Siler City Center

Penalty

Inspection fine: $19,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow physician and hospital discharge orders for a knee immobilizer and to provide adequate skin assessment and monitoring, resulting in a facility-acquired pressure ulcer under the device. The resident was admitted after a left patella fracture with hospital discharge instructions specifying that the knee immobilizer should be worn when bearing weight and could be removed when not bearing weight for comfort. However, when the order was transcribed into the facility’s EMR by a house supervisor, it was entered as “left knee immobilizer in place at all times. May remove for bathing and skin checks every day and night shift,” which did not match the hospital discharge instructions. Neither of the two house supervisors who handled admissions could explain where the “at all times” language originated, and no documentation was produced to support that wording. The resident was admitted with multiple diagnoses including left patella fracture, A-fib, CHF, hypothyroidism, Alzheimer’s disease, and later-documented moderate protein-calorie malnutrition. On admission, nursing documentation noted a dark spot on the coccyx, an open area on the spine, and redness to the left knee, but these findings were not reflected on the admission MDS, which indicated no pressure ulcers, no other skin problems, and no malnutrition or risk for malnutrition. The care plan identified risk for skin breakdown and nutritional risk but did not include specific interventions related to the knee immobilizer or to the coccyx and spinal skin issues noted on admission. Subsequent Braden and advanced skin checks at various dates documented normal skin findings and, on at least two occasions, incorrectly indicated that the resident did not have an external device, despite the presence of the immobilizer. Throughout October and early November, the TAR carried the order for the immobilizer to be in place at all times, with removal allowed for bathing and skin checks, and nurses consistently initialed that the order was carried out. Multiple nurses and NAs reported that they either did not fully remove the immobilizer or could not recall doing so, and some stated they believed the order did not require full removal except for baths. One nurse later acknowledged seeing redness and indentations from the brace on the lower leg or back of the thigh on at least two days but did not document or report these findings, considering them not significant. Another staff member documented that the splint was removed and inspected and that no concerning changes were seen, while other staff described only partially opening the brace or being able to see the skin “fine” without fully removing it. On a follow-up visit, the orthopedic NP recommended that the resident be weight bearing as tolerated with the immobilizer and to continue the immobilizer when sitting and lying, with PT allowed to remove it for range of motion up to 60 degrees of flexion. Later, an NA providing a bed bath observed yellow drainage on the bed sheet and, upon opening the immobilizer and lifting the leg, found an open, dark-colored wound on the back of the left lower leg at the point where the immobilizer ended, with indentations all over the leg from the brace. The nurse who assessed the wound documented it as a new, in-house acquired pressure ulcer and initially mis-located it on the front lateral lower leg due to confusion with directions. The wound was described by staff as open, with red and yellow tissue and “yellowy-red” drainage, and another nurse noted that the immobilizer remained in place and was pushing into the wound. The facility contacted the orthopedic NP days later to ask about removing the immobilizer; the NP gave a verbal order to remove it and requested to see the resident the same day, but the visit was delayed due to transportation issues, and interviews indicated the immobilizer was not actually removed until several days after the verbal order, during which time it potentially continued to exert pressure on the ulcer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in food storage and sanitation practices in the facility’s kitchen. During an initial kitchen tour with the Dietary Manager, a large bin of flour was observed with the scoop stored directly inside the flour, rather than in a manner that prevented contact with the food product. The Dietary Manager explained that the hook intended for hanging the scoop was inside the container and that when the lid was slid closed, it often knocked the scoop back into the flour. No residents or their specific medical conditions were mentioned in relation to this observation. Further observations showed additional sanitation issues. The underside of the steam table hood was found to have orange and brown residue and felt slick to the touch, and the Dietary Manager acknowledged that while the steam table was cleaned between meals, the underside of the hood had likely not been cleaned for some time. On a follow-up kitchen tour, surveyors observed that 20 of 30 plastic plate bases on the tray line were stacked while still wet and ready for use. The Dietary Manager stated she had checked other dishware for dryness but had not checked the plastic plate bases. The Administrator later stated he did not know why the hood was not clean or why the scoop was left in the