NC DHSR ACLS: Statement of Deficiency

Home , Bed bug

PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

C 000 Initial Comments C 000

The Adult Care Licensure Section conducted an initial survey on site on January 14, 2021 and January 19, 2021 with a desk review on January 15, 2021, January 20, 2021 and January 21, 2021 and an exit via telephone on January 22, 2021.

C 022 10A NCAC 13G .0302 (b) Design And C 022 Construction

10A NCAC 13G .0302 Design And Construction

(b) Each home shall be planned, constructed, equipped and maintained to provide the services offered in the home.

This Rule is not met as evidenced by: TYPE B VIOLATION

Based on observations, record reviews and interviews, the facility failed to ensure the residents' evacuation capabilities were in accordance with the evacuation capability listed on the facility's license for 1 of 1 sampled resident (#2) residing in the facility with cognitive impairments which could prevent the resident from evacuating the facility independently.

The findings are:

Review of the facility's license effective September 14, 2020 revealed the facility was licensed for a capacity of six ambulatory residents.

Review of the facility's census revealed there Division of Health Service Regulation LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 8UQN11 If continuation sheet 1 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 022 Continued From page 1 C 022 were six residents.

Review of Resident #2's current FL-2 dated 07/19/19 revealed diagnoses included vascular dementia, heart failure, and glaucoma.

On 01/15/21, the survey team requested and did not receive a complete Resident Register for Resident #2. Page 1 of the Resident Register (which documented the date of admission) was not provided.

Review of Resident #2's care plan dated 12/16/20 revealed: -Resident #2 needed limited assistance with ambulation/locomotion, dressing, grooming/personal hygiene, toileting, and transferring, and extensive assistance with dressing. -Resident #2 displayed disruptive behavior. -Resident #2 was sometimes disoriented and needed reminders. -Resident #2's hearing was very limited and she used a hearing aid. -Resident #2 had limited range of motion and strength in her upper extremities. -Resident #2 used a walker and had no problems with ambulation/locomotion.

Review of the facility's fire drill logs revealed: -Fire drills were conducted monthly from 01/2020-08/2020 between the hours of 1:00pm and 4:30pm. -The length of time for the fire drills was from one minute forty-five seconds to three minutes. -The last documented fire drill was on 08/22/20.

Observation of Resident #2 on 01/14/21 at 12:38pm revealed the medication aide (MA) guided Resident #2 to the dining room by placing Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 2 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 022 Continued From page 2 C 022 one hand on the resident's walker and one hand on the resident's back.

Observation on 01/14/21 at 3:18pm revealed: -The MA was getting ready to serve snacks in the dining room. -Resident #2 was seated in the living room. -The MA moved Resident #2's rollator into the dining room and left Resident #2 seated in the living room. -Resident #2 began to move her hands around, searching for her rollator. -The MA was alerted to this behavior and told Resident #2 to wait. -The MA left Resident #2's rollator in the dining room and assisted Resident #2 with walking into the dining room and sitting on a chair.

Observation on 01/19/21 at 9:26am revealed the MA assisted Resident #2 onto a chair in the living room.

Observation on 01/19/21 from 12:10pm-12:32pm revealed: -The MA assisted Resident #2 from a chair in the living room, placed her hands on Resident #2 and the rollator, and assisted Resident #2 to a chair in the dining room. -Resident #2 picked up her fork, leaned over in the chair, and began to shake and sway the fork above the floor. -Resident #2 reached for her milk glass and caused it to almost tumble; she did not drink the milk. -Resident #2 twice reached for food on another resident's plate and was redirected by the MA.

Interview with the MA on 01/14/21 at 2:57pm revealed: -Resident #2 was alert and oriented most days. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 3 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 022 Continued From page 3 C 022 -She walked beside Resident #2 while Resident #2 used her rollator. -She helped Resident #2 to stand up. -Some days, about once a week, she had to give Resident #2 verbal cues.

Interview with a resident on 01/19/21 at 10:35am revealed: -The residents were expected to stand up and go outside during the fire drill. -Resident #2 sometimes needed to be told to get up and go outside during the fire drill. -Resident #2's ability to get up on her own had changed in the last 3-4 months. -Resident #2 needed help to stand up.

Interview with the MA on 01/19/21 at 11:02am revealed: -The last fire drill was conducted two months ago. -All of the residents were seated in the living room before the MA activated the fire alarm. -The residents were expected to meet on the front porch. -Resident #2 responded to the fire drill independently and was able to get herself onto the front porch.

Telephone interview with Resident #2's family member on 01/21/21 at 9:34am revealed: -As Resident #2's dementia increased, her mobility decreased. -Resident #2's physician informed her two years ago that Resident #2's vascular dementia was "severe." -It was over a year since she last spoke with Resident #2's physician. -Resident #2 was "getting fragile." -Resident #2 was able to follow directions at the previous facility in which she resided. -She believed Resident #2 would probably grab Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 4 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 022 Continued From page 4 C 022 her rollator and head toward the door during a fire drill. -She thought something "down inside" Resident #2 would prompt her to try to find people and go out with the group during a fire or a fire drill.

Second telephone interview with Resident #2's family member on 01/21/21 at 11:51am revealed: -Staff walked beside Resident #2 sometimes. -Resident #2 used her rollator and walked to the front door independently two weeks ago when her family member visited.

Telephone interview with the Administrator on 01/21/21 at 12:15pm revealed: -She was aware what the term ambulatory meant related to the facility license. -All of the residents were expected to evacuate the facility, walk down the ramp, and meet at the sister facility two houses away during a fire drill. -Residents who used assistive devices were expected to evacuate by themselves through the nearest exit. -She did not remember the last time she conducted a fire drill with Resident #2. -In December 2020, she conducted a practice drill with Resident #2 and announced, "It's a fire drill." -Resident #2 was able to independently use her rollator and would know to get up and evacuate if no one gave a prompt. -Staff was not supposed to direct residents or assist with ambulation during fire drills.

Telephone with Resident #2' primary care provider (PCP) on 01/21/21 at 2:19pm revealed: -During an emergency, if staff were to go to Resident #2 first and let her know she had to evacuate the facility, Resident #2 would be able to evacuate. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 5 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 022 Continued From page 5 C 022 -Resident #2 had always been in a chair whenever the PCP visited the facility. -She had never seen Resident #2 ambulate.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:38am revealed: -He did not provide verbal instruction or physical assistance to any of the residents during fire drills. -He had conducted fire drills when the residents were in other locations in the facility besides the living room. -Resident #2 was able to get up and go outside like all the other residents. -Resident #2's rollator was supposed to be available to her at all times.

