Summit Place of Mooresville

The facility failed to ensure proper referral and follow-up for a resident's healthcare needs regarding medication administration. Specifically, staff failed to notify the Primary Care Provider about medications that could not be crushed as required by facility policy. This resulted in the administration of whole capsules to a resident who experienced difficulty swallowing and facial grimacing.

The facility failed to ensure referral and follow-up to meet the routine healthcare needs for a resident by not notifying the Primary Care Provider about medications that could not be crushed. Specifically, Anastrozole was administered whole despite manufacturer instructions stating it should not be crushed, without obtaining an alternative medication order.

The facility failed to administer medications as ordered to two residents, specifically regarding medications for hypothyroidism, wheezing, and dementia. For one resident, levothyroxine was not administered for multiple periods across November 2023, December 2023, and January 2024 due to unaddressed pharmacy delays. Staff failed to follow reordering protocols and did not notify the physician of the missed doses.

The facility failed to administer medications as ordered to 2 of 5 sampled residents. Specifically, Resident #5 missed multiple doses of levothyroxine between November 2023 and January 2024 due to the facility awaiting medication from the pharmacy.

The facility failed to notify the Primary Care Provider regarding a resident's refusal of compression stockings. This lack of communication prevented the physician from addressing potential risks, such as worsening peripheral edema or the need for adjusted diuretics.

The facility failed to administer medications as ordered for two sampled residents. Specifically, the facility failed to provide a vitamin supplement and stomach acid medication for resident #6, and a blood pressure medication for resident #7.

The facility failed to ensure appropriate referral and follow-up for a resident's health needs. Specifically, staff failed to notify the Primary Care Provider when a resident refused to wear prescribed compression stockings for edema. This lack of communication prevented the provider from addressing the resident's refusal and managing his medical condition effectively.

The facility failed to implement physician-ordered treatments for a resident, specifically regarding a wound dressing change and skin care. An inspection revealed a resident had an outdated dressing dated June 30, 2018, and skin that was pale, dry, and flaky, despite orders for regular dressing changes and lotion application.

The facility failed to implement physician-ordered treatments for a resident, specifically regarding a wound dressing change for the left lateral foot. Although orders required dressing changes every other day, a resident was found with a dressing dated 06/30/18 during a July survey. Staff also failed to provide prescribed lotion to the resident's legs and feet twice daily.