flour and indicated he would want the kitchen kept clean and dishware clean and dry before use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess and authorize a cognitively intact resident’s ability to self-administer a prescribed steroid nasal spray that was kept at bedside. The resident had a physician’s order for fluticasone propionate nasal suspension, 50 micrograms, two sprays in both nostrils twice daily for allergies. The quarterly MDS documented that the resident was cognitively intact, and the DON and Medical Director both acknowledged the resident had the potential or ability to self-administer medication. However, the resident’s care plan contained no goals or interventions related to self-administration of medications, and the medical record did not contain any assessment for self-administration or an order permitting the resident to keep the nasal spray at bedside. Surveyors observed the resident’s prescribed nasal spray on the overbed table on multiple occasions over two consecutive days, and the resident stated that a nurse had left it in the room and that she knew she should not have it there, but it made it easier to use when needed. A nurse assigned to the resident stated she was unsure of the process for residents who self-administer medications, believed no residents on that hall self-administered, and said she would remove any medication found in a resident’s room, yet she had not noticed the nasal spray earlier that day when administering medications. During an interview and concurrent room observation, this nurse then discovered the nasal spray on the overbed table behind a tissue box and removed it. The DON and Administrator both described a facility process requiring an assessment, an order, a lock box, and care plan interventions for self-administration, and both stated they were not aware of residents on that hall self-administering medications, confirming that these required steps had not been completed for this resident despite the medication being left at bedside.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to complete an accurate MDS assessment regarding skin conditions for one resident. The resident was admitted with diagnoses including a left patella fracture, A-fib, CHF, hypothyroidism, and Alzheimer’s disease. On admission, a nurse documented a dark spot on the coccyx, an open area on the spine, and redness to the left knee. The resident’s care plan, initiated the day after admission, identified her as being at risk for skin breakdown and included general preventive skin care interventions such as patting the skin dry, observing for signs of breakdown, using barrier creams, and checking the skin weekly by a licensed nurse. Despite these documented skin findings and risk factors, the admission MDS indicated that the resident was severely cognitively impaired and required extensive assistance with ADLs but did not accurately reflect her existing skin issues. The MDS stated that the resident did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, and under other ulcers, wounds, and skin problems, it indicated none were present. The MDS also did not indicate the need for a pressure-relieving device in the chair, participation in a reposition/turning program, or inclusion in a nutrition and hydration program for skin, resulting in an inaccurate assessment of the resident’s skin condition and related care needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to secure medications and prevent unauthorized self-administration for a resident who had explicit physician orders prohibiting self-administration. The resident was admitted on a specified date and had a physician’s order dated 6/25/2025 stating that he may not administer his own medications, as well as an order for staff to monitor his swallowing during medication passes and document any coughing, pain, or difficulty swallowing. During an observation on 2/24/2026 at 2:50 PM, surveyors found a medication cup containing seven pills on the resident’s bedside table while the assigned nurse was no longer passing medications on the hallway. The resident stated he would take the medications in the cup when they let him out of the facility. At 2:55 PM the same day, the assigned nurse confirmed that the cup contained the resident’s lunch medications, which she had given him at approximately 1:30 PM, and acknowledged that he usually took them when handed to him. When the nurse asked the resident to take the medications, he refused, repeating that he would take them when he got up out of there, and did not take them at that time. The nurse then removed the medication cup and later stated she had trusted the resident would take the medications and recognized this as a lapse in judgment, acknowledging she knew he was not to have medications left at the bedside and that she was required to monitor and document his swallowing. The physician later stated he did not recall the no self-administration order but agreed that if such an order existed, the resident probably should not self-administer, and he expected staff to follow physician orders. The DON confirmed that only one resident in the facility had an order to self-administer medications and that all others, including this resident, had orders that they may not self-administer medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to keep the area around the trash compactor free of accumulated trash and debris. During an observation of the dumpster area with the Dietary Manager, the trash compactor was seen in a fenced area behind the kitchen entrance, with a cement platform in front and grassy areas to the left and back. In the grassy area on the left side of the compactor, surveyors noted four plastic bottles, six disposable cups, four disposable gloves, and seven straws that had not been removed. The Dietary Manager reported that a member of the kitchen staff cleaned only the cement platform on a weekly basis and confirmed that the trash and debris on the left side and back of the trash compactor were not being picked up. The Dietary Manager stated she did not know why those areas were not attended to and noted that all departments in the facility used the same trash compactor. In a separate interview, the Administrator stated he did not know why the trash compactor area had not been cleaned and indicated he would want the area free of debris.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations involving one resident with dementia and behavioral symptoms. This resident had diagnoses including dementia, psychotic and mood disturbances, and anxiety, and was assessed as severely cognitively impaired with no physical limitations. His care plan, revised multiple times, documented a history and risk of physical behaviors toward others, including prior resident-to-resident incidents. Despite this, his MDS assessments did not reflect behaviors directed toward others during the lookback periods, and the care plan interventions relied on staff recognizing triggers, observing for non-verbal signs of aggression, and removing or diverting the resident as needed. On one occasion, an altercation occurred between this resident and another cognitively impaired resident with dementia and depressive disorder. The second resident’s care plan documented physical behaviors such as grabbing, pushing, and aggression, as well as verbal behaviors including threatening, cursing, agitation, and delusions. Staff accounts and the facility’s investigation showed that the first resident reported finding the second resident in his room going through his belongings, after which an unwitnessed altercation occurred in the room. Shortly afterward, in front of the nursing station, staff observed the first resident, visibly upset and speaking in broken English, approach the second resident and strike him in the face with an open hand. Staff present at the nursing station were unable to separate the residents quickly enough to prevent the slap. In a separate incident, the same resident with dementia shared a room with another resident who was cognitively intact but had psychiatric diagnoses including schizoaffective disorder, major depressive disorder, bipolar disorder, PTSD, and a history of hallucinations. This roommate’s care plan noted fluctuating mood, agitation, and anxiety, with interventions focused on redirection and observation for worsening psychiatric symptoms. Staff reported that the two roommates had argued over television volume earlier in the day, with a nursing assistant notifying a nurse about the dispute. Later, a nurse responding to the resident with dementia observed the shared room in disarray and found the cognitively intact roommate with blood on his forehead. The injured resident stated he had been struck on the head with a reaching device by his roommate, and continued to complain about the television volume. The actual assault was not witnessed by staff. Another incident involved the same aggressive resident and a severely cognitively impaired resident with vascular dementia, insomnia, and anxiety, who was known to wander, enter other residents’ rooms, and show poor awareness of personal space. This resident’s care plan included interventions such as gently guiding him from environments and diverting him with alternative activities. On the date of the incident, the aggressive resident was under 1:1 supervision near the nursing station. Witnesses, including a nurse and the nursing assistant assigned to 1:1, reported that the wandering resident approached and leaned in close to the supervised resident while speaking. Within seconds, the supervised resident stood or reached up and struck the approaching resident across the face with an open hand. The nursing assistant providing 1:1 supervision stated she was within arm’s reach but did not anticipate an altercation and was unable to intervene in time. Interviews with nursing assistants assigned to provide 1:1 supervision revealed they were not informed of the specific reasons for the supervision or of the resident’s known triggers for aggression, such as others touching his belongings or entering his personal space. One assistant reported only being told to notify a nurse if the resident became upset, and another stated she had not received instructions about triggers or what to avoid. The DON acknowledged being unaware whether NAs assigned to 1:1 supervision were educated about the resident’s triggers, while the ADON stated that staff were supposed to be told triggers but could not recall any formal in-service specific to this resident’s aggression. These gaps in communication and implementation of individualized interventions contributed to repeated resident-to-resident physical abuse incidents involving the same resident, including one that occurred while he was on 1:1 supervision.