Based on observations, interviews and record reviews, it was determined Resident #2 was not interviewable. ______The facility failed to ensure a resident (#2) with vascular dementia was able to evacuate the facility in an emergency without physicial or verbal prompting by staff. This failure was detrimental to the health and safety of the resident and constitutes a Type B violation. ______The facility provided a plan of protection in accordance with G.S. 131D-34 on 01/21/21 for this violation.

CORRECTION DATE FOR THE TYPE B VIOLATION SHALL NOT EXCEED MARCH 8, 2021.

C 074 10A NCAC 13G .0315(a)(1) Housekeeping and C 074 Furnishings

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 6 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 074 Continued From page 6 C 074 10A NCAC 13G .0315 Housekeeping And Furnishings (a) Each family care home shall: (1) have walls, ceilings, and floors or floor coverings kept clean and in good repair; This Rule shall apply to new and existing homes.

This Rule is not met as evidenced by: Based on observations and interviews, the facility failed to ensure the wall in the dining room and a ceiling vent in the hallway, a floor strip at a threshold in the hallway, broken mini blinds, windowsills in resident bedrooms, the cabinets and the wall in one of the resident bathrooms were kept clean and in good repair.

The findings are:

Observations on 01/14/21 at 9:16am and 10:43am revealed: -There was bubbling and peeling paint on the wall above the toilets in both bathrooms. -There was a bathroom cabinet door consisting of only a frame; there was no material covering the door in one of the residents' bathrooms. -There was a large amount of dust on the windowsill in a resident's room.

Observation of resident room #2 on 01/14/21 at 9:42am revealed the mini blinds on the windows had broken or missing slats.

Observation of the dining room on 01/14/21 at 2:26am revealed: -There were thick clumps of dust on the wall. -There was a thick layer of dust on the top edge Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 7 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 074 Continued From page 7 C 074 of a picture frame hanging on the wall. -There was a thick layer of dust on the top edge of the door frame of the door leading out of the dining room and into the kitchen.

Observation on 01/19/21 at 12:11pm revealed there was a large amount of dust on the intake vent in the hallway ceiling.

Observation of the hallway outside the medication room on 01/19/21 at 10:39am revealed: -There was a metal strip across the floor at the threshold of the main hallway and the short hallway in front of the medication storage room that lead to the laundry room. -The end of the metal strip was not secured to the floor and had about five inches that had begun to curl upwards creating a trip hazard.

Interview with the medication aide (MA) on 01/14/21 at 2:28pm revealed: -She would clean items that needed to be cleaned as she saw they needed cleaning; she cleaned certain things every day. -She had not seen the dust, but she had been off for a few days and had not had the chance to clean the dust.

Interview with the MA on 01/19/21 at 10:29 revealed: -The Administrator knew about the floor strip that was peeling up because she had told her Thursday or Friday the week before. -The Administrator said she would have someone fix the peeling strip. -She had noticed the broken blinds in the dining room and in resident bedroom #2 three or four days ago; the Administrator had told her last week that she was going to replace the blinds in the bedrooms. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 8 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 074 Continued From page 8 C 074 -She thought the cabinet doors in the bathroom had not been broken for "too long"; she had noticed them a few days ago. -The Administrator had noticed the cabinet doors "about a few days ago" and told her then that she was going to get thing repaired. -She reported broken items to the Administrator as soon as she saw them. Telephone interview with the Administrator on 01/21/21 at 12:15pm revealed: -Her staff took care of maintenance needs, although she might notice things before staff noticed them. -She "picked up" on items that needed repaired or the staff called to inform her. -She walked through the facility daily and saw things that needed repair. -She did not notice everything, but whatever she saw would get repaired. -She was not previously aware of the peeling paint in the bathroom, but it would be repaired. -She knew the floor strip needed a tack in it. -Last week, staff informed her that the floor strip between the hallway and laundry room was loose. -She had a list of needed repairs. -She was aware of the broken blinds; she noticed them a couple of weeks ago. -A couple of weeks ago, she noticed the bathroom cabinet needed to be repaired. -Everything that needed to be repaired would be repaired.

C 076 10A NCAC 13G .0315(a)(3) Housekeeping and C 076 Furnishings

10A NCAC 13G .0315 Housekeeping and Furnishings (a) Each family care home shall: (3) have furniture clean and in good repair;

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 9 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 076 Continued From page 9 C 076 This Rule shall apply to new and existing homes.

This Rule is not met as evidenced by: Based on observations and interviews the facility failed to ensure the furniture in the dining room, living room, and on the front porch were clean and in good repair.

Observation of the front porch on 01/14/21 at 9:00am revealed one of the runners on a wooden rocking chair was broken off behind the base of a back leg.

Observations on 01/14/21 from 9:16am-10:43am revealed: -There was a large amount of dust, hair, yellow splotches, and other debris on the footboard of a resident's bed. -The fabric on the loveseat and another chair in the living room had large tears in it, exposing the foam cushion.

Observation of the resident dining room on 01/19/21 at 10:09am and 10:17am revealed: -There was a wooden table with six chairs; five of the chairs were wooden and similar in style and one was upholstered with arms. -Four of the wooden chairs were either broken or missing support rungs; the chairs moved and were not stable when residents were seated in them and posed a risk for a fall from a resident. -One wooden chair had a support rung that no longer fit into a leg which caused movement and swaying of the chair while a resident was seated in the chair. -A second wooden chair had a support rung that was broken and had part of it missing which caused the chair to move and sway while a resident was seated in the chair. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 10 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 076 Continued From page 10 C 076 -A third chair had missing supports on the back of the chair that caused a rocking movement of the chair when a resident pulled the chair out and sat in it. -A fourth chair had a broken support rung that caused movement and swaying while a resident was seated in the chair. -There were broken slats on the blinds in the dining room.

Interview with the medication aide (MA) on 01/19/21 at 10:04am revealed: -She had not noticed the dining room chair with the broken and missing support on the first wooden chair. -She had reported two of the wooden chairs were broken to the Administrator 3 or 4 days ago; she was "keeping an eye on another chair". -She had noticed the broken blinds in the dining room and in resident bedroom #2 three or four days ago; the Administrator had told her last week that she was going to replace the blinds in the bedrooms. -She reported broken items to the Administrator as soon as she saw them. -She thought the cabinet doors in the bathroom had not been broken for "too long"; she had noticed them a few days ago. -The Administrator had noticed the cabinet doors "about a few days ago" and told her then that she was going to get thing repaired.

