The Carrolton of Fayetteville

Inspectors wroteBased on observation, record review, and interviews with staff, Consultant Pharmacist, and Physician, the facility failed to ensure documentation of administered doses of Resident # 1's seizure medication could be accurately reconciled with the number of tablets dispensed from the pharmacy and removed from Resident # 1's supply of seizure medication, which could indicate the possibility that the seizure medication may not have been given as ordered or that staff were borrowing the medication from other residents' supplies. This was for 1 of 2 residents whose medications were reviewed (Resident # 1).

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure debris was removed from in front of the dumpsters for 2 of 3 dumpsters observed. The facility also failed to ensure that the doors to the dumpsters were closed for 1 of 3 dumpsters. This practice had the potential to attract pests and rodents.

Inspectors wroteBased on record review and staff interviews, the facility failed to obtain and document consent from a resident's Responsible Party (RP) for the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #55).

Inspectors wroteBased on record review and staff interviews, the facility failed to inform a resident and/or Responsible Party (RP) of their right to accept or refuse medical or surgical treatment or to formulate an advance directive for 1 of 24 residents reviewed for advance directives (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with newly evident mental health diagnoses for 1 of 2 sampled resident reviewed for PASRR (Resident #10).

Inspectors wroteBased on record review and staff interviews, the facility failed to apply for a Preadmission Screening and Resident Review (PASRR) Level II screening for 1 of 5 residents reviewed for PASRR Level II screenings (Resident #4).

Inspectors wroteBased on record review, Responsible Party (RP) and staff interviews, the facility failed to inform the RP of skin tears and bruises for one (1) out of four (4) sampled residents reviewed. (Resident #150)

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure the facility was free of medication errors due to an incorrectly transcribed admission order to stop Lovenox (A medication that helps prevent the formation of blood clots.) when the International Normalized Ratio (INR) (a blood test that indicates how well the blood can clot.) was less than 2.0. The Physician's order was to stop Lovenox when INR was greater than 2.0. The deficient practice was for 1 of 3 residents reviewed for medication errors (Resident #1).

Inspectors wroteBased on record reviews and resident, staff and physician interviews, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse for 1 of 3 residents reviewed for abuse (Resident #1).

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Floor Technician #1) took money from a Resident's pants pocket while he was in bed without the resident's consent. The deficient practice was for 1 of 3 residents reviewed for misappropriation of resident property (Resident #2).

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure the facility was free of medication errors due to a missed dose of Intravenous (IV) Therapy. The deficient practice was for 1 of 4 residents reviewed for medication errors (Resident #4).

Inspectors wroteBased on record review and staff and Medical Director interviews, the facility failed to complete and document comprehensive weekly skins assessments and nursing notes related to treatment or prevention of pressure ulcers, provide treatments as ordered, and initiate an air mattress and protective heel boots when recommended for a resident with and at risk for pressure ulcers. Resident #1 developed new pressure ulcers and existing pressure ulcers deteriorated. This deficient practice occurred for 1 of 3 residents reviewed for pressure ulcers (Resident #1).

Inspectors wroteBased on medical record review and staff interviews the facility failed to complete a comprehensive assessment including Minimum Data Set (MDS) within 14 days of admission for 1 of 3 residents (Resident #2).

Inspectors wroteBased on interviews with staff and medical record review the facility failed to develop a baseline care plan within 48 hours after admission for 1 of 1 resident reviewed for pressure ulcers (Resident #1).

Inspectors wroteBased on interviews with staff and medical record review the facility failed to develop a person-centered comprehensive care plan for 2 of 3 residents reviewed for care plans (Resident #1 and #2).

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility neglected to provide tracheostomy care as ordered by the medical doctor for 1 of 1 resident reviewed for respiratory care (Resident #25) and the facility neglected to clarify or obtain orders for indwelling urinary catheter changes for 1 of 1 resident reviewed (Resident #25) resulting in a resident's indwelling urinary catheter not being changed for several months and a hospitalization for a urinary tract infection (UTI). Immediate Jeopardy for Resident #25 began on 05/18/18 and was removed on 07/03/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at scope and severity of a G (actual harm that is not Immediate Jeopardy) for example 1b. The Findings Included: Resident #25 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review, resident interview and facility staff and hospital staff interviews, the facility failed to provide tracheostomy care as ordered by the medical doctor for 1 of 1 resident reviewed for respiratory care (Resident #25). Immediate Jeopardy began on 05/18/18 and was removed on 07/03/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at scope and severity of D (not actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to allow for ongoing in-servicing and monitoring to be accomplished.

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to clarify indwelling urinary catheter orders for 1 of 1 resident reviewed (Resident #25) resulting in a resident's indwelling urinary catheter not being changed for several months and a hospitalization for a urinary tract infection (UTI). The Findings Included: Resident #25 was admitted to the facility on [DATE]. Her medical diagnoses included, in part, Multiple Sclerosis (MS), calculus (stone) in urethra, calculus of kidney, chronic obstructive pyelonephritis (kidney infection), reflux uropathy (urine flow from bladder toward the kidney), retention of urine and history of urinary tract infection (UTI). [...]

Inspectors wroteBased on observations and interviews, the facility failed to properly label food stored in the reach-in refrigerator, failed to properly store scoops, failed to clean and sanitize food carts, failed to clean and sanitize utility carts, failed to clean open floor area below the steam table and failed to clean a wall in the dishwashing area.

Inspectors wroteBased on record reviews, observations, and resident and staff interviews the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification/complaint survey of 07/21/17 and the complaint survey of 09/27/17. This was for 2 deficiencies originally cited in July 2017 and 1 deficiency cited in September 2017. These 3 deficiencies were subsequently recited on the current recertification complaint survey of 05/26/18. The continued failure of the facility during 3 federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure the commercial high temperature dishwasher rinse temperature gauge was functioning according to the manufacturer's instruction.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to accurately code the Quarterly Minimum Data Set (MDS) assessment for 1 of 1 sampled resident reviewed for hospice care (Resident #15).

Inspectors wroteBased on observations, record review and resident and staff interviews, the facility failed to provide showers as scheduled for 1 of 3 residents reviewed (Resident #21).

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to implement interventions to prevent falls which resulted in multiple falls for 1 of 1 sampled resident. (Resident #74)

Inspectors wroteBased on observation, record reviews and staff interviews the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 25 opportunities. 1 of 5 Residents (Resident #90) reviewed had medication errors during the observation of the medication pass. The Medication error rate was 8 percent.

Inspectors wroteBased on observations and staff interviews the facility failed to secure a bottle of Humalog insulin and an unopened insulin syringe in a locked medication cart (300 hall cart) for 1 of 3 medication carts.