Truewood by Merrill New Bern Memory Care

The facility failed to maintain the Special Care Unit (SCU) in an uncluttered and hazard-free manner. Specifically, various toiletries including shampoo, body wash, lotions, and disposable razors were left accessible to residents in their rooms and bathrooms. Additionally, the soiled linen and eye wash station door was found unlocked and cracked open.

The facility failed to maintain the Special Care Unit (SCU) in an uncluttered and hazard-free manner. Specifically, various toiletries, including body wash, toothpaste, and aerosol sprays, were left accessible to residents in several rooms. Additionally, a biohazard room was found unlocked and containing accessible foaming cleanser.

The facility failed to complete a required resident assessment and care plan within 10 days following a significant change in condition. Specifically, one resident experienced a significant change in mobility characterized by repeated falls, but no updated assessment was documented.

The facility failed to complete a required resident assessment and care plan within 10 days following a significant change in condition for one resident. Specifically, the resident experienced a significant change in mobility characterized by repeated falls, but the necessary assessment was not performed.

The facility failed to provide appropriate supervision for a resident who experienced six falls within a four-month period, the most recent of which resulted in nasal bone fractures. Despite the resident's documented history of dementia, recurrent falls, and need for supervision during ambulation, the facility did not implement necessary interventions to reduce fall risk.

The facility failed to provide appropriate supervision for a resident who experienced six falls within a four-month period, the most recent of which resulted in nasal bone fractures. A review of the facility's fall policy showed a lack of specific procedures for managing head injuries and evaluating emerging health concerns. Consequently, the resident's care needs were not met in accordance with their assessed level of supervision.

The facility failed to notify the primary practitioner when a required medication, Advair Discus, was unavailable for administration. This resulted in Resident #3 missing multiple doses of their bronchodilator between May 18 and May 20, 2016.

Review of Resident 63's Medication Administration Record (MAR) revealed that additional diagnoses, including asthma and chronic obstructive pulmonary disease, were not listed on the MAR. Furthermore, multiple entries between May 1 and May 23, 2016, showed that the resident did not receive prescribed doses of Avlar Discus, and documentation indicated the medication was not available in the facility.

The facility's policy and procedure for re-ordering medication was reviewed, noting that all medication should be re-ordered when only a five-day supply remains. However, care notes from May 20, 2016, indicated a fax error from the pharmacy regarding an Avlar Discus order being sent too soon, and there were no notes regarding notifying the medical doctor when medication ran out.