Telephone interview with the Administrator on 01/21/21 at 12:15pm revealed: -She did not know the chairs to the dining room table had missing or broken supports; she just knew they were loose. -She ordered a new dining room set; she did not remember the date she ordered the new dining Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 11 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 076 Continued From page 11 C 076 room set. -She then said she did not order a new dining room set. -She was shopping for living room and dining room sets; she was looking for a bargain and then would purchase new furnishings. -She noticed a couple of weeks ago that the upholstered furniture in the living room was tearing at the seams and the foam was exposed; she just needed to recover the cushions. -She did not know the rocking chair on the front porch was broken. -She had a list of needed repairs. -Everything that needed to be repaired or replaced would get done. -She "picked up" on items that needed repaired or the staff called to inform her. -She walked through of the facility everyday and looked but she "might not pick up on everything".

C 078 10A NCAC 13G .0315(a)(5) Housekeeping and C 078 Furnishings

10A NCAC 13G .0315 Housekeeping and Furnishings (a) Each family care home shall: (5) be maintained in an uncluttered, clean and orderly manner, free of all obstructions and hazards; This Rule shall apply to new and existing homes.

This Rule is not met as evidenced by: TYPE B VIOLATION

Based on observations and interviews, the facility failed to ensure the facility was clean and free of

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 12 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 12 C 078 hazards as evidenced by the presence of bed bug activity in all resident rooms and in the living room.

The findings are:

Observation of a closet containing cleaning supplies on 01/14/21 at 11:11am revealed: -There was a nearly-full 32-ounce spray container of "bed bug killer." -The label indicated the spray killed bed bugs and bed bug eggs by contact. -The label indicated the spray also killed fleas and dust mites.

Observation of room #2 on 01/14/21 at 9:22am revealed: -The room was shared by two residents. -The linens on the bed closer to the window had multiple blood spots on them. -There was a live bedbug on the sheet. -There was a bedbug crawling on the curtain.

Interview with a resident who resided in room #2 on 01/14/21 at 12:53pm revealed she had seen bed bugs on her roommate's body.

Interview with a second resident who resided in room #2 on 01/14/21 at 2:23pm revealed: -She was bitten by a bed bug on her left arm yesterday. -She did not tell anyone she was bitten. -The curtains in her room were taken down today and new linens were placed on the bed.

Observation of a resident who resided in room #2 on 01/14/21 at 2:23pm revealed there were two red areas with scabs on the resident's left forearm.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 13 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 13 C 078 Observation of a resident who resided in room #2 on 01/14/21 from 3:20pm to 3:28pm revealed: -She walked from her bedroom to the residents' living room and she had a live bedbug crawling up her back. -The resident sat down on the sofa next to another resident. -She then went from the living room sofa to the dining room and sat next to two other residents; she had a live bedbug on her shoulder.

Observation of room #2 on 01/19/21 at 9:36am revealed: -There was a live bedbug on the pillow on the resident's bed. -The resident knocked the bedbug off the pillow and then stepped on the bedbug after identifying the bug as a bedbug. -The dead bedbug had a red residue around the area where it was stepped on and mashed.

Observation of room #1 on 01/14/21 at 9:32am revealed: -The room was shared by two residents. -The mattresses and box springs on both beds were encased in plastic -There was a bed bug shell between the mattress and box spring of the bed that was located next to the window. -There were five dead bed bugs in a pink basin in the closet. -There was a dead bed bug on the windowsill. -There was a dead bed bug on the floor behind a chair. -There were multiple dead bed bugs in the corner behind the bed that was located near the door.

Observation of a resident who resided in room #1 on 01/14/21 at 9:32am revealed a small round spot on the resident's left forearm. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 14 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 14 C 078

Interview with a resident who resided in room #1 on 01/14/21 at 9:32am revealed: -She saw a live bed bug on her roommate's chair the previous day. -She swatted the bug off her roommate's chair and stomped it on the floor. -She saw a live bed bug on the curtain next to her bed last week. -She informed the medication aide (MA) and the MA sprayed in the room. -She could not remember if the linens were changed after she informed the MA of the bugs. -Her clothes were not put into the dryer after she informed the MA of the bugs. -She was awakened from sleep one night because a bug was on the back of her neck. -She had a scar on her left wrist from a previous bed bug bite. -She had not seen a professional exterminator at the facility.

Interview with a second resident who resided room #1 on 01/14/21 at 10:20am revealed: -She woke up in the middle of the night last week with a bug on the back of her neck. -She knocked the bug off her neck and she did not know where it went. -She told the MA and the MA sprayed in the room last week. -Her sheets were not changed after she reported the bug to the MA. -An exterminator did not visit the facility after she reported the bug to the MA.

Second interview with a resident who resided in room #1 on 01/19/21 at 9:27am revealed: -There was a bed bug on her arm three days ago. -She informed the Administrator and was told something would be done about it. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 15 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 15 C 078

Observation of the living room on 01/14/21 at 12:45pm revealed: -There was a bed bug crawling on the cushion of a chair. -The MA used a paper towel to grab the bed bug and disposed of it after being alerted by the survey team.

Interview with a resident on 01/14/21 at 12:53pm revealed: -On 01/31/21, she killed a bed bug that was crawling on the wood trim on the loveseat in the living room. -The bed bug was crawling on the wood trim on the smaller sofa. -She did not tell the MA about the bed bug. -The MA sprayed the living room this morning. -She knew the living room had been sprayed because the furniture cushions were propped up and the wood trim was wet. -The MA let the wood dry before the cushions would be returned to place. -The Administrator talked with the residents about general bug control last year and said they try to keep things under control by spraying the facility. -The Administrator wanted to be informed whenever residents saw any type of bug. -The exterminator visited the facility in the fall of 2020 and sprayed everywhere. -Bed linens were changed weekly. -Bed linens were not changed after bed bugs were seen on the sheets.

Interview with a second resident on 01/14/21 at 2:23pm revealed: -She saw a bed bug on the sofa in the living room today and killed it. -She did not tell the MA about the bed bug.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 16 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 16 C 078 Interviews with a resident who resided in room #3 on 01/14/21 at 9:52am, 10:28am, and 12:45pm revealed: -She saw bedbugs occasionally; she saw a live bedbug in the residents' living room on 01/13/21 and she killed it. -When the MA changed the bed sheets once a week she also sprayed the mattresses; she did not know what the spray was. -There were bedbugs in her room two years ago, but she had not seen them in a long time. -She had not been bitten by a bedbug. -There had been bedbugs in the facility for the last year. -She had told the Administrator and the Assistant to the Administrator about the bedbugs when she moved into her room a year ago.

