Universal Health Care/north Raleigh

F-F686: During the complaint survey of 8/6/2024 the facility failed to 1) ensure orders were entered into the electronic medical record upon admission and after treatment order changes were made by a weekly visiting Wound Physician in order that nurses would know and provide the correct treatment on correct days 2) clarify which Wound Physician was to be overseeing the care of a resident's pressure sores when the facility became aware the resident had an appointment with an outside wound clinic who provided orders and while

the resident was simultaneously being followed in house by the facility's Wound Physician who was giving orders 3) provide an air mattress per order 4) follow up on the Registered Dietician's recommendations for nutritional support to heal his pressure sores. This was for one of three sampled residents with pressure sores.

During the complaint survey of 6/6/2024 the facility failed to have a system in place to accurately evaluate

the extent nutrition was contributing to the development and non-healing of the wounds and develop a plan to address any nutritional deficit for one of three sampled residents reviewed for pressure sores.

F-F692. The Administrator also confirmed the ADON was trusted to monitor the resident Medication Administration records (MARs) and Treatment Administration records (TARs) so the information could be accurately presented to the Interdisciplinary team at the QAPI meeting. The Administrator revealed she really did think the monitoring of the records was being completed despite a lack of any evidence of any monitoring of the records for accuracy or completeness. The Administrator indicated she really did think the communication in the QAPI meetings indicated the facility plan of correction was working and was being monitored.

An interview was conducted with the ADON on 8/2/2024 at 12:15 PM. The ADON was unable to explain why sampled residents for the current survey were not a part of the facility QAPI monitoring process for residents with pressure sores and residents requiring nutritional interventions. The ADON stated she thought the monitoring process for QAPI was complete. The ADON was also unable to provide any evidence the facility had QAPI monitoring tools of the resident MARs and TARs for accuracy and completeness of the record.

The ADON stated she was aware in the 7/30/2024 QAPI meeting with the interdisciplinary team that the MARs and TARs had a lot of blanks. The ADON stated the QAPI team decided to implement further measures of education, disciplinary action, intercom announcements, and signs posted throughout the building to try to improve the consistency of documentation by the nursing staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 345529

F-F842: During the complaint survey of 8/6/2024 the facility failed to ensure the medical records were accurate and complete regarding administration of medication and treatments. This was for four of six sampled residents whose medical records were reviewed for documentation related to medications and treatments being documented correctly in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 345529 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345529 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Universal Health Care/North Raleigh 5201 Clarks Fork Drive NW Raleigh, NC 27616

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 0867 During the complaint survey of 6/6/2024 the facility failed to ensure the medical record was complete and accurate regarding administration of treatments, administration of medications, administration of enteral Level of Harm - Minimal harm or feedings, and weights for one of one sampled resident reviewed for accuracy of medical records. potential for actual harm

An interview was conducted with the facility Administrator on 8/2/2024 at 10:55 AM. The Administrator stated Residents Affected - Some she had trusted the Assistant Director of Nursing (ADON) to work with the Registered Dietitian to make sure

the facility was compliant with monitoring weights and nutritional requirements for the residents with pressure sores and/or at nutritional risk. The Administrator confirmed the facility had QAPI meetings on 6/25/2024 and 7/30/2024 during which the ADON was trusted to monitor and present actual information regarding residents with pressure sores and residents at nutritional risk to make sure the facility was compliant with citations