Lotus Village Center for Nursing and Rehabilitatio

Inspectors wroteBased on observations, record review, North Caroliana (NC) Department of Transportation (DOT) website, and resident, staff, Physician Assistant and Medical Director interviews, the facility failed to supervise a resident, who had a diagnosis of dementia with other behavioral disturbance and known exit-seeking behaviors, from exiting the facility's locked memory care unit unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #58). Prior to her admission to the Skilled Nursing Facility (SNF), Resident #58 eloped from the previous SNF where she had resided by climbing out a window. On 01/06/26 Resident #58 was deemed incompetent by a court and appointed a guardian. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to develop individualized, person-centered care plans that included areas of focus for smoking, exit-seeking behaviors, use of an elopement alarm device, and activities of daily living (ADL) for 3 of 28 sampled residents (Residents #58, #69 and #3).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to date medications when opened and remove expired and unlabeled medications from 4 of 4 medication carts reviewed for medication storage (Medication Carts 100/200/300/400).

Inspectors wroteBased on record review and staff and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 2 of 5 residents reviewed for unnecessary medications (Resident #9 and Resident #58).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure code status information was accurate throughout the medical record and in locations designated by the facility for 1 of 1 resident reviewed for advance directives (Resident #63).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete admission Minimum Data Set (MDS) assessments no later than 14 calendar days after the residents' admission (Residents #2 and #63) and failed to complete Care Area Assessments (CAA) comprehensively that addressed the underlying causes and contributing factors of the triggered care area (Residents #58 and #9) for 4 of 28 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 1 of 28 sampled residents reviewed (Residents #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR) (Resident #6), alarms (Resident #58 and Resident #3) and current tobacco use (Resident #58) for 3 of 28 residents reviewed for accuracy of assessments.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to revise a resident's care plan to indicate the development of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #70).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #69).

Inspectors wroteBased on record review and interviews with staff, the Physician Assistant, and the Medical Director, the facility failed to implement an order for a urinalysis with reflex to culture (a two-step urine testing method) for 1 of 2 residents reviewed with symptoms of a urinary tract infection (Resident #27).

Inspectors wroteBased on record review, interviews with the resident, staff, Physician Assistant and Medical Director, the facility failed to provide pain management for a resident who reported acute, severe pain rated at a 8 out of 10 (0 meaning no pain and 10 meaning the worst pain experienced) during wound care treatment of a Stage 3 pressure ulcer. This deficient practice affected 1 of 3 residents reviewed for effective pain management (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by not documenting a resident's elopement from the facility and not documenting a nurse assessment to check for injuries upon the resident's return for 1 of 3 residents reviewed for complete and accurate medical records (Resident #58).

Inspectors wroteBased on record review and staff interviews, the facility failed to document that a Resident or Responsible Party (RP) were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization or if the Resident received the influenza and pneumococcal immunization or did not receive the vaccines due to a medical contradiction or refusal. In addition, there was no documentation that the Resident was offered the influenza and pneumococcal immunization. This occurred for 1 of 5 residents reviewed for immunizations (Resident #58).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccination for 3 of 5 residents reviewed for immunizations (Resident #2, Resident #6 and Resident #9).

Inspectors wroteBased on record review, and staff and Physician Assistant (PA) interviews, the facility failed to transcribe on admission an order for surgical wound care and subsequently failed to provide care to the surgical wound as ordered by the physician for 1 of 3 residents reviewed for quality of care (Resident #1).

Inspectors wroteBased on record review, staff and Physician Assistant interviews, the facility failed to maintain a complete and accurate medical record related to a resident's abdominal incision and colostomy for 1 of 3 residents reviewed for complete and accurate medical records (Resident #1).

Inspectors wroteBased on observations, record reviews and staff and Consultant Pharmacist interviews, the facility failed to remove loose and unsecure pills of various shapes, sizes and colors, failed to remove expired and unlabeled medications, failed to remove discharged residents' medications from a medication cart and failed to secure medications in locked medication carts. These failures occurred on 4 of 4 medication carts (100 Hall, 200 Hall, 300 Hall and 400 Hall medication carts) and 1 of 1 medication room (the main medication room) reviewed for medication storage.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 2 residents reviewed for Activities of Daily Living and Indwelling Urinary Catheters (Resident #82).

Inspectors wroteBased on observation, staff interviews and record reviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #44).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 1 of 23 residents reviewed for Resident Assessment (Resident #38).

