Wrightsville Manor Health and Rehab

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Elopement, the facility failed to ensure the facility was free of accident hazards for one of 22 residents (R) (R2) on elopement risk. Specifically, R2 was able to exit the facility without supervision. This deficient practice had the potential to place R2 at increased risk of avoidable injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in a manner to prevent cross-contamination for seven of 13 residents (R) (R62, R65, R56, R30, R33, R22, and R45) observed receiving medications. This deficient practice had the potential to place R62, R65, R56, R30, R33, R22, and R45 at risk of avoidable infections.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure one of 22 sampled residents (R) (R4) was treated with dignity during dining and during the care of an indwelling urinary catheter. This failure had the potential to place R4 at risk of experiencing low self-esteem and embarrassment.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to provide the resident and/or their responsible party (RP) a written transfer notice, including the resident's appeal rights and ombudsman contact information, at the time the resident was transferred to the hospital, and failed to send a copy of the notice to the Long Term Care Ombudsman for five of five residents (R) (R6, R7, R28, R71, and R76) reviewed for hospitalizations in a total sample of 22. [...]

Inspectors wroteBased on observation, staff interview, record review, and review of facility policy titled Foley Catheter Policy, the facility failed to manage a urinary catheter and drainage bag appropriately for one of one resident (R) (R4) reviewed for urinary catheters out of a total sample of 22 residents. This deficient practice had the potential to place R4 at risk of urinary tract complications.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure communication with the dialysis center, failed to monitor the dialysis access site, and failed to have documented blood pressures and weights, as ordered by the physician, for one of one resident (R) (R9) reviewed for dialysis out of a total sample of 22. These deficient practices had the potential to place R9 at increased risk of complications related to dialysis.

Inspectors wroteBased on observations, staff interviews, record review, review of manufacturer's guidelines, and review of facility policies titled Insulin Administration, and Administering Medications through a Handheld Nebulizer, the facility failed to ensure a medication error rate of less than five percent for four of 13 residents (R) (R64, R48, R7, and R16) observed during the medication pass out of a total sample of 22 residents. There were four errors out of 34 opportunities, resulting in a medication error rate of 11.76 percent. These failures had the potential to place R64, R48, R7, and R16 at risk of not receiving the prescribed dosage of medication.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to document an episode of hypoglycemia (low blood sugar) for one of five residents (R) (R8) reviewed for unnecessary medications out of a total sample of 22. This deficient practice had the potential to place R8 at increased risk for medical complications.

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect Resident (R1)'s right to be free from sexual abuse by Resident (R2). The facility census was 75. On 2/4/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/4/2025 at 4:13 pm. The noncompliance related to the IJ was identified to have existed on 11/29/2024. An Acceptable IJ Removal Plan was received on 2/8/2025. [...]

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility Administration failed to protect one resident (R) (R1) was free from sexual abuse by R2, and the facility failed to complete a thorough investigation following an allegation of resident-to-resident sexual abuse involving two Residents (R) (R1 and R2). This failure resulted in R1 being transferred to the emergency room for evaluation of sexual assault. On 2/4/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/4/2025 at 4:13 pm. [...]

Inspectors wroteBased on observations, staff interviews, and a review of the facility policies titled, Food Storage, General HACCP Guidelines for Food Safety, and Cleaning Dishes - Manual Dishwashing the facility failed to label and date opened food items in the reach-in refrigerator, dry storage area, and walk-in freezer. In addition, the facility failed to properly thaw food items to prevent food borne illness and failed to demonstrate the correct usage of the three compartment sink to prevent cross contamination. The facility census was 83 with 76 residents consuming an oral diet.

Inspectors wroteBased on observations, staff interviews, and a review of facility's policy titled, Infection Prevention and Control Policy, and Glucometer Policy, the facility failed to practice acceptable infection control practices to prevent possible cross-contamination by not ensuring resident bath basins and urinals were labeled and covered for 10 of 44 rooms. In addition, the facility failed to ensure a glucometer (a device used to measure blood sugar levels) was disinfected after each use and prior to use on other residents for two of three residents (R) (R18 and R3) and failed to provide a clean barrier between clean and contaminated surfaces. This failure had the potential to expose patients to infections due to cross-contamination.

Inspectors wroteBased on observation, staff interviews, record review, and review of facility policy, the facility failed to accurately assess one resident (R) (41) reviewed for smoking of 26 residents that smoke.

Inspectors wroteBased on interviews, review of facility documentation, and policy review titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to failure to label and date open food items in the dry storage and walk in refrigerator and discard expired meat in the walk in refrigerator. This had the potential to affect 75 of 81 residents who receive food from the kitchen.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment related to dirt buildup and disrepair of resident rooms and bathrooms including toilets, sinks, floors, walls, privacy curtains, and vents in 9 of 45 resident rooms (210, 302, 303, 305, 306, 307, 309, 310, and 312) and one of two dayrooms (300 hall). Findings Include: During observation tour of facility on 5/13/22 at 9:08 a.m. revealed the following: 1. room [ROOM NUMBER] the wall under the TV had thick black scuff marks and missing paint and the door frame had chipped and missing paint. 2. [...]

Inspectors wroteBased on observations, interviews, and review of facility policies titled General Sanitation of Kitchen, Food Safety -Director of Food and Nutrition Services Responsibility, and Production, storage and dispensing of ice, the facility failed to maintain clean and sanitary ice machines which is used for resident hydration and for meal service, and the facility also failed to maintain clean and sanitary oven and fryer used to prepare residents meals. The deficient practice had the potential to affect 74 of 78 residents receiving an oral diet. Findings Include: Observation of two ice machines located in the main dining room of the facility on 5/13/22 at 7:50 a.m. that were in use for residents and facility staff. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility Care Plan Policy Statement and Behavior Monitoring Policy the facility failed to implement interventions in the comprehensive, person centered, care plan related to behavior monitoring for one resident (R) (#64) who was prescribed an antianxiety, antipsychotic and hypnotic medication with care planned behaviors, of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, staff and resident interview, and review of the facility Behavior Monitoring Policy the facility failed to initiate behavior monitoring for one resident (R) (#64) who was prescribed an antianxiety, antipsychotic, and hypnotic of five residents reviewed for unnecessary medications.