Macon Valley Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed (Resident #473). The findings included: Resident #473 was admitted to the facility on [DATE]. The resident was discharged from the facility on 08/15/2024. A physician order dated 07/18/2024 read Oxycodone HCL (controlled pain medication) oral tablet 5 milligrams (mg). Give 2 tablets by mouth every 6 hours as needed for pain. A packing slip from the pharmacy dated 08/03/24 revealed that 120 Oxycodone 5 mg tablets were delivered to the facility on [DATE] no time noted. Nurse #2 and Nurse #3 initialed the packing slip along with the courier from the pharmacy. The facility reported incident dated 08/07/2024 read in part, the Director of Nursing (DON) and Administrator were notified that a count of a resident's narcotic medication revealed a discrepancy. Facility verified that the resident still…

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 develop a baseline care plan that addressed the resident's anticoagulant (blood thinner) therapy and pain medication for 1 of 5 residents reviewed for baseline care plan (Resident #523). The findings included: Resident #523 was admitted to the facility on [DATE] with diagnoses that included a history of deep vein thrombosis (a blood clot in a deep vein), and pulmonary embolism (a serious medical condition involving a blockage in a lung artery), avascular necrosis of bilateral lower extremities (a condition where bone tissue dies due to insufficient blood supply) on chronic opiate therapy, lower quadrant pain. Resident #523's baseline care plan dated 5/31/2025 did not include goals and interventions for the use of anticoagulant therapy or the use of narcotic/pain medication. Record review revealed Resident #523 had admission orders for: Xarelto 20 milligram (mg) give one tablet by mouth one time a day for blood thinner. Oxycodone HCL 5mg tablet…

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 resident, staff, and the Medical Director (MD), the facility failed to protect residents' rights to be free from misappropriation of controlled substances for 1 of 1 resident (Resident #1) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised on September 11, 2017, revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. Resident #1 was admitted to the facility on [DATE] with diagnoses including osteoporosis and hip fractures. A review of the physician's order dated 02/10/24 revealed Resident #1 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once every 3 hours as needed for pain. The admission Minimum Data Set (MDS) dated [DATE] coded Resident #1 with an intact cognition. A review of the medication administration records…

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 resident, staff, and the Medical Director (MD), the facility failed to keep an accurate accounting of controlled medications on the controlled substance count sheets and failed to conduct controlled substance counts in the medication cart with at least 2 nurses for verification of accuracy during shift transitions. As a result, a blister card of 30 tablets of a controlled substance was missing from a medication cart during shift transition for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including osteoporosis and hip fractures. A review of the physician's order dated 02/10/24 revealed Resident #1 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once every 3 hours as needed for pain. A review of the medication administration records (MARs) revealed Resident #1 had received 1…

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, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 02/16/24 and the complaint investigation survey conducted on 04/02/24. This was for a repeat deficiency in the area of misappropriation/exploitation of resident's property that was originally cited on 02/16/24 during the recertification and complaint survey, and subsequently recited during the complaint investigation survey completed on 04/02/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F 602 - Based on record review and interviews with resident, staff, and the Medical Director (MD), the facility failed to protect residents' rights to be free from misappropriation of controlled substances for 1 of 1 resident (Resident #1) reviewed for…

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 residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 4 of 4 residents (Resident #16, #17, #35, and #116) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised on [DATE], revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. A review of the initial allegation report dated [DATE] revealed the facility became aware of the misappropriation of residents' property on [DATE] at 6:35 AM when a total of 4 tablets of oxycodone (a semi-synthetic narcotic analgesic for pain) had potentially been diverted (1 tablet each for Resident #16, #17, #35, and #116) by Nurse #1. The 5-day investigation report dated [DATE] revealed on [DATE], 4 tablets of oxycodone 5 milligrams (mg) were signed out as given by Nurse #1.…

