Eckerd Living Center

bed-hold policies.

record review and staff interviews, the facility failed to complete a discharge summary that included

#47).

Findings included:Resident #47 was admitted to the facility on [DATE].The 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition and active discharge planning was in place.The discharge-return not anticipated MDS assessment dated [DATE] revealed Resident #47 discharged to the community.Review of Resident #47's electronic medical record on 04/10/26 revealed an undated, Transfer/Discharge Report containing the resident's demographic and clinical information including date of birth , date of admission to the facility, age, insurance details, allergies, primary contact information, primary physician information, medical diagnoses, most recent vital signs, and immunization history. It was noted under the section for current medications to refer to the medication administration record.

The following sections of the report were left blank:*Advanced directive*Diet type/texture/fluid consistency*Resident-specific information related to behavior(s), ambulation, bladder/bowel status, feeding, and usual level of functioning.*Signature and date indicating the resident or representative received a copy of the Transfer/Discharge Report.

During an interview on 04/10/26 at 11:14 PM, the Social Worker (SW) revealed she was responsible for long-term resident discharges and the Discharge Planner/Case Manger handled short-term resident discharges.

The SW explained that the discharge process included arranging post-discharge needs, such as follow-up appointments, home health or equipment, and providing the resident or their representative with a satisfaction survey and list of the resident's medications with administration times.

She also documented a progress note in the resident's medical record outlining the discharge arrangements.

The SW stated if a follow-up appointment was arranged prior to the resident's discharge, the resident's medical records were faxed to the provider that included provider notes, therapy notes, and list of medications.

The SW indicated she was not aware that a discharge summary that included a recapitulation of the resident's course of treatment while residing in the facility was also required.The Discharge Planner/Case Manager responsible for short-term resident discharges was unavailable for an interview.

During an interview on 04/10/26 at 3:15 PM, the Administrator acknowledged that although the Transfer/Discharge Report they utilized contained some of the required discharge summary components, it did not summarize the resident's course of treatment while at the facility.

The Administrator stated a discharge summary that included a recapitulation of Resident 47's stay with input from all disciplines should have been completed per the regulatory guidelines.

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Eckerd Living Center 250 Hospital Drive Highlands, NC 28741

Review of Mental Health Psychiatric Nurse Practitioner (NP) medication management progress note dated 05/12/24 revealed Resident #3 was evaluated to have an active bipolar disorder diagnosis.Review of a Mental Health NP medication management progress note dated 03/17/26 revealed Resident #3 was evaluated for an active psychiatric diagnosis of bipolar disorder and recommended to continue the current treatment that included aripiprazole (antipsychotic) 7.5 milligrams (mg) at bedtime and bupropion (antidepressant) 300 mg extended release 24 hours.Review of the annual MDS assessment dated [DATE] revealed Resident #3 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.

The MDS revealed Resident #3 was taking antipsychotic medications on a routine basis only and an antidepressant medication.Resident #3's comprehensive care plan revised on 04/06/26 included the use of psychotropic medications related to a bipolar disorder diagnosis with the goal to be free from psychotropic drug related complications through the review date.

Interventions included to monitor, document, and report any adverse reactions of psychotropic medications.

During an interview on 04/08/26 at 4:40 PM, the Social Worker (SW) revealed she had been in her position for five years and was responsible for ensuring newly admitted residents had a PASRR prior to their admission.

She was aware Resident #3 had an active bipolar disorder diagnosis and was referred to psychiatric services.

She explained no request for a Level II PASRR evaluation was made when Resident #3 was admitted on [DATE] because the resident did not demonstrate behaviors.

She stated it was her understanding when a resident demonstrated behaviors, she needed to request an evaluation for Level II PASRR.

The SW revealed she was not aware an evaluation for a Level II PASRR was needed when a resident was admitted with a mental health diagnosis and had a Level I PASRR.

The SW confirmed on 02/28/24 she checked the North Carolina PASRR website prior to Resident #3's admission to ensure the resident had a PASRR but after 02/28/24 no request for a Level II PASRR evaluation had been made.

During an interview on 04/10/26 at 3:12 PM, the Administrator confirmed no request was made for a Level II PASRR evaluation when Resident #3 was admitted on [DATE] with a mental health diagnosis.

The Administrator stated going forward mental health diagnoses would be reviewed for newly admitted residents and if present a request would be made for a Level II PASRR evaluation.

345437 04/10/2026

Eckerd Living Center 250 Hospital Drive Highlands, NC 28741

During an interview on 04/10/26 at 11:33 AM, the Nurse Team Lead revealed she was responsible for keeping track of when physician regulatory visits were due.

The Nurse Team Lead explained she ran a report from the computer system that listed the date residents were last seen by a provider (NP, PA or Physician,) manually marked the provider who conducted the visit on the report and then let the provider know what residents needed to be seen the next time the provider was at the facility.

She stated once the resident was seen by the provider, she entered the date in the computer system.

The Nurse Team Lead explained that typically the physician saw a resident for the initial admission visit; however, when the physician was at the facility on 02/25/26, Resident #2 did not show up on the list to be seen because the NP and PA had already seen him.

She confirmed Resident #2 had not yet been seen by the physician and acknowledged it was an oversight.

During an interview on 04/10/26 at 3:15 PM, the Administrator revealed the Nurse Team Lead was responsible for tracking when physician visits were due.

The Administrator confirmed that although Resident #2 had been seen by both the NP and PA, he had not yet been seen by the physician.

She explained the Nurse Team Lead was typically very good with keeping track of physician visits that were due but since Resident #2 was seen by both the NP and PA shortly after his admission, he did not appear on the physician-visit list and was inadvertently overlooked.