Inspection Reports for Yancey House

The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents, with documentation inaccuracies and missing medications. Additionally, the facility failed to maintain accurate electronic medication administration records for 2 residents and did not complete Special Care Unit resident profiles on a quarterly basis for 2 residents.

The facility failed to ensure the electronic medication administration record (eMAR) was accurate for one of five sampled residents (Resident #3) regarding a cream to treat a yeast infection. The medication was applied but not documented in the eMAR system, and the facility lacked a system to ensure medication orders were properly entered and authorized in the eMAR.

The complaint investigation was initiated by the Yancey County Department of Social Services on 02/01/23 and included a follow-up survey conducted on 02/07/23 through 02/08/23.

The facility failed to administer medications as ordered for multiple residents, including missed doses and incorrect dosages of antipsychotic medication, medication for joint inflammation, dementia treatment, and a vitamin/mineral supplement. These failures placed residents at risk for increased anxiety, aggression, withdrawal symptoms, joint discomfort, increased pain, confusion, and hindered bone healing.

The facility failed to obtain a Health Care Personnel Registry check for one staff member prior to employment and failed to ensure referral and follow-up for a resident related to antibiotic therapy for pneumonia. Additionally, the facility failed to administer medications as ordered for two residents, including antibiotics and wound care medication, placing residents at risk of worsening conditions.

The facility failed to respond immediately and in accordance with policy for a resident who had an unwitnessed fall and was moved before EMS arrival, failed to ensure medications were not transferred to non-pharmacy containers risking contamination, failed to administer medications as ordered including pulse checks prior to administration, and failed to ensure two-person witness and documentation of destruction of used fentanyl patches.

The facility failed to ensure that care plan assessors signed the care plans upon completion for 5 sampled residents. Additionally, the facility failed to ensure timely contact with a resident's physician regarding a delayed medication order and failed to administer medication as ordered for one resident. There were also issues with proper documentation of medication administration.

The facility failed to administer medications as ordered for 5 of 6 sampled residents, including antibiotic eye drops and quetiapine for Resident #2, vitamin B12 and Zanaflex for Resident #3, amlodipine for Resident #4, and Lasix for Residents #5 and #7. This failure increased the risk of adverse health outcomes such as continued infection, vitamin deficiency, high blood pressure, dehydration, and low blood pressure.

The facility failed to correct several deficiencies including non-working lighted exit signs near room 101 and the Special Care nursing station, lack of handrails in the rear service corridor, and a non-functioning exhaust ventilation system in bedroom 409 bathroom.

Multiple deficiencies were cited including failure to meet building code requirements for exits and exit signage, unresolved deficiencies in the annual fire sprinkler inspection, corridors obstructed by equipment, lack of wanderer alarms on exit doors, housekeeping and furnishings not maintained, electrical outlets in wet locations lacking ground fault interrupters, building equipment and fire safety systems not maintained in safe operating condition, fire doors not latching properly, firestopping gaps in electrical rooms, use of prohibited portable electric heaters, and failure of exhaust ventilation in a bathroom.

The facility was found deficient in multiple areas including failure to ensure tuberculosis testing compliance for staff and residents, incomplete staff job descriptions, lack of competency validation for staff performing licensed health professional support tasks, inadequate table service lacking knives for residents, and medication administration errors involving incorrect dosing and missing medications.

The deficiency regarding corridor doors not closing quickly and latching properly was not corrected. Specifically, one side of the smoke barrier doors near room 307 would not latch when closed, posing a fire safety risk.

Several deficiencies remained uncorrected, including lack of handrails in the rear service corridor, incomplete fire safety rehearsal records, corridor doors not closing or latching properly, inadequate exit signage, sprinkler escutcheon not properly fitted, and non-functioning exhaust ventilation in certain bathrooms.

Multiple deficiencies were identified related to physical plant and safety, including lack of handrails in corridors, housekeeping hazards, fire safety rehearsal documentation issues, malfunctioning corridor doors and emergency lighting, missing panic bar hardware, sprinkler escutcheon not properly fitted, and non-working exhaust ventilation in bathrooms.

The facility failed to ensure staff tuberculosis testing compliance, did not provide physician-ordered therapeutic diets properly, and failed to respond reasonably to residents' food requests. Issues included incomplete TB skin testing for staff, serving unchopped meat contrary to orders, and multiple resident complaints about food quality, variety, and preparation.

The facility failed to have a designated qualified activity director and did not provide the required 14 hours of planned group activities per week. The facility also failed to assure tuberculosis testing for all staff, document food substitutions, provide adequate staffing on the Special Care Unit, maintain resident rights regarding respectful treatment, and provide reasonable dietary accommodations for diabetic residents.