Spicewood Cottages Elms

The facility failed to ensure that 2 of 3 sampled residents were free from abuse and neglect. Specifically, staff was observed using unauthorized 'pressure point' techniques and physical force on residents, resulting in visible bruising and physical pain. Furthermore, management failed to take appropriate action or investigate reports of staff hitting residents despite multiple staff members notifying the Administrator of the behavior.

The facility failed to implement CDC and NCDHHS guidance regarding the COVID-19 pandemic. Specifically, the facility did not properly screen staff and visitors for symptoms of fever or virus presence, and failed to ensure visitors wore facemasks while inside the facility.

The facility failed to provide residents with a complete non-disposable place setting, specifically omitting knives during the noon meal. Staff did not offer to cut food for residents, and some residents were observed using their fingers to tear meat. Staff stated knives were withheld because the facility was a locked unit.

The facility failed to ensure necessary follow-up care for a resident with an order for a hand x-ray. Although an x-ray was ordered due to a hand injury, the order was discontinued after the resident's POA refused the procedure without the facility notifying the Nurse Practitioner. Consequently, the resident's medical needs were not properly addressed.