NC State Veterans Home - Black Mountain

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for residents with serious mental health disorders for 4 of 6 residents reviewed for PASRR (Resident #48, Resident #71, Resident #7, and Resident #73).Findings included: 1. A PASRR Determination Notification letter dated 04/14/22 revealed Resident #48 had a Level I PASRR with no expiration date. Resident #48 was admitted to the facility on [DATE] with diagnoses that included vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #48's list of cumulative diagnoses revealed active diagnoses of Post Traumatic Stress Disorder (PTSD), major depressive disorder, delusional disorder, restlessness and agitation. A care plan last revised on 11/12/25 revealed Resident #48 was at risk for PTSD related his to Navy service during the Vietnam war and active diagnoses of PTSD,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and staff interviews, the facility failed to implement their infection control policy and procedures when a Nurse Aide (NA) did not follow droplet-contact isolation precautions before entering Resident #14's room who had tested positive for influenza. This occurred for 1 of 3 staff members reviewed for infection control (NA #1). Findings included: The facility's Infection Control Policy and Procedure Measures for Influenza (Flu) last revised on 02/26/25 read in part, Residents will be placed on droplet-contact precautions for 7 days and can be taken off on day 8 if symptoms are improved and afebrile (no fever) for the last 24 hours of isolation period. A review of the test results dated 11/24/25 revealed Resident #14 was positive for influenza A. An observation of meal tray service was conducted on 12/01/25 at 12:44 PM. A droplet-contact precaution sign was posted on the door of Resident #14's room with directions to follow the instructions before entering the room. The instructions included everyone must clean hands before entering and when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, the facility failed to ensure staff implemented their abuse policy and procedure in the area of reporting when nursing staff did not immediately inform the Administrator that a Nurse Aide had reported an alleged use of a physical restraint for a resident with no medical symptoms. This failure resulted in a delay in the facility investigating the allegation and reporting the allegation to the State Agency for 1 of 3 residents reviewed for restraints (Resident #1). Findings included: The facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property last reviewed on 01/11/24 revealed in part, the facility would actively preserve each resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property and assure that staff was provided information on how and to who they reported concerns. The facility would also assure residents were free from physical or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 6 of 7 months reviewed (August 2023, January 2024, March 2024, April 2024, May 2024, and June 2024). Findings included: Review of the Resident Council Minutes for the period 08/17/23 through 08/15/24 revealed the following: a. A Resident Council Response Form attached to the 08/17/23 Resident Council meeting minutes noted residents voiced they did not have faith that anything they asked for would be done and no changes would be made. The resolution noted that the Administrator was working to reassure residents that they have been heard and explain that changes take time. The section at the bottom of the form indicating the date the resolution was reported back to the Resident Council and by whom was left blank. b. The Resident Council meeting minutes dated 01/11/24 noted a concern was voiced regarding the garbage truck driver and staff were driving too fast…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record reviews, the facility failed to secure zinc oxide ointment for 1 of 1 Resident (Resident #6) review for medication storage, failed to remove expired over-the-counter (OTC) medications from the medication cart in accordance with the manufacturer's expiration date, and failed to discard an eye drops from the medication carts as specified by the manufacturer's guidelines for 2 of 3 medication carts (B halls and D halls). The findings included: a. Resident #6 was admitted to the facility on [DATE] with diagnoses including dermatitis. A review of Resident #6's medication records revealed he had never been assessed nor approved for self-administration of medication. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #6 with an intact cognition The physician's orders dated 08/21/24 revealed Resident #6 had an order to receive a thin film of zinc oxide ointment 20% topically to both sides of groin and scrotum twice daily for diaper rashes. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to discard potentially hazardous food with signs of spoilage in 1 of 1 walk-in refrigerators and discard expired food items available for resident use in 1 of 1 walk-in freezers. This practice had the potential to affect food served to residents. Findings included: a. An observation of the walk-in refrigerator on 08/26/24 at 08:58 AM revealed the following: • A box containing 2 unopened bags of green leaf lettuce with browning leaves and brown liquid present inside of the bag with a received by the facility date of 7/29/24. • A box of celery with a white fuzzy substance on the celery with no visible date was present. b. An observation of the walk-in freezer on 08/26/24 at 09:09 AM revealed the following: • An open box of cinnamon rolls with an expiration date of 12/29/22. An interview with the Dietary Manager on 08/26/24 at 09:10 AM revealed that a dietary staff member stocked and checked the walk-in refrigerator and walk-in freezer weekly for expiration dates and spoiled food. He stated that the expired and spoiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) prior to discharge from Medicare Part A skilled services to 2 of 3 residents reviewed for beneficiary notification review (Residents #12 and #70). The Findings Included: 1. Resident #12 was admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #12's Responsible Party (RP) on 04/02/24 which indicated Resident #12's Medicare Part A coverage for skilled services would end on 04/04/24. Resident #12 remained in the facility. Review of Resident #12's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #12 or Resident #12's RP. During an interview on 08/28/24 at 9:28 AM, the Business Office Manager revealed when a resident's Medicare Part A services were ending, the Minimum Data Set (MDS) Coordinators forwarded her the NOMNC to review with the resident or their RP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect a resident's right to privacy when Nurse Aide #1 used her cellphone to take an unauthorized video of a resident displaying behaviors and sent the video to Nurse #4 via a cellphone messenger application for 1 of 3 sampled residents (Resident #324). A reasonable person would have experienced embarrassment. Findings included: Resident #324 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia with other behavioral disturbance. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #324 had severe cognitive impairment. Review of a Facility Reported Incident (FRI) dated 12/28/23 revealed the facility was made aware on 12/28/23 (no time listed) that Nurse Aide #1 had used her cellphone to take a video of Resident #324 displaying inappropriate behaviors with a Santa Claus mannequin (Christmas decoration). Review of the facility's investigation file revealed an undated typed summary of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Wound Care Nurse Practitioner (NP) and staff the facility failed to obtain an x-ray as ordered by the Wound Care NP to rule out a possible fracture and osteomyelitis (an infection of the bone) for 1 of 2 residents reviewed for non-pressure skin conditions (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE]. His diagnoses included peripheral vascular disease, cellulitis (a bacterial skin infection) of the right toe, and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #7 cognition was severely impaired with no rejection of care behaviors. Review of the nurse's progress note dated 08/18/24 revealed it was communicated to the provider Resident #7s right foot appeared with increased tenderness when touched during dressings changes and care. Review of the Nurse Practitioner (NP) progress note dated 08/19/24 revealed Resident #7 was evaluated for right foot tenderness with increased redness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to remove expired medications from 2 of 4 medication carts (B hall and D hall) and 1 of 4 medication rooms (D hall). The findings included: 1.a. An observation on 5/12/23 at 10:15 AM with Nurse #2 of the B hall medication cart revealed a medication card of Acetaminophen 325 milligram tablets that had a total of 8 pills left marked with a discard date of 4/11/23 from the pharmacy and no manufacturer expiration date. Acetaminophen is used to treat pain and to reduce fever. The expired Acetaminophen card was left available for use in the B hall medication cart. An interview with Nurse #2 on 5/12/23 at 10:18 AM indicated that the nurses should check medication dates before administration and the medication carts once a week. Nurse #2 stated that the pharmacy checked medication carts once a month. She further stated that the night shift nurses were responsible for stocking and reordering the medications for the cart. She stated that the resident no longer used the Acetaminophen, and that it was overlooked. An interview with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to remove expired and spoiled food items available for use in 1 of 1 walk-in cooler and 1 of 1 reach-in cooler; remove expired food from 1 of 1 dry storage room; and failed to ensure a pipe in 1 of 1 walk-in freezer was free from leaks. This practice had the potential to affect food served to residents. The findings included: 1. An initial observation of the walk-in cooler on 05/08/23 at 10:37 AM revealed the following: a. An opened box containing 6 cantaloupes with white and brown spots. The date received on the box of cantaloupes was 04/24/23. b. An opened box of green peppers that contained multiple black spots. The date received on the box of green peppers was 04/24/23. c. A 5-pound bag of carrots with yellow discoloration. There was no received-on or best by date on the bag of carrots. d. An opened box of celery with brown discoloration. There was no received-on or best by date on the box of celery. e. 2 boxes of tomatoes with black and white spots. There was no received-on or best by date on the boxes of tomatoes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.