Penalty

Inspection fine: $7,909

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a cognitively impaired male resident was not protected from sexual abuse by another cognitively impaired male resident. The incident took place in a shared room within the memory care unit, where a nurse aide overheard unusual laughter from one resident and, upon entering the room, observed one resident lying in bed with his penis exposed while the other resident was standing beside the bed, grasping and moving the exposed penis in an up and down motion. Both residents were severely cognitively impaired and lacked the capacity to consent to sexual activity. The nurse aide immediately intervened by instructing the resident to stop and separated the two individuals. Prior to the incident, neither resident had a documented history of sexually inappropriate behaviors. Both residents had care plans that addressed other behavioral symptoms such as wandering, disrobing in public, and physical or verbal behaviors, but there were no interventions or monitoring in place for sexually inappropriate conduct. The residents were both independent with eating, bed mobility, and transfers, but required staff assistance for other activities of daily living. One resident was being treated for a urinary tract infection and had been observed pulling at his groin area earlier that morning, but this behavior had not previously been associated with sexual activity. The facility's staff, including the nurse aide, nurse, unit manager, DON, and administrator, confirmed that neither resident had previously exhibited inappropriate sexual behaviors. The incident was witnessed directly by the nurse aide, and subsequent interviews with staff and responsible parties indicated that the event was unexpected and not anticipated based on the residents' prior behavior or care plans. The lack of identification and intervention for potential sexually inappropriate behaviors in the care planning process contributed to the failure to protect the resident from abuse.

Removal Plan

• Both residents were separated and placed on one-to-one supervision by facility staff.
• Staff that witnessed the event were interviewed by the Nurse Supervisor and statements were obtained.
• The Nurse Supervisor interviewed both residents regarding the occurrence.
• Resident #2 was moved to a different room.
• Responsible Parties for both residents were notified by the licensed nurse.
• The Medical Director and Nurse Practitioner were notified of the occurrence.
• The local Police Department was notified by the Nurse Supervisor.
• Licensed Nurse conducted skin assessments on both residents.
• An initial report was sent to the North Carolina Department of Health and Human Services.
• Adult Protective Services was notified of the allegation of resident abuse.
• Psychiatric services was notified for Resident #1; a telehealth and follow-up in-person visit were conducted.
• Medication changes were recommended and implemented for Resident #1 (increased Depakote, Hydroxyzine as needed).
• Resident #2’s Zoloft was increased to decrease libido.
• A chart review was completed for both residents by the Director of Nursing.
• Skin assessments were completed on all non-alert/oriented residents by licensed nursing staff.
• Social Worker Director and Assistant Social Worker interviewed all alert and oriented residents regarding resident abuse.
• Residents with roommates were interviewed to ensure roommate compatibility.
• Medical record audit of all residents was completed to identify residents with behaviors and review for sexual behaviors.
• Residents identified as having behaviors are reviewed in clinical morning meetings to ensure appropriate interventions are in place.
• Interventions for residents with behaviors include medication regimen review, one-to-one supervision, psychiatric consultation/visit, physician notification and assessment, and roommate compatibility.
• Education was provided to all facility staff (including agency staff) on the abuse policy with emphasis on sexual behaviors, management of symptoms, and ensuring resident safety by reporting, identifying, preventing, and managing behavioral symptoms.
• Any staff not receiving abuse education will not be allowed to work before receiving education.
• All newly hired staff, including new agency staff, will be educated on the facility's abuse prohibition policy in new hire orientation.
