Davis Health And Wellness Center At Cambridge Vill

Findings included: Resident #13 was admitted on [DATE] with diagnosis which included chronic osteomyelitis (bone infection) and diabetes.

Review of a physician order dated 2/13/26 indicated Resident #13 was ordered doxycycline 100 milligrams (mg) by mouth twice per day indefinitely for chronic osteomyelitis.

Review of Resident #13's Medication Administration Record (MAR) for March 2026 revealed the following documentation for the medication doxycycline 100 mg twice a day. On 3/9/26 the lunch dose was documented by Nurse #6 as the medication was unavailable and the medication was not administered. On 3/9/26 PM (evening) dose was documented by Nurse #1 as the medication was unavailable and the medication was not administered.

There was no documentation in the nursing progress notes that the physician was notified of the missed medication.On 3/10/26 lunch dose was documented by Nurse #7 as the medication was unavailable and the medication was not administered.

There was no documentation in the nursing progress notes that the physician was notified of the missed medication.On 3/10/26 PM dose was documented by Nurse #1 as waiting pharmacy delivery and the medication was not administered. On 3/11/26 lunch dose was documented by Nurse #5 as the medication was unavailable, awaiting pharmacy refill and the medication was not administered. On 3/11/26 PM dose was documented by Nurse #2 as the medication was unavailable and the medication was not administered. On 3/12/26 lunch dose was documented by Nurse #7 as medication was unavailable and the medication was not administered. On 3/12/26 PM dose was documented by Nurse #2 as medication was unavailable and the medication was not administered. An interview conducted with Nurse #6 on 3/23/26 at 11:20 AM revealed that she was assigned to Resident #13 on 3/9/26 from 7:00 AM to 7:00 PM and she did not administer the prescribed antibiotic.

Nurse #6 stated that she did not call the physician to report the medication was not administered and she did not recall why she did not report this to the physician.

Attempts were made to interview Nurse #1 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received.

Attempts were made to interview Nurse #7 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received. An interview with Nurse #5 on 3/25/26 at 1:50 PM revealed that she was assigned to Resident #13 on 3/11/26 from 7:00 AM to 7:00 PM.

She stated that the doxycycline was not available for Resident #13 on 3/11/26, and she did not notify the physician that the resident did not receive the prescribed dose.

Nurse #5 stated that she did not think it was necessary to inform the physician that the resident did not receive the prescribed antibiotic. An interview was conducted with Nurse #2 on 3/25/26 at 12:15 PM.

Nurse #2 was assigned to resident #13 on 3/11/26 and 3/12/26 from 7:00 PM to 7:00 AM.

Nurse #2 stated that the medication doxycycline was unavailable for Resident #13 on 3/11/26 so she did not administer it.

Nurse #2 stated that she did not inform the physician that the antibiotic doxycycline was not administered as ordered on 3/11/26 and 3/12/26.

Nurse #2 acknowledged that she should have informed the physician of the missed doses of antibiotic, but at the time she did not realize it was necessary. An interview with the Director of Nursing (DON) on 3/25/26 at 2:30 PM revealed that she expected medications to be administered as ordered by the physician.

The DON stated she would expect nursing staff to notify the provider when a medication was not available so that an alternate medication could be prescribed, if necessary. An interview conducted with the Physician on 3/25/26 at 3:45 PM revealed that she was unaware that Resident #13 had missed 8 doses of the prescribed antibiotic.

The Physician stated that medications should be available and administered as ordered.

The Physician further stated that if a medication was not available the provider should be notified to determine if another medication should be ordered.

345568 03/26/2026

Davis Health and Wellness Center at Cambridge Vill 83 Cavalier Drive Ste 200 Wilmington, NC 28405

nurses on a full time basis.

for at least eight consecutive hours per day seven days a week for 9 of 172 days reviewed for

9/21/25).Finding included:The Payroll Based Journal (PBJ) report for the Federal Fiscal third quarter of 2025 (April, May, June) and the Federal Fiscal fourth quarter of 2025 (July, August, September) reported the facility was without RN coverage for eight consecutive hours per day.A review of the daily census posting sheets for the months of 4/12/25 to 9/30/25, indicated a consistent census less than 60 residents in the facility and no RN coverage for eight consecutive hours for the following dates: 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25. A review of the daily nursing staffing sheets for the months of 4/1/25 to 9/30/25 indicated there was no RN scheduled for at least eight consecutive hours for the following dates: 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25.

