Nc State Veterans Home - Salisbury

Inspectors wroteBased on observation, record review, and interviews with staff and the Physician's Assistant (PA), facility staff used a shared blood glucose meter located in the medication cart without cleaning and disinfecting it before and after each use. This occurred while there were two residents identified with a known bloodborne pathogen in the facility with 1 of the 2 residents requiring blood glucose monitoring. Shared blood glucose meters can be contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared blood glucose meter has a high likelihood of exposing residents to the spread of blood borne infections. [...]

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to honor a resident's request for a shower to be stopped when the resident told Nursing Assistant (NA) #3 to stop because he was man handling him. Resident #13 stated he was fearful of NA #3 and felt like no one was listening to him when he told staff about the incident. Additionally, the facility failed to maintain a resident's dignity by not placing a privacy/ dignity cover over his urine collection bag exposing his urine which was visible from the hallway to other residents, staff and visitors. This occurred for 2 of 3 residents reviewed for dignity (Resident #13 and Resident #3).

Inspectors wroteBased on record review, and staff, Consultant Pharmacist and Physician interviews, the facility failed to ensure Resident #2 had a diagnosis for the use of antipsychotic medication and the as needed (PRN) antipsychotic medication, Haldol, used to regulate mood, behaviors, and thoughts, had a stop date of 14 days. The facility also failed to ensure Resident #1 had a diagnosis for the use of antipsychotic medication and antidepressant medication. This occurred for 2 of 5 residents reviewed for unnecessary medications (Resident #2, and Resident #1).

Inspectors wroteBased on record review, staff, and resident, Resident Representative, Physician Assistant, and Psychiatric Nurse Practitioner interviews, the facility failed to follow and implement their abuse policy and procedures in the areas of protecting and reporting to the Administrator for 1 of 3 residents reviewed for abuse (Resident #13). Resident #13 told Nursing Assistant (NA) #3 that the NA was treating him roughly and man handling him and to stop care. NA #3 did not stop the care. NA #9 heard Resident #13 state that NA #3 treated him roughly and was man handling him during his shower. Neither NA #3 or NA #9 reported the incident to administration or the charge nurse on duty allowing NA #3 to finish his shift and to return to work the next day. This failure resulted in a lack of protection for other residents.

Inspectors wroteBased on observations, record review, and staff and physician interviews, the facility failed to administer lidocaine 4% external pain patches per the Physician order for 1 of 6 residents reviewed for medication regimen review (Resident #34).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to complete a smoking safety screen in August 2025 for 1 of 1 resident reviewed for smoking (Resident # 48).

Inspectors wroteBased on record review, observations, staff, and Physician Assistant interviews, the facility failed to keep a urinary catheter collection bag from touching the floor to reduce the risk of infection for 1 of 3 residents reviewed for urinary catheters (Resident #51).

Inspectors wroteBased on record review, and interviews with staff, Consultant Pharmacist, and the Physician Assistant, the Consultant Pharmacist failed to identify drug irregularities related to the indicated use and scheduled stop date of an as needed (PRN) antipsychotic, and the indicated use of an antidepressant for 2 of 5 residents (Resident #2 and Resident #1) reviewed for drug regimen review.

Inspectors wroteBased on observations, record review, and staff and interviews, the facility failed to maintain an accurate medical record related to documentation of medication administration for 1 of 2 residents reviewed for accurate medical records (Resident #34).

Inspectors wroteBased on record review and staff interviews, the facility failed to (1) document that education of the influenza vaccine was provided for Resident #20 and (2) failed to obtain Resident #72's signature on the influenza vaccine consent/refusal form prior to administering the influenza vaccine. This occurred for 2 of 5 residents reviewed for immunizations.

Inspectors wroteBased on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all required state agencies and advocacy groups, including the State Survey Agency, Adult Protective Services, State Long-Term Care Ombudsman Program, and the Resident Advocacy Network, Home and Community Based Service Programs, or Medicaid Fraud Control Unit information. These observations occurred on 4 of the 5 days of the onsite recertification survey.

Inspectors wroteBased on record review and interviews with resident representatives and staff, the facility failed to explain the arbitration agreement to a resident's representative prior to having them sign the agreement. This occurred for 2 of 5 residents reviewed for arbitration (Resident #1 and Resident #66).

Inspectors wroteBased on observation and staff interviews, the facility failed to remove unlabeled items from 2 of 2 nourishment rooms. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record reviews, staff and resident interviews, the facility failed to honor residents' preference for eating in the dining room in the evenings for 1 of 1 resident reviewed for choices (Residents #58).

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to provide shaving for 1 of 4 residents (Resident #4) reviewed for personal hygiene. Resident #4 was dependent on staff for personal hygiene.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to provide nail care for 1 of 3 residents who were reviewed for being dependent on staff for personal care (Resident #215).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to have a hospice admission, plan of care, and hospice visits notes in the electronic medical record for 1 of 1 resident reviewed for hospice care (Resident #31).