• The Director of Nursing and Nurse Practice Educator are tracking abuse education to ensure no staff works prior to receiving education.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess and obtain a physician's order for the self-administration of medications for a resident diagnosed with chronic obstructive pulmonary disease, diabetes type 2, and hypertension. The resident was cognitively intact and displayed no behaviors or rejection of care according to a quarterly Minimum Data Set assessment. However, a review of the resident's medical record did not reveal an order to self-administer medications. During an observation, medications were found in a medication cup on the resident's over the bed table, which the resident stated had been left there since breakfast. The resident did not indicate an intention to take the medications. An interview with a nurse revealed that she had left the morning medications on the over the bed table for the resident to take, assuming the resident would do so. When the nurse returned, the resident stated he did not want to take them at that time, leading the nurse to retrieve the medications and mark them as refused on the Medication Administration Record. The Director of Nursing confirmed that medications should not be left unsecured at the bedside unless there is an order for self-administration, which the resident did not have.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. Three residents, all cognitively intact, reported receiving mail that had been opened prior to their receipt. These residents were unable to provide specific dates but indicated that the opened mail was related to their financial status. The Activity Director confirmed that mail was sometimes delivered taped closed, indicating it had been opened previously. The Business Office Manager admitted to opening all mail without checking the addressee, especially if the mail was related to financial matters. She stated that she opened mail for residents with impaired cognition but acknowledged that she should not open mail for cognitively intact residents. The Administrator was unaware of this practice and confirmed that mail should only be opened if addressed to the facility or if the resident was cognitively impaired. The improper handling of mail led to a breach of privacy for the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer water flushes via a feeding tube at the physician-ordered flow rate for a resident with a feeding tube. Resident #22, who was admitted with diagnoses including dysphagia and the presence of a feeding tube, was observed to have her feeding tube connected to a continuous bottle of formula with a standby bag of water. The physician's order specified that the feeding tube should be flushed with 110 milliliters of water every 3 hours during continuous feedings. However, observations revealed that the water flush was set to run every 4 hours instead of the prescribed 3-hour interval. During an observation with Nurse #1, it was confirmed that the water flush settings were incorrect, with the frequency set at every 4 hours instead of the ordered 3 hours. Nurse #1 acknowledged the discrepancy after reviewing the physician orders but was unable to explain why the settings differed from the physician's order. The Director of Nursing later stated that she expected water flushes to be administered at the prescribed rate, indicating a failure in adhering to the physician's orders for Resident #22's care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to a physician's order regarding the administration of Midodrine, a blood pressure medication, for a resident diagnosed with low blood pressure. The order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was less than 120. However, a review of the Medication Administration Records (MARs) for October and November 2024 revealed that the resident received the medication on multiple occasions when the SBP was above 120. Specific instances included SBP readings of 122, 124, and even as high as 134, yet the medication was still administered. Interviews with nursing staff indicated that the failure to hold the medication as per the physician's order was an oversight. Nurse #5, who was responsible for administering the medication on several dates, acknowledged the error upon reviewing the MARs. Similarly, Nurse #3 also recognized the oversight during their interview. Attempts to contact other nurses involved were unsuccessful. The Director of Nursing and the Medical Director both expressed that they expected the medication to be administered according to the physician's orders, although the Medical Director noted that the deviation did not result in serious harm to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the dignity of a resident by not ensuring urinals were emptied in a timely manner, particularly before meals. Resident #41, who was moderately cognitively impaired and required assistance with toileting, was observed with urinals containing urine on his nightstand on multiple occasions. Despite expressing his desire for the urinals to be emptied more frequently, especially before meals, the staff did not consistently fulfill this request. Observations revealed that the urinals remained unemptied for extended periods, even when meals were served, which the resident found unsanitary. Interviews with nursing assistants and the Director of Nursing (DON) highlighted a lack of adherence to the expected practice of emptying urinals before meals and as needed. Nursing assistants either failed to notice the urinals or did not respond to inquiries about their last emptying. The DON acknowledged the expectation for staff to ensure urinals were emptied regularly and before meals, but this was not consistently practiced, leading to the deficiency in maintaining the resident's dignity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification to residents or their responsible parties (RPs) regarding hospital transfers, as required by regulations. This deficiency was identified for four residents who were transferred to the hospital on multiple occasions without receiving the necessary written notices. The facility's practice involved sending a copy of the face sheet, physician orders, medication list, DNR information, and bed hold policy with the resident during transfers, but did not include a written notice of the transfer to the resident or RP. Resident #22, who had severely impaired cognition, was transferred to the hospital twice without written notification being provided to her RP. Similarly, Resident #58, who was cognitively intact, was transferred twice without receiving the required written notices. Resident #111, with moderately impaired cognition, experienced three hospital transfers without written notification to the RP. Lastly, Resident #132, who was cognitively intact, called 911 himself for a hospital transfer, and although his POA and hospice were notified, no written notice was provided. Interviews with staff, including Nurse #2 and the DON, revealed a lack of awareness regarding the requirement for written notifications. The DON confirmed that phone notifications were made to RPs, but written notices were not sent. The Administrator was also unaware of this oversight and expected the regulation to be followed, indicating a systemic issue in the facility's transfer notification process.