Zebulon House

The facility failed to ensure proper referral and follow-up for ordered laboratory tests for a resident. Specifically, a physician's order for a potassium level test from January 2025 was not completed, and the facility failed to notify the physician that the lab work had not been performed.

The facility failed to ensure that the remaining personal funds of residents were refunded within 14 days of their departure. This was evidenced by a failure to refund funds for 3 out of 5 sampled residents within the required timeframe.

The facility failed to ensure proper referral and follow-up for a resident's ordered laboratory tests. Specifically, a physician had ordered a repeat potassium level following an elevated result, but there was no documentation of the follow-up lab results being obtained or reviewed after the order date of 01/15/25.

The facility failed to administer medications as ordered for residents, specifically regarding medications used to treat constipation and manage phosphate levels. During an 8:00am medication pass, the medication error rate was 6%, including a failure to administer the correct dose of sevelamer carbonate to Resident #1.

The facility failed to administer medications as ordered for residents, specifically regarding medications used to treat constipation and prevent high phosphate levels. During an 8:00am medication pass, a 6% error rate was observed, including the failure to administer sevelamer carbonate as prescribed.

The facility failed to ensure medications were administered in accordance with physician orders. Specifically, during medication passes, staff failed to administer prescribed medications for several residents, including treatments for breathing conditions, low potassium, thyroid hormone levels, and dementia. This resulted in a medication error rate of 6% during the observed 8:00am medication pass.

The facility failed to administer medications according to physician orders for 2 of 5 residents observed during medication passes. Specific errors included crushing a medication that should not be crushed and failing to provide a medication for a breathing condition and a supplement for low potassium. Additionally, medication administration errors were noted for residents with thyroid and dementia diagnoses.

The facility failed to implement required COVID-19 screening protocols for staff as established by the CDC and NCDHHS. Specifically, multiple staff members failed to sign the COVID-19 Screening Log at the beginning of their shifts on several dates between December 30, 2020, and January 5, 2021.

The facility failed to implement and maintain recommended COVID-19 screening protocols for staff as established by the CDC, NCDHHS, and local health department. Specifically, the facility did not ensure that personnel were screened for fever and symptoms before starting each shift. This failure included not adhering to the facility's own policy requiring temperature checks and symptom questionnaires upon arrival.