Cardinal Care of Dunn

The facility failed to provide adequate supervision for a resident in the Special Care Unit (SCU) who had a known history of wandering and exit-seeking behaviors. This lack of supervision resulted in the resident eloping from the facility by climbing out of a window and walking down the driveway.

The facility failed to provide adequate supervision for a resident in the Special Care Unit with a history of wandering and exit-seeking behaviors, resulting in the resident climbing out of a laundry room window and eloping. During the inspection, the laundry room door was found propped open with a chair and the window was left partially open, creating an unsafe environment. This lack of oversight allowed the resident to exit the building and walk down the road.

The facility failed to ensure medications were administered according to physician orders, resulting in an 8% medication error rate. Specifically, a resident's Levothyroxine was administered with other medications rather than at least 30 minutes before breakfast as required. Additionally, errors were noted regarding vitamin supplements and medications for anxiety and agitation.

The facility failed to ensure medications were administered as ordered for two residents, specifically involving errors with Levothyroxine and vitamin supplements. For Resident #9, Levothyroxine was administered after the resident had already begun eating breakfast, violating the order to administer it at least 30 minutes before meals. The medication error rate was calculated at 8% during the 7:00am/8:00am medication pass.

The facility failed to maintain common bathrooms in an uncluttered and safe manner by leaving hazardous items unsecured and accessible to residents. Specifically, personal care products, razor blades, bleach-based cleaning products, and hand sanitizers were found unattended in unlocked shower rooms.

The facility failed to maintain common bathrooms in an uncluttered and safe manner by leaving personal hygiene products, razor blades, and cleaning products unsecured and accessible to residents. Specifically, unlocked cabinets and unattended items like hair conditioner, body spray, and shaving cream were found in accessible shower rooms, increasing the risk of resident misuse or ingestion.

The facility failed to maintain common bathrooms in an uncluttered and safe manner by leaving hazardous items unsecured and accessible to residents. Specifically, personal care products, razor blades, bleach-based cleaning products, and hand sanitizers were found unattended in unlocked shower rooms.

The facility failed to maintain a clean and orderly environment free of hazards. Specific issues included an unstable wooden fence and overgrown shrubs in the courtyard, unlocked personal hygiene products in common and individual bathrooms, and accessible cleaning chemicals in janitor closets.