Terrabella Southern Pines

The facility failed to ensure residents received necessary personal care according to their care plans. Specifically, for 2 of 5 sampled residents, staff did not provide adequate assistance with personal care needs that the residents were unable to attend to themselves.

The facility failed to ensure residents received necessary personal care for 2 of 5 sampled residents. Specifically, for Resident #1, documentation and observations indicated a failure to provide adequate assistance with hygiene and monitoring, as evidenced by a room smelling of urine and a bed soaked in urine.

The facility failed to ensure residents received necessary personal care according to their care plans. Specifically, for 2 of 5 sampled residents, staff did not provide adequate assistance with personal needs that the residents were unable to attend to themselves.

The facility failed to ensure physician orders were implemented for a resident who had an order for weekly weights. Specifically, while a weight was recorded in October 2024, no weights were documented for the month of November 2024. Staff admitted the order fell through the cracks due to failure to follow the established order processing method.

The facility failed to ensure the main entrance door was equipped with an audible sounding device that activates when opened. This was observed on multiple occasions when the door was unlocked and did not alarm upon entry, posing a risk to residents identified as disoriented or having wandering behaviors.

The facility failed to ensure medications were administered as ordered, specifically regarding the improper crushing of Jardiance for Resident #6 and errors with dementia medication for Resident #7. Additionally, errors were noted with long-acting insulin for Resident #1. These errors resulted in a 7% medication error rate during the 8:00am medication pass.

The facility failed to ensure the Cook completed the required food service orientation program within 30 days of hire. A review of the staff record showed the cook had the orientation manual and a post-test, but the post-test was not completed and the training transcript did not include the required module.

The facility failed to protect food from contamination and maintain clean food storage areas. Observations revealed a large amount of frozen tan-colored crumbs on the floor of the freezer and a build-up of grime in the refrigerator in the Special Care Unit kitchen.

The facility failed to ensure medications were administered as prescribed for one resident. Specifically, the resident was ordered Aricept 10 mg daily, but the medication administration records showed the medication was being documented as administered only every other day.