and staff and the Physician's interviews, the facility failed to obtain weekly weights as ordered for a resident (Resident #1) who was a new admission and receiving enteral feedings (tube feeding). This occurred for 1 of 5 residents reviewed for nutrition.

Inspectors wroteBased on record review, and staff, Physician and Consultant Pharmacist's interviews, the Pharmacist failed to identify and address during the monthly medication regimen reviews that a resident's Midodrine 10 mg (milligrams) prescribed for hypotension was administered outside of the set parameters 38 times during January 2025, 44 times in February 2025 and 15 times in March 2025 when the Consultant Pharmacist completed her monthly March review on 03/14/25. This occurred for 1 of 1 resident (Resident #95) reviewed for medication administration. Resident #95 experienced no significant outcome.

Inspectors wroteBased on record review, resident, staff and Nurse Practitioner interviews, the facility failed to provide rehabilitation services per the resident's plan of care. This was for 1 of 2 residents (Resident # 93) reviewed for rehabilitation services.

Inspectors wroteBased on record review, and staff and Physician interviews, the facility failed to maintain a complete medical record by 1.) not documenting a pulse (heart rate) prior to the administration of the medication for a resident with an order for hydralazine, a medication to treat high blood pressure, with a parameter to hold the medication for a heart rate less than 60 beats per minute (Resident #24). 2.) maintain an accurate medical record for weight monitoring (Resident #17). This was observed for 2 of 6 residents whose medical record was reviewed.

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews, the facility failed to follow the parameter ordered for administration of a medication used to treat diabetes resulting in 7 doses of insulin Glargine 25 units administered in error for 1 of 1 resident (Resident #47) reviewed for medication error.

Inspectors wroteBased on observation and staff interviews the facility failed to: a) ensure leftover food items were labeled and dated when stored in the walk-in refrigerator, b) discard an opened, partially used dairy product that had exceeded the shelf life, and c) ensure the temperature of a cold salad on the tray line was 41 degrees Fahrenheit or below. These practices had the potential to affect food served to residents in the facility.

Inspectors wroteBased on record review, observations, Nurse Practitioner interview, and staff interviews, the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 07/19/21, an on-site revisit survey completed on 09/08/21 and a recertification and complaint investigation survey completed on 0929/22. This was for four repeat deficiencies originally cited in the areas of Pharmacy Srvcs/Procedures/Pharmacist/Records (F755), Residents Are Free of Significant Med Errors (F760), Label/Store Drugs and Biologicals (F761), and Food Procurement, Store/Prepare/Serve-Sanitary (F812). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide a physician order for the care of and daily flush of a cholecystostomy (gallbladder) drainage tube for 1 of 1 resident (Resident #36) reviewed for a drainage tube.

Inspectors wroteBased on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide education to the nursing staff to deliver care for a cholecystostomy (gallbladder)drainage tube for 1 of 1 resident (Resident #36) reviewed for a drainage tube.

Inspectors wroteBased on record review and staff interviews, the facility failed to secure unused narcotic medications for disposition (the process of returning unused medications to the pharmacy) resulting in possible diversion (the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use). This was for 1 of 1 discharged resident (Resident #256) reviewed for pharmacy services.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to date opened multi-dose inhalers and an insulin pen and failed to discard loose pills in the medication cart drawers for 2 of 6 medication carts (300 Hall and 800 Hall carts).

Inspectors wroteBased on observations, record review, resident and staff interviews the facility failed to provide adaptive equipment for 1 of 1 resident reviewed for adaptive devices (Resident #29).