Inspectors wroteBased on record review and staff and Nurse Practitioner (NP) interviews, the facility failed to change an indwelling urinary catheter as ordered for 1 of 1 resident reviewed for urinary catheters (Resident #82).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to follow their Hand Hygiene and Enhanced Barrier Precautions policies when Nurse #2 did not perform hand hygiene prior to donning second pair of gloves and when she did not perform hand hygiene and don new gloves prior to reinserting a new disposable trach cannula. This deficient practice occurred for 1 of 2 staff members observed for infection control practices (Nurse #2).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner, resident and staff, the facility failed to notify the physician when a one-time dose of methyl prednisolone (a steroid medication used to treat inflammatory conditions) was not administered as ordered for the treatment of an allergic reaction. The administration of methyl prednisolone was delayed five days for treatment of a rash that had worsened causing increased redness and hives, increased itching, and a low-grade fever for 1 of 1 resident reviewed for significant medication errors (Resident #1).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner, Director of Pharmacy Operations, resident and staff, the facility failed to have effective systems in place to ensure a one-time dose of an intramuscular injection of methylprednisolone (steroid) prescribed for the treatment of an allergic reaction was administered resulting in a five-day delay of it being administered. Resident #1 had an itchy rash which worsened and spread over his entire body, hives, and a low-grade fever. Resident #1 stated the rash was very itchy and he continuously scratched himself. This occurred for 1 of 1 resident reviewed for significant medication error (Resident #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a Minimum Data Set assessment in the area of dental for 1 of 3 residents reviewed for accuracy of assessment (Resident #1).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner, Director of Dental Clinical Operations and staff, the facility failed to withhold antiplatelet medication per physician's order prior to a scheduled dental visit for tooth extractions which delayed the tooth extractions for 1 of 1 resident reviewed for providing care according to professional standards (Resident #1).

Inspectors wroteBased on observations, record review, and staff, Nurse Practitioner (NP), Medical Director (MD) and Poison Control interviews, the facility failed to provide an environment free from a potential hazard when Sodium Polyacrylate (a super-absorbent powder used to absorb large volumes of liquids) and a glass of solidified fruit punch was left at the bedside within a resident's reach for 1 of 3 residents (Resident #1) reviewed for accidents.

Inspectors wroteBased on observations, record review, and staff, Law Enforcement Officer and Medical Director (MD) interviews, the facility failed to supervise a cognitively impaired resident from exiting the locked memory care unit of the facility unsupervised without staff knowledge for 1 of 2 residents reviewed for accidents (Resident #1). Resident #1 went through the adjoining bathroom to the neighboring room and removed a windowpane and exited through the window. Resident #1 walked approximately 2/10 mile after dark on a two-lane street with streetlights and no sidewalk. He was wearing pants, shirt, jacket, and shoes. Resident #1 was found across the three-lane road from the gas station/convenience store by a staff member. He was transported back to the facility by a law enforcement officer. [...]

Inspectors wroteBased on record review, staff, and Nurse Practitioner interviews the facility failed to notify the medical provider of an allegation of alleged sexual abuse involving Resident #2. This affected 1 of 4 residents reviewed for abuse.

Inspectors wroteBased on observations, record reviews, resident, and staff interviews the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #7 hit Resident #4 with a closed fist in the left eye after Resident #7 believed that Resident #4 was looking at inappropriate pictures on the shared facility computer located in the communal activity room. Resident #4 had a red area under his left eye and since the incident avoided Resident #7 and the use of the shared facility computer for approximately a week and a half which Resident #4 spent a lot of time on a daily basis. This affected 1 of 4 residents reviewed for abuse (Resident #4).

Inspectors wroteBased on record reviews, staff, Resident, family member and Police Detective interviews the facility failed to have systems in place to prevent illegal substances from entering the facility. This affected 2 of 3 residents (Resident #1 and Resident #3) reviewed for supervision to prevent accidents.

Inspectors wroteBased on record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician and Medical Doctor interviews the facility failed to protect a Resident's right to be free from neglect when the facility failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing nursing assessments, schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency for 1 of 3 residents (Resident #1) reviewed for neglect. Resident #1 experienced a serious adverse outcome when an acute change in condition was noted on 03/11/24 with a blood pressure of 86/42 and weakness. The Resident was sent to the local emergency department where he was transferred to a hospital for a higher level of care and diagnosed with severe septic shock and urinary tract infection. [...]

Inspectors wroteBased on record reviews and staff, family member, Nurse Practitioner (NP), Urology Surgeon and Wound Physician interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1's left testicle and complete and document thorough and ongoing nursing assessments of left testicle after [DATE] to determine the need for further medical attention. In addition, the Urology Consultation for evaluation of the Resident's left testicle was scheduled for [DATE] which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on [DATE] with a blood pressure of 86/42 (normal blood pressure range 120/80) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. [...]

Inspectors wroteBased on record reviews, and staff, Nurse Practitioner, and Medical Doctor interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1's left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification. [...]