There was no RN recorded as working eight consecutive hours on the timecard records reviewed for the following dates 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25.

During an interview with the Administrator on 3/26/26 at 8:55 AM, she stated that she was responsible for ensuring that an RN was scheduled to work eight consecutive hours each day in the facility.

She acknowledged that since beginning her role last year, she had been aware of ongoing difficulties in maintaining this required RN coverage.

She explained that the facility relied on agency nurses for RN shifts, and when an agency RN failed to report for a scheduled shift, she was often unable to secure a replacement and the previous Director of Nursing was unavailable, resulting in gaps in the required eight consecutive hours of RN coverage.

The Administrator reported that she had since hired additional Registered Nurses and had a new Director of Nursing who understood the responsibility to ensure consistent RN coverage.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

345568 03/26/2026

Davis Health and Wellness Center at Cambridge Vill 83 Cavalier Drive Ste 200 Wilmington, NC 28405

instead of twice daily.

She acknowledged that she should have requested immediate delivery to

between the pharmacy and the facility.Attempts were made to interview Nurse #7 with voicemail

at 2:30 PM revealed that she expected medications to be administered as ordered by the physician.

The DON stated she would expect nursing staff to notify the pharmacy when a medication was not available in the facility so that the medication could be obtained through the local backup pharmacy.

The DON further explained that the facility utilized an automated medicationˆdispensing machine that housed an emergency supply of select medications.

She stated that once the nurses determined the medication was not in the resident's medication cabinet, they should have checked the automated dispensing machine. If the medication was not available there, the next step should have been to contact the pharmacy to obtain the medication from the local backup pharmacy.

The DON stated that she had since learned that the automated medication-dispensing machine did not contain the correct dose of doxycycline.An interview conducted with the Physician on 3/25/26 at 3:45 PM revealed that she was unaware that Resident #13 had missed 8 doses of the prescribed antibiotic.

The Physician stated that medications should be available and administered as ordered.

The Physician indicated that there was a potential for the infection that the antibiotic was ordered to treat to worsen if it was not administered for several days. An interview with the Pharmacy Manager was conducted on 3/26/26 at 12:00 PM.

The Pharmacy Manager stated that the pharmacy had systems in place to ensure medications were available daily, including twiceˆdaily deliveries and backup processes when necessary.

The Pharmacy Manager indicated that if the pharmacy was notified that the doxycycline was not available in the facility, it would have been sent to the facility through the backup system.

The Pharmacy Manager was unable to explain why the pharmacy had entered the order for doxycycline as once daily rather than twice daily. He stated that the pharmacy reconciled the orders sent to the pharmacy with what was entered by the nursing staff into the computer, after which a label was generated and the prescription was filled. He indicated that although missing eight doses of doxycycline was not expected to result in a significant clinical outcome, there was a potential risk for worsening of the infection for which the medication had been prescribed.

345568 03/26/2026

Davis Health and Wellness Center at Cambridge Vill 83 Cavalier Drive Ste 200 Wilmington, NC 28405

Findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses including pruritus (persistent itching). A physician's order dated 7/10/23 for Resident #8 revealed hydroxyzine 25 milligram tablets three times a day for pruritus.

The Consultant's Pharmacist's Medication Regimen Review dated 1/12/26 noted that the Physician signed the pharmacy consult report on 12/12/25 to change Resident #8's hydroxyzine to 25 milligrams every morning and midday and discontinue three times a day.

This order was not changed in the electronic medical record.

Please correct and report the medication error.

Review of Resident #8's Medication Administration Record (MAR) dated 12/12/25 through 1/18/26 revealed Resident #8 continued to receive hydroxyzine 25 mgs three times a day as evidenced by the nurse's signatures.

