Siler City Center

Inspectors wroteBased on observation and staff interviews, the facility failed to store a scoop in a manner that prevented it from becoming contaminated by direct contact with flour, maintaining a clean steam table hood, and ensuring plastic plate bases were dried before being stacked for 2 of 2 kitchen observations. This deficient practice had the potential to affect food served to residents.

Inspectors wroteBased on record review, observation, resident, staff, and Medical Director interviews the facility failed to assess a resident's ability to keep steroid nasal spray at bed side for self-administration for 1 of 1 resident reviewed for self-administration of medications (Resident #138).

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the residents' right to be from physical abuse when Resident #86 hit Resident #14 with a grabber (handheld device used to assist in obtaining items out of reach) on 12/2/25 which resulted in an abrasion to Resident #14's forehead and Resident #86 hit Resident #54 with an open hand across the face while Resident #86 was receiving one-on-one (1:1) supervision on 12/24/25. This for 1 of 4 residents reviewed for abuse (Resident #86).

Inspectors wroteBased on record review, the facility failed to complete an accurate Minimum Data Set (MDS) assessment in the area of skin conditions for 1 of 11 residents who MDS assessments were reviewed (Resident #5).

Inspectors wroteBased on observations, record review and resident, staff and Physician interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #7).

Inspectors wroteBased on observation and staff interviews, the facility failed to keep the area around the trash compactor free from accumulated trash and debris for 1 of 1 trash compactor observed. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on record review, observation, and interviews with the Responsible Parties (RPs), PACE (Program of All-Inclusive Care for the Elderly) Nurse Practitioner, psychiatric Nurse Practitioner and staff, the facility failed to protect a cognitively impaired male resident's right to be free from sexual abuse (Resident #2) perpetrated by a cognitively impaired male resident (Resident #1). On 9/1/25 Nurse Aide (NA) #1 overheard Resident #2 laughing from the hallway and proceeded to the room he shared with Resident #1 as this was an unusual behavior for Resident #2. When NA #1 stepped into the doorway of the room, she observed Resident #2 lying on his back in bed with his penis exposed on the left side of his brief as Resident #1 stood beside the bed grasping Resident #2's penis with his hand as he moved his hand in an up and down motion. [...]

Inspectors wroteBased on record review, observations, and resident and staff interviews the facility failed to maintain the resident's dignity by not emptying urinals prior to lunch and as needed. This was evident for 1 of 4 residents (Resident #41) reviewed for dignity.

Inspectors wroteBased on record review, observations, and interviews with resident and staff, the facility failed to assess and obtain a physician's order for the self-administration of medications found at bedside for 1 of 1 resident (Resident #58).

Inspectors wroteBased on resident and staff interviews, the facility failed to deliver resident mail unopened for 3 of 7 residents reviewed for mail delivery (Resident #29, Resident #91, and Resident #100).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to administer water flushes via a feeding tube at the physician ordered flow rate for 1 of 2 residents reviewed with tube feedings (Resident #22).

Inspectors wroteBased on record review, and Medical Director and staff interviews, the facility failed to hold blood pressure medication as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #95).

Inspectors wrote4. Resident #132 was admitted to the facility on [DATE]. Resident #132's medical record revealed he was transferred to the hospital on [DATE]. There was no documentation that written notices of transfers were provided to the RP for the reasons for the transfers. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #132's Resident #132 was cognitively intact. An interview was conducted with Nurse #6 on 11/07/24 at 4:23 PM. She indicated Resident #132 called 911 himself for transport to the hospital due to him not feeling well. He did not notify staff he was calling 911. She stated emergency medical services (EMS) arrived, took face sheet, list of medications, and DNR form and transported Resident #132 to the hospital per his request. She notified his power of attorney (POA), Hospice, and the Director of Nursing (DON) of the transfer. [...]

Inspectors wroteBased on record review, police reports, resident, staff, and psychotherapist interviews, the facility failed to protect moderately cognitively impaired residents (Resident #135 and Resident #49) right to be free from sexual abuse from a cognitively intact resident (Resident #122). During the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M., Resident #122 entered Resident #135's room, while he was sleeping, lifted Resident #135's blanket and reached his hand into Resident #135's brief, and then stimulated Resident #135's penis. Resident #135 reported the sexual abuse to Nurse Aide (NA) #1 on 7/12/23 at approximately 4:00 A.M. Resident #135 explained Resident #122 had not been invited into his room and the physical touch was not consensual. Resident #135 reported the incident hurt me mentally and he made me sick. [...]

Inspectors wroteBased on record reviews, resident, staff, Nurse Practitioner and Medical Director (MD) interviews, the facility failed to hold an anticoagulant for a resident (Resident #345) who had oral surgery resulting in significant bleeding and emergency treatment, the facility also failed to wait for a nurse to asses a resident for injuries prior to moving her up off the floor (Resident #106). This was for 2 of 2 residents reviewed for standards of care.

Inspectors wroteBased on record review, interviews with resident, staff, and Medical Director, the facility failed to discontinue a resident's antiepileptic medication per neurologist recommendation for 2 months in 1 of 6 residents (Resident #95) reviewed for unnecessary medications.

Inspectors wroteBased on observations and staff interviews, the facility failed to date sliced fruit stored inside the reach in refrigerator and the Dietary Manager (DM) and dietary aide #1 failed to wear hair coverings for 2 of 5 staff working in the kitchen. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 03/17/22 and during a complaint investigation on 6/12/23. This was for 4 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment, Care Plan Timing and Revision, Free of Accident Hazards/Supervision/Devices, Food Procurement, Store/Prepare/Serve-Sanitary, which were previously cited on 03/17/22, and Free of Accident Hazards/Supervision/Devices was cited on 06/12/23. All 4 of these deficient practice areas were recited on the current recertification, follow up, and complaint survey of 8/2/23. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to 1) replace 2 bed side commodes with visible rust on the legs and frame for 2 of 6 resident bathrooms (room [ROOM NUMBER] and 106) and 2) failed to repair or replace broken Packaged Terminal Air Conditioner (PTAC) air filters for 1 out of 12 resident rooms (room [ROOM NUMBER]) reviewed for comfortable, clean, and homelike environment.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to implement their policy for reporting an allegation of sexual abuse to the state agency within 2 hours for 1 of 3 residents reviewed for alleged sexual abuse investigations (Resident #49).

Inspectors wroteBased on staff interviews and record review, the facility failed to revise the comprehensive care plan in the area of transfer status for 2 (Resident #106 and Resident #30) of 30 residents reviewed for care plan revision.

Inspectors wroteBased on resident, staff, Medical Director (MD) and Therapy Director interviews and record review, the facility failed to transfer a resident using a sit to stand lift (a mechanical lift that assist a resident with limited mobility in standing up from a seated position) as care planned and according to the physical therapy discharge summary (Resident #106). The facility also failed to transfer a resident requiring a total mechanical lift (portable total body lift used to minimize physical effort) for transfers resulting in a fall without injury (Resident #30). This was for 2 of 8 residents reviewed for accidents.