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 staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations and cholesterol levels for 1 of 5 residents reviewed for unnecessary medications (Resident #25). Review of the lipid guidelines published in 2019 by the American College of Cardiology and American Heart Association indicated a lipid panel should be conducted at baseline for patient receiving statin (medications used to lower cholesterol) therapy, then 4 to 12 weeks after statin therapy was started or when dosage was adjusted. Afterwards, lipid panel test should be repeated once every 3 to 12 months as needed. Resident #25 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (high level of lipids/fats in the blood). Review of Resident #25's medical records revealed the most recent lipid panel was done on 12/22/22 when Resident #25 was in the hospital prior to being admitted to the facility. The…

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 resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to monitor thyroid stimulating hormone (TSH) (Resident #20) and cholesterol levels (Resident #25) for 2 of 5 residents reviewed for unnecessary medications. The findings included: 1.A review of the guidelines published in 2017 by American Thyroid Association indicated TSH level should be checked about 6-8 weeks after starting levothyroxine or having a change in the dosage. Then, it should be monitored at least once a year to ensure TSH level remained wiin the normal ranges of 0.4 to 4.0 milli-international units per milliliter ([NAME]/mL). Resident #20 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (A condition occurred when the thyroid gland could not make enough thyroid hormone to keep the body functioning normally). A review of Resident #20's lab records revealed her most recent TSH lab was completed on 02/03/23 when she was in the hospital. No…

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 observations and staff interviews the facility failed to indicate the expiration date of thawed milkshakes in 2 of 2 nourishment rooms (Spark Unit and 100 Hall). This practice had the potential to affect beverage items served to residents. Findings included: 1. An observation of the Spark Unit nourishment room refrigerator on [DATE] at 3:43 PM revealed 8 thawed milkshakes sitting on a shelf. The manufacturer's instructions stamped on each carton of milkshake indicated the product was good for 14 days after being thawed. The milkshakes did not have a date indicating when they were placed in the refrigerator or when they expired. An interview with the Dietary Manager on [DATE] at 9:02 AM revealed dietary staff dated the milkshakes when they removed them from the walk-in freezer in the kitchen, and they were good for 14 days after being removed from the freezer. She explained the milkshakes were then placed in the nourishment room refrigerators by dietary staff. The Dietary Manager confirmed the milkshakes…

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 interview the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with mental health disorders and received a change in treatment (Resident #37) for 1 of 2 residents reviewed for PASRR. The findings included: Record review of the North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 05/08/21 revealed Resident #37 had a Level I PASRR effective 05/08/21. There were no requests for a Level II PASRR evaluation submitted or completed since 05/08/21. Resident #37 was admitted to the facility on [DATE] with diagnosis that included vascular dementia severe with mood disturbance, bipolar disorder, delusional disorders, psychological and behavioral factors associated with disorders or diseases classified elsewhere. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had not been evaluated by Level II PASRR…

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 observations, record review, interviews with the Responsible Party and staff the facility failed to assess the risk of entrapment after the placement of an alternating pressure air mattress for a cognitively impaired resident dependent on staff for bed mobility (Resident #27) and failed to complete the bed rail assessment and obtain informed consent from the Responsible Party (Resident #28) for 2 of 3 residents reviewed for bed rails. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia and chronic obstructive pulmonary disease. A physician's order with a start date of 03/28/22 with directions to validate the settings of the alternating pressure air mattress. Review of the alternating pressure air mattress operation manual for the type used on the bed of Resident #27 revealed no warnings or contraindications for use with bed rails. The care plan focus area for bed rails revised on 09/05/23 indicated Resident #27 required the use of bilateral bed…

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, observations, and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 1 medication given without a Physician's order and failure to administer 1 medication according to the Physician's order. These errors constituted 2 out of 26 opportunities, resulting in a medication error rate of 7.69% for 2 of 8 residents observed during medication administration pass (Resident #7 and Resident #28). The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. An observation was made on 6/15/2022 at 8:50 AM of Nurse #1 while she prepared and administered Resident #7's medications. Nurse #1 did look at the Medication Administration Record (MAR) while she prepared the medications which included Polyethylene Glycol powder 17 grams (medication used to relieve symptoms of constipation) that she pulled from the house stock and mixed in water. Nurse #1 administered the medications which…

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.