Interviews with a MA on 01/14/21 at 10:19am, 11:58am, 1:20pm and 2:36pm revealed: -She washed the residents' bed linens once a week and sprayed the bed with a bleach or a bug spray. -There were no bedbugs in the facility and none of the residents had complained of bedbugs to her. -She used a bedbug spray on as much she could, and she sprayed two times a week. -There was an exterminator that came to the facility and sprayed once a month. -She used the bedbug spray to spray the inside of the facility because "people in [named town] have them". -The facility did not allow anyone to bring clothes into the facility; everything had to be new with tags. -She knew what a bedbug looked like and she knew what evidence of bedbugs looked like; 'little dots and spots on anything" and the spots were black. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 17 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 17 C 078 -She had not noticed any bites on the residents' bodies when she assisted them with bathing. -She told the residents to wake her up during the night if there were any problems or if they needed something. -A couple of months ago she went to the storage room and got the bed bug killer spray. -She sprayed it in every room along the baseboards. -The last time she used the spray was yesterday morning. -She sprayed the bedrooms, including the mattresses and box springs, and the living room. -She did not know what bed bugs looked like. -She had not seen a bed bug until today when one was pointed out by the survey team. -She had never seen bed bugs in the staff bedroom.

Interview with the Administrator on 01/14/20 at 1:05pm revealed: -The exterminator visited the facility quarterly and the last visit was before Christmas 2020. -The exterminator sprayed for fleas, roaches, ants, spiders, essentially all insects. -The facility had never been treated for bed bugs. -There were no complaints about bed bugs from staff or residents. -Newly admitted residents' clothing was left on the front porch until they were washed in hot water by staff. -She did not know who bought the bed bug killer spray that was in the closet. -She used the spray to control ants between the exterminator's visits. -She did not call the exterminator to visit the facility between the quarterly visits -She expected the exterminator to inspect for bed bugs when he visited the facility. -The exterminator had never seen bed bugs in Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 18 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 18 C 078 the facility. -She did not know what bed bugs looked like. -She researched bed bugs on the internet in the distant past; she wanted to know "how they look and what they do." -No one had mentioned any bed bug sightings to her. -"If I would have known, I would have treated the rooms." -Linens were changed every Wednesday or as needed. -Some of the residents were not reliable historians.

Telephone interviews with the facility's exterminator on 01/21/21 at 3:43pm and 4:15pm revealed: -He was at the facility on 01/21/21. -He provided quarterly services to the facility since April 2017. -He sprayed for ants, spiders, and rodents during those visits. -He sprayed as far as he was able along the baseboards, under the beds, and behind furniture. -Bed bug service required a separate call and an additional charge. -He never noticed bed bug activity at the facility and he never treated the facility for bed bugs. -The Administrator contacted him last week for bed bug treatment. -He informed the Administrator the facility needed to be vacant for 72 hours after he treated for bed bugs. -He advised the Administrator to pack the residents' clothing and possessions in trash bags before he treated the facility. -He advised the Administrator the residents' clothing needed to be run through the dryer after the treatment was completed. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 19 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 078 Continued From page 19 C 078 -He was chemically treating the facility for bed bug control. -Today he saw bed bugs in two of the bedrooms and on the recliner in the living room.

On 01/15/21, the survey team requested and did not receive the facility's bed bug policy and invoices from the facility's exterminator. ______The facility failed to ensure the facility was clean and free of hazards as evidenced by the presence of live bed bugs in all resident rooms and in the living room, resulting in residents having to live in an environment with bed bugs and being disrupted from sleep due to bed bug bites. This failure was detrimental to the health, safety, and welfare of the residents and constitutes a Type B Violation. ______The facility provided a plan of protection in accordance with G.S. 131D-34 on 01/15/21 for this violation.

CORRECTION DATE FOR THE TYPE B VIOLATION SHALL NOT EXCEED MARCH 8, 2021.

C 185 10A NCAC 13G .0601(a) Management and Other C 185 Staff

10A NCAC 13G .0601Mangement and Other Staff (a) A family care home administrator shall be responsible for the total operation of a family care home and shall also be responsible to the Division of Health Service Regulation and the county department of social services for meeting and maintaining the rules of this Subchapter. The co-administrator, when there is one, shall

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 20 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 20 C 185 share equal responsibility with the administrator for the operation of the home and for meeting and maintaining the rules of this Subchapter. The term administrator also refers to co-administrator where it is used in this Subchapter.

This Rule is not met as evidenced by: TYPE B VIOLATION

Based on observations, record reviews and interviews the Administrator failed to ensure the total operation of the facility to meet and maintain rules related to infection prevention and control program, medication administration, health care, resident records, housekeeping and furnishings, capacity, design and construction, reporting of incidents and accidents, medication aide training and competency evaluation requirements and resident rights.

The findings are:

Interview with a resident on 01/14/21 at 9:52am revealed the Administrator came to the facility two to three times a week and the Assistant to the Administrator was at the facility about once a week.

Interview with the MA on 01/14/21 at 9:39am and 11:45am revealed the Administrator came to the facility two to three times a week.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:36am revealed he was responsible for the "paperwork" for the facility and auditing the residents' records; he was at the facility twice a month. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 21 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 21 C 185

Telephone interview with the Administrator on 01/21/21 at 12:15pm revealed: -She walked through the facility every day and noticed things that needed to be fixed. -She "ran a business and paid other people to do stuff" and she should be able to have them do their jobs without her making sure everything was done. -She assumed things were done because she "paid that person" to do the job. -The Assistant to the Administrator did all the paperwork and the medication aides (MAs) were responsible for the medication. -She checked on things herself but she did not check everyday. -She knew she was "ultimately responsible" for everything herself.

Noncompliance identified during the survey included:

1. Based on observations, record reviews and interviews, the facility failed to ensure the residents' evacuation capabilities were in accordance with the evacuation capability listed on the facility's license for 1 of 1 sampled resident (#2) residing in the facility with cognitive impairments which could prevent the resident from evacuating the facility independently. [Refer to Tag 022 10A NCAC 13G .0302(b) Design and Construction (Type B Violation)].

2. Based on observations and interviews, the facility failed to ensure the facility was clean and free of hazards as evidenced by the presence of bed bug activity in all resident rooms and in the living room. [Refer to Tag 078 10A NCAC 13G .0315(a)(5) Housekeeping and Furnishing (Type B Violation)]. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 22 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 22 C 185

3. Based on observations, record reviews, and interviews the facility failed to ensure each resident was treated with respect, consideration, and dignity related to the right to be free of physical abuse related to a resident (#1) being struck by her roommate and the right to have personal possessions related to having her personal cell phone confiscated as punishment for behaviors. [Refer to Tag 311 10A NCAC 13G .0909 Residents Rights (Type B Violation)].

