Mount Olive Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and did not provide documentation. During an interview with the Director of Nursing (DON) on 9/15/25 at 4:48 PM she reported Resident #13 could not swallow liquids or food. She reported she was aware that the resident would go through the trash, ask other residents for drinks and would disconnect her tube feeding at times. The DON was also aware Resident #13 would chew food items and spit them out. She reported

the resident had been educated about the dangers of these behaviors by the staff members when they made the observation. The DON indicated that the resident had not been assessed for self-administration of her tube feeding. The DON stated she was not aware the Activities Director was giving food for bingo prizes to Resident #13. The DON acknowledged the dangers of all these behaviors and stated staff members would redirect Resident #13 when they observed the behaviors. An interview was conducted with

the facility Nurse Practitioner (NP) on 9/17/25 at 12:25 PM. She reported it was dangerous for Resident #13 to self-administer her tube feedings. She stated Resident #13 had low blood sugars in the past from not receiving her tube feedings because she disconnected herself from the pump. NP further stated she was aware of Resident #13 self-administering her tube feeding and putting sports drink in her g-tube. She further stated she had seen Resident #13 in the trash and had witnessed her steal items such as gauze, gloves and briefs from the nurse's cart and she convinced Resident #13 to return the items. The NP stated

the Registered Dietician needs to be aware of a deviation in the amount of tube feeding solution Resident #13 received in order to adjust tube feeding to ensure Resident #13 receives an adequate number of calories. She stated she was not aware the Registered Dietitian had not been informed about Resident #13 disconnecting her tube feedings and she had not discussed this with the physician. The NP stated that Resident #13 was going to do what she was going to do and that she did not have time to call the physician every time Resident #13 had behaviors. She stated she had talked with Resident #13 about the dangers of not getting her full amount of tube feeding but Resident #13 voiced compliance but then would continue the behaviors.During an interview with the Medical Director on 9/18/25 at 11:10 AM he stated Resident #13 self-administering her tube feedings put Resident #13 at risk of serious injury/harm from aspiration, overfeeding, and infection. He stated he was not made aware of this behavior or the behaviors such as digging in the trash and chewing/spitting out food. and had he been made aware he would have recommended 100% supervision during Resident #13's tube feedings.The Administrator was notified of Immediate[TRUNCATE

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Olive Center

228 Smith Chapel Road Mount Olive, NC 28365

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

medication if systolic blood pressure was less than 150 and started Resident #113 on Midodrine HCL 5mg

a day for the orthostatic hypotension. She explained she had not seen Resident #113's July 2025, August 2025 or September 2025 Medication Administration Records that indicated the blood pressure medication was given when a blood pressure was recorded less than 150. She explained Midodrine HCL was medication that Resident #113 received daily to elevate Resident #113's blood pressure and therefore, when Coreg was administered when Resident #113's systolic blood pressure was less than 150mmHg, Resident #113's blood pressure was able to remain in the normal range for blood pressures.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Olive Center

228 Smith Chapel Road Mount Olive, NC 28365

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

A review of Resident #39's September 2025 Medication Administration Record (MAR) recorded Resident #39 received 3 liters of oxygen via nasal cannula on 9/15/25 and recorded oxygen saturation was 97 percent (%) documented by Medication Aide #1

Observation on 9/15/25 at 8:44 am Resident #39 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 4 liters per minute.

During an interview with Medication Aide #1 on 9/15/25 at 1:15 pm, she stated she was the medication aide for Resident #39 on day shift (7:00 am until 3:00 pm) for 9/15/25. Medication Aide #1 further stated the oxygen concentrator read 4 liters per minute and she documented at 4 liters per minute.

During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift for accurate documentation.

1. 3. Resident #91 was admitted to the facility on [DATE REDACTED] with diagnoses which included chronic obstructive

pulmonary disease (COPD), altered mental status, chronic systolic heart failure, and wheezing.

Resident #91's Physician order dated 7/5/24 for oxygen at 2 liters per minute via nasal cannula for hypoxia.

A review of Resident #91's September 2025 Medication Administration Record (MAR) recorded Resident #91 received 2 liters of oxygen via nasal cannula each shift on 9/14/25 and recorded oxygen saturations of 97 percent (%) documented by Nurse #2.

Observations on 9/14/25 at 9:22 am and 9/14/25 at 1:45 pm revealed Resident #91 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 6 liters per minute.

In a phone interview with Nurse #2 on 9/17/25 at 4:15 pm, she stated she was the nurse for Resident #91

during the night shift (7:00 pm to 7:00 am). Nurse #2 further stated she documented Resident #91 was on 2 liters per minute in the MAR.

During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift for accurate documentation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet