Springs of Catawba

The facility failed to provide adequate supervision for a resident with a history of frequent falls and injuries. Specifically, the facility's accident/falls policy lacked information regarding supervision for residents with falls, and the resident's care plan requirements for supervision during transferring and ambulation were not being met, as evidenced by eleven unwitnessed falls.

The facility failed to provide adequate supervision for a resident with a history of frequent falls and injuries. Specifically, the facility's accident/falls policy lacked information regarding supervision for residents with falls, and staff were not following physician orders for hourly checks for Resident #1.

The facility failed to ensure medication administration was in accordance with licensed practitioner orders and facility policies. This included failures related to managing medication availability and notifying providers of errors.

The facility failed to ensure referral and follow-up for a resident regarding a critical missed medication. Specifically, the primary care provider was not informed that the resident had missed an anticoagulant medication for seven consecutive days.

The facility failed to provide the required minimum of 14 hours of planned group activities per week. A review of the May 2017 calendar showed the facility did not meet the variety and frequency of activities required to promote socialization and engagement.

The facility failed to ensure proper referral and follow-up for a resident regarding a critical missed medication. Specifically, the facility did not inform the resident's primary care provider that warfarin was not administered for seven consecutive days in March 2017.

The facility failed to provide adequate supervision for a resident in accordance with their assessed needs. Specifically, a resident with dementia and a history of wandering was not properly supervised during transitions to dialysis, leading to multiple elopement incidents.

The facility failed to provide adequate supervision for a resident in accordance with their assessed needs and care plan. Specifically, a resident documented as a wanderer and disoriented had previously eloped from both the facility and an outpatient dialysis clinic.

The facility failed to ensure proper medical referral and follow-up for a resident following an unwitnessed fall. After the resident was found on the floor, staff instructed the resident to be placed back in bed rather than seeking medical evaluation, which resulted in the resident being hospitalized for a brain hemorrhage and subsequently passing away.