4. Based on observations, record reviews and interviews, the facility failed to administer medications as ordered by a licensed prescribing practitioner for 3 of 3 sampled residents (#1, #2, and #3) related to a medication used to treat cancer (#1), an antibiotic (#2), and a laxative (#3). [Refer to Tag 330 10A NCAC 13G .1004(a) Medication Administration (Type B Violation)].

5. Based on observations, record reviews, and interviews, the facility failed to ensure recommendations and guidance established by the Centers for Disease Control (CDC) and the North Carolina Department of Health and Human Services (NC DHHS) were implemented and maintained to provide protection of the residents during the global coronavirus (COVID-19) pandemic regarding recommended infection prevention and control practices to reduce the risk of transmission and infection as related to staff not wearing surgical facemasks, staff and residents not maintaining a social distance of 6 feet, no signage for visitor restrictions and cough and respiratory hygiene and no screening of staff and visitors. [Refer to Tag 611 10A NCAC 13G .1701 Infection Prevention and Control Program (Type B Violation)].

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 23 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 23 C 185 6. Based on observations and interviews, the facility failed to ensure the wall in the dining room and a ceiling vent in the hallway, a floor strip at a threshold in the hallway, broken mini blinds, windowsills in resident bedrooms, the cabinets and the wall in one of the resident bathrooms were kept clean and in good repair. [Refer to Tag 074 10A NCAC 13G .0315(a)(1) Housekeeping and Furnishing].

7. Based on observations and interviews the facility failed to ensure the furniture in the dining room, living room, and on the front porch were clean and in good repair. [Refer to Tag 076 10A NCAC 13G .0315(a)(3) Housekeeping and Furnishing].

8. Based on observations, interviews and record reviews, the facility failed to ensure follow-up for acute and routine healthcare needs for 2 of 3 residents sampled (#1 and #3) including a missed mammography appointment for a resident undergoing chemotherapy (#1); and a resident who was experiencing constipation (#3). [Refer to Tag 246 10A NCAC 13G .0902(b) Health Care].

9. Based on observations and interviews, the facility failed to return medication to the pharmacy or dispose of expired medications within 90 days of the date of expiration. [Refer to Tag 363 10A NCAC 13G .1007(c) Medication Disposition].

10. Based on observations, interviews and record reviews, the facility failed to maintain resident records in an orderly manner at the facility for 3 of 3 (#1, #2, and #3) sampled residents. [Refer to Tag 415 10A NCAC 13G .1201(a) Resident Records].

11. Based on record reviews and interviews, the Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 24 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 24 C 185 facility failed to notify law enforcement immediately of an incident in which 1 of 4 residents sampled (#1) was harmed by another resident. [Refer to Tag 450 10A NCAC 13G .1213(g) Reporting of Incidents].

12. Based on observations, interviews and record reviews, the facility failed to ensure 1 of 2 sampled staff (Staff B) who administered medications completed the state approved 10-hour medication aide training course and successfully passed the required state medication administration examination. [Refer to Tag 935 G.S. 131D-4.5(B)(b) Medication Aide Training and Competency evaluation Requirements]. ______The Administrator failed to ensure the overall management, operations, and policies of the facility were implemented by failing to ensure the medication aides, who were responsible for the care of the residents, were trained in medication administration which resulted in residents being administered medication incorrectly (#1, #2,#3), not notifying the physician or law enforcement when two residents had a fight (#1, #4), for not identifying an infestation of bed bugs, allowing a resident who was not ambulatory and unable to evacuate independently (#2) to remain in the facility; and not having a system was in place to screen residents and staff for COVID-19 per the Center for Disease Control guidelines, ensuring staff were wearing surgical facemask and residents were practicing social distancing from residents during communal dining. This failure was detrimental to the health, safety and welfare of the residents and constitutes a Type B Violation. ______The facility provided a plan of protection in accordance with G.S. 131D-34 on 01/15/21 for Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 25 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 185 Continued From page 25 C 185 this violation.

CORRECTION DATE FOR THE TYPE B VIOLATION SHALL NOT EXCEED MARCH 8, 2021.

C 246 10A NCAC 13G .0902(b) Health Care C 246

10A NCAC 13G .0902 Health Care (b) The facility shall assure referral and follow-up to meet the routine and acute health care needs of residents.

This Rule is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to ensure follow-up for acute and routine healthcare needs for 2 of 3 residents sampled (#1 and #3) including a missed mammography appointment for a resident undergoing chemotherapy (#1); and a resident who was experiencing constipation (#3).

The findings are:

1. Review of Resident #1's current FL-2 dated 02/20/20 revealed diagnoses included bipolar disorder, type two diabetes mellitus, hyperlipidemia, thrombocytopenia, rectal carcinoma, colon carcinoma metastasis of the lining, and neuropathy.

Review of Resident #1's curent care plan dated 8/31/20 revealed: -Resident #1 was ambulatory. -Resident #1 had a colostomy. -Resident #1 was sometimes disoriented. -Resident #1's mental health history was listed as resisting care, disruptive behavior and she was socially inappropriate.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 26 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 246 Continued From page 26 C 246 -Resident #1 required extensive assistance with bathing including help getting in and out of the tub, washing and drying herself.

Review of orders from Resident #1's Oncologist revealed: -There was an order for a mammogram for Resident #1 dated 10/15/20. -There was a note for Resident #1 dated 12/23/20 that Resident #1 still needed a mammogram and to call [the Oncologist] if another order was needed.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:15pm revealed: -Resident #1 had an appointment for the mammogram in October 2020 at the local hospital. -He knew Resident #1 did not go to the appointment in October 2020, but he could not remember why she did not go for the scheduled mammogram. -Resident #1 had another appointment to have a mammogram scheduled sometime in January 2021 but he could not remember the exact date. -The local hospital had rescheduled the appointment in October 2020 for the January 2021 date. -He did not know why the appointment in January 2021 was scheduled so long after the original missed appointment. -The order dated 10/15/20 did not have a date to have the mammogram completed by so that was why there was a delay in the facility setting the appointment.

Telephone interview with a representative from the imagining center at the local hospital on 01/22/21 at 3:05pm revealed: -Resident #1 had and appointment scheduled on Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 27 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 246 Continued From page 27 C 246 10/30/20 for a mammogram; the hospital did not cancel or reschedule the appointment. -The mammogram appointment scheduled for 10/30/20 was made on 10/16/20. -Resident #1 failed to show for the appointment on 10/30/20; no one from the facility called to cancel the appointment or to reschedule another one. -Resident #1 did not have an appointment scheduled for January 2021 and she did not have any future appointments scheduled.

