Wayne County Rest Villa no. 2

The facility failed to ensure a referral to a dermatologist was followed up with an appointment for one resident. Although a physician's order for the referral existed, the facility did not verify that the appointment was scheduled.

The facility failed to ensure that medication administration was documented correctly. Specifically, there was a lack of documentation regarding the administration of certain medications to residents.

The facility failed to maintain accurate medication administration records. There were instances where the timing or dosage of medication administration was not properly recorded.

The facility failed to ensure that all medications were administered according to the prescribed instructions. Discrepancies were noted between the physician orders and the actual administration records.

The facility failed to properly monitor and document the effects of medications on residents. There was insufficient evidence that the facility was assessing for adverse reactions or effectiveness of administered drugs.

The facility failed to ensure that medication storage was secure and appropriate. Certain medications were not stored in a manner that prevented unauthorized access or maintained required temperature controls.

The facility failed to maintain proper control over controlled substances. There were inconsistencies in the logging and tracking of controlled medication usage.

The facility failed to ensure that staff members were properly trained in medication administration procedures. Documentation did not sufficiently demonstrate that all personnel involved in medication tasks had completed required competency assessments.

The facility failed to ensure that medication errors were properly investigated and reported. There was no evidence of a systematic process for reviewing medication discrepancies to prevent recurrence.

The facility failed to ensure that medication-related supplies, such as syringes or administration tools, were properly maintained and clean. Inadequate oversight of the cleanliness of administration equipment was observed.

The facility failed to ensure that medication orders were reviewed and updated regularly. There were instances where outdated physician orders were still being used for medication administration.

The facility failed to ensure that residents' medication needs were properly assessed upon admission. There was a lack of documented assessment regarding the necessity of certain medications following changes in resident status.

The facility failed to administer medications as ordered by the primary care provider for 3 of 3 sampled residents. Specifically, for Resident #3, the medication aide administered one whole 5mg Zyprexa tablet instead of the prescribed 2.5mg dose (one half tablet) because the pharmacy label and eMAR were not properly reconciled. The medication aide also lacked a pill cutter to facilitate the correct dosage.

The facility failed to maintain a clean and orderly environment free of hazards, as evidenced by active roaches, spiders, and bed bugs throughout the facility. Specific findings included live bed bugs in resident rooms, roaches in the kitchen pantry, and evidence of pests in furniture and wall art.

The facility failed to maintain an environment free of hazards and obstructions due to active vermin infestations. Inspections and resident interviews revealed live roaches in the kitchen pantry, bed bugs in multiple resident rooms, and spiders in closets.

The facility failed to maintain a North Carolina Division of Environmental Health sanitation score of 85 or above. An inspection revealed a provisional classification with 21 demerits, including issues such as improper food storage, pest infestations (roaches, bed bugs, and spiders), and water damage/mold in the kitchen. Additionally, there were observations of dirty surfaces, damaged walls, and lack of soap in the medication room.

The facility failed to maintain a North Carolina Division of Environmental Health sanitation score of 85 or above. An inspection on 09/08/21 revealed 21 demerits and a provisional classification, with issues including pest infestations (roaches, bed bugs, spiders), moisture damage in kitchen cabinets, and improper food storage.

The facility failed to ensure that 2 of 3 sampled residents received quarterly on-site Licensed Health Professional Support reviews and evaluations. Specifically, Resident #1 did not have a required LHPS review completed in February 2015.