Inspectors wroteBased on observations, record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician, and Medical Doctor interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Complaint Survey on 07/12/23 and Recertification and Complaint Survey of 09/14/22. This failure was for 3 deficiencies that were originally cited in the areas of (F580) Notification of Change, (F600) Neglect and (F684) Quality of Care that were subsequently recited on the current Complaint Survey on 04/08/24. The repeat deficiencies during the three surveys of record showed a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on medical record review, staff interviews, and review of the facility's Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a residents code status election was evident and accurately documented in the medical record for 10 of 10 (Resident #7, #12, #25, #27, #50, #63, #67, #71, #73, and #84) residents reviewed for advance directive.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint surveys conducted on [DATE] and [DATE]. This failure was for 8 deficiencies that were originally cited in the areas of (F561) Self Determination, (F578) Request/Refuse/Discontinue Treatment/Formulate Advanced Directive, (F641) Accuracy of Assessments, (F656) Develop, Implement Comprehensive Care Plan, (F688) Increase/Prevent Decrease in ROM/Mobility, (F690) Bowel/Bladder Incontinence, Catheter, UTI, (F695) Respiratory/Tracheostomy Care and Suctioning, and (F761) Label/Store Drugs and Biologicals that were subsequently recited on the current recertification and complaint survey on [DATE]. [...]

Inspectors wroteBased on observations, record review, interviews with residents and staff, the facility failed to honor residents' choice to eat their meals in the main dining room (Residents #2, #21, #22, #23, #51, and #53) for 6 of 6 sampled residents.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to secure a free standing oxygen cylinder in a resident room (Resident #27), failed to ensure an oxygen filter was free from dust and debris (Resident #63), failed to ensure oxygen was delivered at the prescribed rate (Resident #25 and Resident #73), and failed to ensure oxygen in use signage was noted in the residents' environment (Resident #8, Resident #10, Resident #25, Resident #63, and Resident #73). These practices occurred for 6 of 6 residents reviewed for respiratory care and services.

Inspectors wroteBased on record review and staff interviews the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization for 3 of 5 (Resident #63, Resident #75, and Resident #84) residents reviewed for infection control.

Inspectors wroteBased on record review, Guardian and staff interviews, the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 1 sampled resident (Resident #139).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code an attempted gradual dose reduction of an antipsychotic medication and failed to code a level 2 PASARR (preadmission screening and resident review) for 1 of 5 residents reviewed for unnecessary medications (Resident #2) and 1 of 2 residents reviewed for PASARR (Resident #61).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to develop a care plan in the area of Level II Preadmission Screening and Resident Review (PASRR) (Resident #61) and failed to implement the care plan in the area of range of motion (Resident #50) for 2 of 31 residents reviewed for care planning.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide a shower, shave, clean, and trim a dependent resident's fingernails for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #63).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to apply a resting hand splint as directed by the functional maintenance program for 1 of 2 residents reviewed for range of motion (Resident #50).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to keep an indwelling catheter bag off the floor to decrease the risk of infection and secured the tubing to prevent irritation for 1 of 1 resident reviewed with a catheter (Resident #84).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to complete a bed rail assessment to determine the need for bed rail use for 1 of 1 sampled resident (Resident #41). Findings Included: Resident #41 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and insomnia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #41 with severe cognitive impairment. Resident #41 was dependent on staff assistance for bed mobility with rolling left and right and bed rails were not used as a restraint. An observation on 02/19/24 at 10:41 AM revealed Resident #41 lying in bed with bilateral quarter bed rails in the up position. Review of Resident #41's electronic medical record on 02/20/24 revealed the last completed bed rail assessment was dated 02/17/22. [...]

Inspectors wroteBased on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents choices were honored for eating meals in the main dining room, bathing and personal hygiene was provided as needed and resting hand splints were applied as directed for 8 of 15 sampled residents (Residents #2, #21, #22, #23, #50, #51, #53, and #63) reviewed for choices and activities of daily living. This tag is cross-referenced to: F561: Based on observations, record review, interviews with residents and staff, the facility failed to honor residents' choice to eat their meals in the main dining room (Residents #2, #21, #22, #23, #51 and #53) for 6 of 6 sampled residents. F 677: [...]

Inspectors wroteBased on observations, record reviews and staff interviews the facility failed to store schedule III and IV controlled medications in a locked compartment in the refrigerator in 1 of 1 medication room reviewed for medication storage.

Inspectors wroteBased on record review, and resident and staff interviews the facility failed to included documentation in the medical record of education regarding the benefits and potential side effects of the Influenza immunization for 2 of 5 (Resident #63, Resident #84) residents reviewed and failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Pneumococcal immunization for 2 of 5 residents reviewed (Resident #63 and Resident #75).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASARR) for a resident with a change in condition regarding his depression for 1 of 1 resident reviewed for PASARR (Resident #19).