2. Review of Resident #3's current FL-2 dated 12/08/20 revealed diagnoses included schizophrenia, drug-induced Parkinsonism, high blood pressure, and degenerative osteoarthritis.

Interview with Resident #3 on 01/14/21 at 9:32am revealed: -She experienced chronic constipation. -The medication aide (MA) was aware she experienced constipation.

Interview with a MA on 01/19/21 at 11:02am revealed: -She did not and does not call the primary care provider (PCP). -She informed the Administrator or the Assistant to the Administrator when the PCP needed to be called. -Three weeks ago, she asked the Assistant to the Administrator if Resident #3 could get a laxative; he said he would take care of it. -Yesterday she told Resident #3 that she was going to follow-up with the Assistant to the Administrator today.

Telephone interview with a medical assistant from Resident #3's PCP's office revealed there was no Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 28 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 246 Continued From page 28 C 246 documentation in Resident #3's record indicating anyone from the facility had contacted the PCP's office to report Resident #3 was experiencing constipation.

Review of Resident #3's record revealed there was no documentation Resident #3's PCP was notified Resident #3 was experiencing constipation.

Telephone interview with a nurse practitioner from Resident #3's PCP's office revealed: -She was not told Resident #3 was experiencing constipation. -She expected to be notified if Resident #3 had any medical concerns.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:38am revealed: -He expected staff to let him or the Administrator know when the PCP needed to be called about a medical concern. -The MA was allowed to contact the PCP. -He knew Resident #3 was experiencing constipation. -He was not told Resident #3's constipation was a major problem. -He did not contact the PCP to report Resident #3 was experiencing constipation.

C 311 10A NCAC 13G .0909 Residents' Rights C 311

10A NCAC 13G .0909 Resident Rights A family care home shall assure that the rights of all residents guaranteed under G.S. 131D-21, Declaration of Residents' Rights, are maintained and may be exercised without hindrance.

This Rule is not met as evidenced by:

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 29 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 29 C 311 TYPE B VIOLATION

Based on observations, record reviews, and interviews the facility failed to ensure each resident was treated with respect, consideration, and dignity related to the right to be free of physical abuse related to a resident (#1) being struck by her roommate and the right to have personal possessions related to having her personal cell phone confiscated as punishment for behaviors.

The findings are:

Observation of the living room on 01/19/21 at 9:16am revealed: -Resident #1 and her roommate were both sitting in the living room in the corners of separate sofas. -The two residents were speaking to each other in low inaudible tones. -The medication aide (MA) walked over to the two residents and told them to "shhh" and made a motion with one of her hands by holding up her index finger in front of Resident #1. -The two residents began to argue with each other but remained seated. -The MA walked back to them a second time and told them to "stop" and then spelled out "S-T-O-P" with the same hand motion as before. -The two residents began to speak louder to each other a third time and the MA approached them again and spelled out "S-T-O-P" two more times. -The residents did not speak again.

Review of Resident #1's current FL-2 dated 02/20/20 revealed diagnoses included bipolar disorder, type two diabetes mellitus, hyperlipidemia, thrombocytopenia, rectal carcinoma, colon carcinoma metastasis of the Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 30 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 30 C 311 lining, and neuropathy.

a. Review of Resident #1's current Care Plan dated 08/31/20 revealed: -Resident #1 was ambulatory. -Resident #1 had a colostomy. -Resident #1's mental health history was listed as resisting care, disruptive behavior and she was socially inappropriate. -Resident #1 required extensive assistance with bathing including help getting in and out of the tub, washing and drying herself.

Observation of Resident #1 on 01/19/21 at 9:22am revealed: -She had a mark on her face that was dark red and was from the corner of her right eyebrow to her hairline. -She had a second mark on the lower part of her neck just above her left shoulder that was dark red and brown and had a long redline and splotched area; the mark was about 2.5 inches long and a half of an inch wide.

Interview with Resident #1 on 01/19/21 at 9:22am revealed: -The marks on her face and neck occurred when her roommate tried to choke her Sunday evening, 01/17/21 while they were seated in the resident living room. -The staff that was working that night came into the room and broke up the fight. -The police were not called. -She and her roommate had fought in the past; the last fight was about a month ago. -She and her roommate would hit each other; her roommate would hit her in the arm and leave bruises on her. -Her roommate "scared her to death" on 01/17/21 because the roommate had her throat and "cut Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 31 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 31 C 311 her wind this time". -She was also concerned her roommate would pull on her colostomy and could possibly pull it off. -Her roommate would easily get agitated; her roommate would also wake up in the middle of the night and start yelling at her. -She had gone into her room at times and locked the door to get away from her roommate. -She was "tired of this"; staff knew of the fights and so did the Administrator. -She had told the Administrator she was tired of the fights, but she told the Administrator she did not want to move out of her room. -The Administrator talked to them and told them to stop fighting.

Interview with a resident on 01/19/21 at 10:08am revealed. -There were two residents who did not always get along with each other. -She heard them arguing and yelling in their bedroom and in the living room. -She had not seen them get physical with one another. -The MA tried her best to keep the residents from arguing. -The police had not been called to the facility.

Interview with a MA on 01/19/21 on 10:15am revealed: -Resident #1 and her roommate got along most of the time; sometimes she had to stop them from arguing. -Resident #1 and her roommate did not hit each other; they just "fussed" or argued with each other. -Resident #1's roommate walked up and down the hallway and Resident #1 would tell her to sit down. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 32 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 32 C 311

Telephone interview with Resident #1's primary care provider (PCP) on 01/21/21 at 2:00pm revealed: -She had not been told of any changes in Resident #1's behaviors. -She did not know if there were any conflicts between Resident #1 and her roommate. -She visited the facility about once a week; the last time she was in the facility was Sunday (01/17/21) during the day and she did not observe anything out of the ordinary with Resident #1.

Telephone interview with the Assistant to the Administrator on 01/19/21 at 2:29pm revealed: -He knew Resident #1 and her roommate argued but he was not aware of them striking each other. -If they wanted to be placed with other roommates they could. -They had discussed with the two residents about moving one of them out of the room but neither resident wanted to move. -The two residents got along one minute and then argued with each other the next.