The physician's order was updated by the Director of Nursing on 1/19/26 and entered into Resident #8's electronic medical record for hydroxyzine 25 mgs twice a day morning and midday.

During an interview on 3/25/26 at 2:35 PM the Director of Nursing (DON) stated the Consultant Pharmacist emailed her the medication regimen reviews each month.

The DON stated the process now included that once she received the monthly Pharmacy reports, she would address the nursing recommendations and place the physician recommendations in the Physician's notebook for review unless there was something that needed immediate attention then she would call the Physician.

Once the Physician signed off on any medication order changes from the Pharmacy recommendations the DON would make the order change in the resident's electronic medical record.

The DON stated she was new to the facility in December 2025 and did not realize the importance of addressing the pharmacy reviews promptly and therefore there was a delay in addressing the December (2025) reports.

She stated she did not implement the new order to reduce the hydroxyzine 25 mg dose to twice a day until she was notified by the Consultant Pharmacist the following month (January 2026) that she had not changed the frequency.

The DON stated she should have acted on the Pharmacy reports once she received them.

During an interview on 3/26/26 at 11:00 AM the Clinical Compliance Administrator stated that the Consultant Pharmacist's medication regimen reviews should be addressed as soon as the DON received the monthly reports.

She indicated the DON had received education on the importance of addressing the medication regimen reviews promptly.

The Consultant Pharmacist was on leave during the survey and unavailable for an interview.

345568 03/26/2026

Davis Health and Wellness Center at Cambridge Vill 83 Cavalier Drive Ste 200 Wilmington, NC 28405

During an interview on 3/25/26 at 10:00 AM Resident #8 stated she took hydroxyzine for itching.

She indicated she did not know the dosage or how often it was given but stated the medication helped with itching. Resident #8 stated she did not feel the medication made her excessively drowsy.

During an interview on 3/25/26 at 2:35 PM the Director of Nursing (DON) stated she started working in the facility in November 2025 and was new to the role of DON.

She received the medication regimen reviews monthly that were done by the Consultant Pharmacist.

The DON stated she did not realize the importance of addressing the pharmacy reviews promptly and therefore there was a delay in addressing the December (2025) reports.

She stated she did not implement the new order to reduce the hydroxyzine 25 mg dose to twice a day until she was notified by the Consultant Pharmacist the following month (January 2026) that she had not changed the frequency.

The DON stated Resident #8 continued to receive hydroxyzine 25 mg three times a day until she corrected the order on 1/19/26.

The DON stated Resident #8 has had no change in her condition from receiving the medication.

The Consultant Pharmacist was on leave during the survey and unavailable for an interview.

During a phone interview on 3/26/26 at 12:00 PM the Pharmacy Manager stated due to the length of time Resident #8 had received the hydroxyzine 25 mgs it would have no clinical effects on the resident for continuing to receive the medication three times a day. He stated a dose reduction was indicated due to the length of time Resident #8 had been receiving the medication.

During a phone interview on 3/26/26 at 3:30 PM the Physician stated Resident #8 was a long-term care resident and had received hydroxyzine for itching for a long period.

She stated Resident #8 had not experienced any outcome and had no change in condition.

During an interview on 3/22/26 at 10:25 AM [NAME] #1 stated all kitchen staff were responsible for checking for and discarding expired foods. He stated he was the weekend cook and had not gone through the refrigerator this morning (3/22/26) to check it.

He stated he also worked yesterday (3/21/26) and the expired food items were overlooked.

During an interview on 03/24/26 at 12:42 PM the Dietary Manager stated perishable foods were to be discarded after 3 days and staff should have removed the foods from the refrigerator on the discard date. He stated the kitchen staff were aware of this.

During an interview on 03/24/26 at 12:52 PM the Administrator stated she expected the kitchen staff to check for expired foods daily and remove any foods by the discard date.

345568 03/26/2026

Davis Health and Wellness Center at Cambridge Vill 83 Cavalier Drive Ste 200 Wilmington, NC 28405