Peak Resources - Charlotte

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired milk from the kitchen's walk-in refrigerator for 1 of 1 walk-in refrigerator.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of wrong dosage (2 medication errors out of 30 opportunities), resulting in a medication error rate of 6.67% for 2 of 3 residents (Resident #105 and Resident #36) observed during medication pass.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prevent a resident with severe cognitive impairment, who wore an elopement alarm device due to known wandering and exit-seeking behaviors, from exiting the facility unsupervised and without staff knowledge by leaving an unalarmed exit door propped open for 1 of 4 residents reviewed for accidents (Resident #212). On 06/09/23, Resident #212 was noticed by staff at approximately 5:30 PM wandering the halls with her purse and was last seen in the facility at 6:35 PM sitting in the activity room by herself. At approximately 7:30 PM, Resident #212 was observed outside the building in the back parking area by a visitor and staff. [...]

Inspectors wrotec. Resident #17 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe). A physician's order for Resident #17 dated 11/27/23 read, oxygen at 2 liters per minute (LPM) continuously. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had moderate impairment in cognition and received oxygen therapy during the MDS assessment period. An observation conducted on 03/18/24 at 10:30 AM revealed Resident #17 was receiving supplemental oxygen at 2 LPM. There was no sign posted on the door or doorframe of Resident #17's room to indicate oxygen was in use. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean floor in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer; label and date open food items and discard expired food in 1 of 1 walk-in cooler; store food off the floor for 1 of 1 walk-in freezer; and store food off the floor in 1 of 1 dry storage room. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and failed to close the doors to the dumpsters that contained waste for 2 of 2 dumpsters reviewed. These failures had the potential to attract pests and rodents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the focused infection control and complaint investigation survey on 08/27/21, the complaint investigation survey on 12/09/21, the recertification and complaint investigation survey on 09/29/22, complaint investigation survey on 11/03/22, and the complaint investigation survey on 01/11/23. This was for six repeat deficiencies: one in the area of free of accident hazards/supervision/devices originally cited on 08/27/21 during the focused infection control and complaint investigation survey and again on 12/09/21 during the complaint investigation survey, one in the area of food procurement: [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide a dignified dining experience when Nurse Aide (NA) #1 stood at the beside while assisting a dependent resident during a meal for 1 of 7 resident reviewed for dignity (Resident #59). The reasonable person concept was applied to this deficiency as individuals might feel a lack of dignity when staff stood over them and didn't attempt conversation while assisting them with a meal.

Inspectors wroteBased on observations, record review, interviews with the resident and staff the facility failed to assess if a cognitively impaired resident could self-administer inhalers kept at the beside for 1 of 1 resident reviewed for self-administration (Resident #43).

Inspectors wroteBased on observations, record review, and interviews with residents and staff the facility failed to assist dependent residents with removing unwanted chin hairs (Resident #29) and cleaning and trimming dirty fingernails (Resident #60) for 2 of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on record review, observations, and interviews with the Director of Clinical Services Pharmacist and staff the facility failed to store an unopened bottle of medicated eye drops and a multi-use insulin pen per manufacturer's recommendations and failed to discard a multi-use insulin pen by the date on the label and failed to ensure medications left in a resident's room were under direct observation by the administering nurse for 1 of 1 resident (Resident #51) and 2 of 8 medication carts reviewed for medication storage (200-hall med cart and 500-hall med cart #1).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure garbage was contained in a closed dumpster and maintain a clean grease trap free of buildup. This included 1of 2 dumpsters.

Inspectors wroteBased on resident interviews with residents who attended Resident council, and staff interviews, Resident Council minutes, and a Resident Council meeting, the facility failed to resolve a repeat grievance related to call bell response that was discussed during Resident Council meetings for 5 consecutive months, May through September 2022.

Inspectors wroteBased on record review and staff interviews the facility failed to develop care plans for the use of an anticoagulant, use of an antianxiety, use of an antidepressant, use of an antipsychotic and the use of an opioid medications for 2 of 5 residents reviewed for unnecessary meds (Resident #14 and #33).

Inspectors wroteBased on observations, and staff interviews, the facility failed to label and date refrigerated items. The facility also failed to maintain a temperature of 41 degrees or below in a nourishment refrigerator.

Inspectors wroteBased on resident interview, staff interviews and record review, the facility failed to maintain an accurate medication administration record (MAR) for 1 of 1 sampled resident (Resident #16).