Interview with the Administrator on 01/19/21 at 10:51am revealed: -Resident #1 and her roommate fought; they would hit each other every day. -The two residents would fight with each other "every so often"; "maybe three times since June 2020". -They never left marks on each other; she was not worried because "they were young, and they got over it and it does not last long". -Resident #1 got really agitated but both residents provoked the other usually by talking and then arguing with each other. -The two residents usually disagreed about something on the phone or radio. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 33 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 33 C 311 -She had looked for marks on the two residents when they hit each other but had not seen bruises or scars. -She did not think hitting each other was a concern; it was "pushing more than hitting". -She had seen them pushing each other; pushing was not a concern to her. -She did not call for police intervention when the two residents fought. -She did not report the incidents to anyone because "you do not take everything to court or have the sheriff pick them up". -The two residents had not complained to her about each other. -She was aware of the fight that occurred on Sunday evening, 01/17/21, because the personal care aide (PCA) called to inform her. -She saw Resident #1 on Monday, 01/18/21, and did not see marks on Resident #1. -The staff called her Sunday, 01/17/21, and reported the two residents had hit each other and pushed each other in the hallway; she did not know about either residents' hands on the others throat because staff did not say anything about that. -The two residents do not complain about her taking their cell phones away from them. -Staff was always there and would stop them. -Staff had documented when they had to "break up" the two residents from arguing, but most of the time they did not document and there were no bruises; it "just happened". -Her responsibility was to keep the residents safe and take care of them and she did that because she talked to them after they did "this". -She talked to them after each occurrence and they would stop; talking to them was successful because "it only happened 2 to 3 times and that was considered success because it was not happening everyday". Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 34 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 34 C 311 -The two residents were not hurting each other because she thought they would tell her if they were hurting each other. -She was not concerned Resident #1 or Resident #4 would hit another resident; all the residents could report to the staff if they were hit and "plus staff was always here". -Sometimes within 30 minutes after fighting they would be "holding hands," getting along. -"They probably will not hit each other for a month."

Attempts to interview the personal care aide (PCA) on 01/20/21 at 2:52pm and 4:51pm were unsuccessful.

b. Interview with Resident #1 on 01/19/21 at 9:22am revealed: -The staff had to "get" on her and her roommate to stop arguing with each other; then the staff would take away their personal cell phones. -The Administrator would take her cell phone away from her for a few days to correct the behavior. -The Administrator had taken her cell phone away from her on Sunday, 01/17/21,and had not given it back to her after she and her roommate had a fight.

Interview with a resident on 01/19/21 at 10:08am revealed: -The MA told the residents to "shut up" and threatened to take their telephones or radios. -The Administrator currently had both residents' phones in her possession. -She did not know when the phones would be returned to the residents.

Telephone interview with Resident #1's family member on 01/19/21 at 2:56pm revealed: Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 35 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 35 C 311 -She provided Resident #1 with a personal cell phone for her to use. -The Administrator told her it was a privilege for the residents to have a cell phone and it could be taken away from Resident #1 if the phone was misused. -She knew Resident #1 hit another resident and her cell phone was taken away from her for a week; she did not remember when.

Telephone interview with the Assistant to the Administrator on 01/19/21 at 2:29pm revealed: -He did not know about the residents' cell phones being taken away from them because of the fighting or arguing. -The Administrator talked to the two roommates after their arguments about not arguing.

Interview with the Administrator on 01/19/21 at 10:51am revealed: -The personal care aide (PCA) called her Sunday, 01/17/21, and reported the two residents had hit each other and pushed each other in the hallway. -She took their cell phones away from them when they misbehaved; she did that to "let them know they need to behave" and not "put their hands on each other anymore". -The two residents do not complain about taking their cell phones away from them. -By taking their cell phones away from them it showed them that they did not hit anyone; showed them how to be responsible as adults.

Attempts to interview the personal care aide (PCA) on 01/20/21 at 2:52pm and 4:51pm were unsuccessful. ______The facility failed to ensure residents were treated with respect, consideration, dignity and the right Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 36 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 311 Continued From page 36 C 311 to be free of physical abuse when Resident #1 was choked, scared and felt unsafe towards her roommate and the confiscation of Resident #1's personal cell phone as a punishment for fighting. This failure was detrimental to the health, safety, and welfare of the resident which constitutes a Type B violation. ______The facility provided a plan of protection in accordance with G.S. 131D-34 on 01/19/21 for this violation.

CORRECTION DATE FOR THE TYPE B VIOLATION SHALL NOT EXCEED MARCH 08, 2021

C 330 10A NCAC 13G .1004(a) Medication C 330 Administration

10A NCAC 13G .1004 Medication Administration (a) A family care home shall assure that the preparation and administration of medications, prescription and non-prescription and treatments by staff are in accordance with: (1) orders by a licensed prescribing practitioner which are maintained in the resident's record; and (2) rules in this Section and the facility's policies and procedures.

This Rule is not met as evidenced by: TYPE B VIOLATION

Based on observations, record reviews and interviews, the facility failed to administer medications as ordered by a licensed prescribing practitioner for 3 of 3 sampled residents (#1, #2, and #3) related to a medication used to treat cancer (#1), an antibiotic (#2), and a laxative (#3).

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 37 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 37 C 330

The findings are:

1. Review of Resident #1's current FL-2 dated 02/20/20 revealed: -Diagnoses included bipolar disorder, type two diabetes mellitus, hyperlipidemia, thrombocytopenia, rectal carcinoma, colon carcinoma metastasis of the lining, and neuropathy. -Medication orders included capecitabine (a medication used to treat metastatic colorectal cancer) 500mg take two tablets twice daily for 1-14 days then 7 days off for a 21-day cycle.

Review of Resident #1's November 2020 Medication Administration Record (MAR) revealed: -There was a hand-written entry for capecitabine 500mg take 2 tablets (1000mg) twice daily scheduled at 8:00am and 8:00pm on days 1-14 then 7 days 21-day cycle. -Capecitabine 500mg was documented as administered from 11/01/20 through 11/14/20; there was a line drawn across the dates 11/15/20 though 11/21/20 and nothing else was documented.

Review of Resident #1's December 2020 MAR revealed: -There was a hand-written entry for capecitabine 500mg take 2 tablets 1000mg, twice daily scheduled at 8:00am and 8:00pm on days 1-14 then 7 days off 21-day cycle. -Capecitabine 500mg was documented as administered from 12/01/20 through 12/14/20; there was a line drawn across the remainder of the dates on the MAR.

Review of Resident #1's January 2021 MAR Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 38 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 38 C 330 revealed: -There was a hand-written entry for capecitabine 500mg take 2 tablets 1000mg twice daily scheduled at 8:00am and 8:00pm on days 1-14 then 7 days off 21-day cycle. -Capecitabine 500mg was documented as administered from 01/01/21 through 01/14/21; there was a line drawn across the remainder of the dates on the MAR.

Observation of Resident #1's medication on hand on 01/19/21 at 10:22am revealed: -There was a closed plastic bag with the words caution chemotherapy drug use precautions when handling printed on the outside and a pill bottle with the capecitabine on the inside of the bag. -There capecitabine 500mg had a dispense date of 12/23/20 and the quantity of 56 tablets on the label. -The administration directions on the outside of the bottle were take 2 tablets twice daily on days 1-14 then 7 days off for 21-day cycle. -The bottle of capecitabine was three-fourths full.

Interview with Resident #1 on 01/19/21 at 9:36am revealed: -She knew she took a medication for her cancer for the first fourteen days of each month. -She knew she was supposed to be off the medication for another seven days. -She always began the medication on the first day of the month. -When she took the medication, she took two tablets in the morning and two in the evenings.

Telephone interview with a representative from the dispensing pharmacy on 01/15/21 at 12:55pm revealed: -The pharmacy specialized in dispensing Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 39 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 39 C 330 chemotherapy medication. -The pharmacy dispensed medication ordered by Resident #1's Oncologist for Resident #1. -Resident #1 had an active order for capecitabine 500mg 2 tablets administered twice daily for 14 days then hold for 7 days for a 21-day cycle. -There were 56 tablets of capecitabine dispensed on 12/04/20 and 12/23/20; Resident #1 was due for a refill of the capecitabine. -The capecitabine should be restarted at the end of the 21-day cycle and repeat the 14 days on and 7 days off again. -The capecitabine should not be held for longer that the 7 days and should not only be administered for the first fourteen days of each month unless that was the way the 21-day cycle happened to occur. -Capecitabine was used to treat cancer, usually between intravenous (IV) chemotherapy treatments. -If the 21-day cycle were extended it could affect the progress of cancer treatment by affecting the spread or growth of the cancer and could throw off the treatment cycle if the resident were receiving IV chemotherapy treatments.

Telephone interview with the Registered Nurse (RN) from Resident #1's Oncologist office on 01/19/21 at 3:21pm revealed: -Resident #1 was ordered capecitabine 500mg take two tablets twice daily for 14 days then off for seven days for a 21-day cycle; Resident #1 was supposed to repeat the cycle on the 22nd day. -Resident #1's capecitabine was part of the cycle of chemotherapy treatment for her lung cancer. -She received capecitabine for 14 days and then received IV chemotherapy at the Oncology center on the third week. -The 14-day administration of capecitabine gave Resident #1 a continuous infusion of Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 40 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 40 C 330 chemotherapy for 14 days between her IV chemotherapy treatments.

Interview with the medication aide (MA) on 01/19/21 at 10:42am revealed: -She administered the capecitabine to Resident #1. -She always started the capecitabine on the first day of the month and administered it for 14 days then stopped administering the medication on the fifteenth day of the month. -The capecitabine was supposed to be held for 7 days and then restarted on the 22nd day of the month. -She documented on the date the capecitabine was administered; she thought it always started on the first day of the month. -She could not explain why the MAR only showed documentation of the capecitabine being administered for the first 14 days of November 2020, December 2020 and January 2021. -There was only one bottle of capecitabine 500mg for Resident #1; she could not explain why there were extra tablets available for administering.

Interview with the Administrator on 01/19/21 at 11:15am revealed: -Resident #1's capecitabine was only administered for 14 days each month then she was off for seven days. -If the MAs started the capecitabine on the first of the month then it should have started back on the 22nd of the month. -If there was not a signature on the MAR under a date then the capecitabine was not administered on that date. -Then the capecitabine must start on the first of every month and been administered for fourteen days; she did not know what to say she thought it Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 41 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 41 C 330 was "7 days off". -She was not sure what the seven days was for then. -The MAs and the Assistant to the Administrator kept up with the MARs; the Assistant to the Administrator checked the MAR once a week. -The MAs wrote the order for the capecitabine on the new MAR each month.

2. Review of Resident #2's current FL-2 dated 07/19/19 revealed diagnoses included vascular dementia, heart failure, and glaucoma.

Review of Resident #2's orders revealed: -There was an electronic order written by Resident #2's primary care provider (PCP) dated 12/23/20 for cephalexin (an antibiotic) 500mg take one capsule three times a day. -A 14-day supply of 42 capsules was ordered.

Review of Resident #2's medication administration record (MAR) for December 2020 revealed: -There was an entry for cephalexin 500mg take one capsule three times daily scheduled for administration at 8:00am, 1:00pm, and 8:00pm. -Cephalexin was documented as administered from 1:00pm on 12/24/20 through 8:00pm on 12/31/20.

Review of Resident #2's MAR for January 2021 revealed there was no entry for cephalexin.

Observation of Resident #2's medication available for administration on 01/14/21 at 2:11pm revealed there was no cephalexin 500mg among Resident #2's medication.

Interview with a medication aide (MA) on Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 42 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 42 C 330 01/14/21 at 2:51pm revealed: -Resident #2 was prescribed an antibiotic for cellulitis (a bacterial infection) on her legs. -Staff had administered Resident #2's antibiotic as ordered. -Resident #2 was seen by the primary care provider (PCP) less than a week ago. -Another MA was responsible for keeping the resident records up-to-date.

Telephone interview with a pharmacist at the facility's contracted pharmacy on 01/20/21 at 2:59pm revealed: -The pharmacy dispensed 42 (a 14-day supply) cephalexin 500mg capsules for Resident #2 on 12/24/20. -The capsules would have been administered through the first week of January 2021. -The facility may have recorded the administration of the cephalexin 500mg capsules on a supplemental MAR.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:38am revealed: -Staff reviewed the MAR to make sure the correct orders were entered on the MAR. -He double-checked the MAR after staff reviewed it. -The administration of Resident #2's cephalexin should have been documented on the January 2021 MAR. -He did not know why there was no entry for Resident #2's cephalexin on the January 2021 MAR.

Based on observations, interviews and record reviews, it was determined Resident #2 was not interviewable.

3. Review of Resident #3's current FL-2 dated Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 43 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 43 C 330 12/08/20 revealed: -Diagnoses included schizophrenia, drug-induced Parkinsonism, high blood pressure, and degenerative osteoarthritis. -There was no order for a laxative.

Review of Resident #3's subsequent primary care provider's (PCP) orders revealed there was no order for a laxative.

Observation of Resident #3's medication available for administration on 01/14/21 at 2:20pm revealed there was no laxative among Resident #3's medication.

Review of Resident #3's medication administration record (MAR) for December 2020 revealed: -There was no entry for a laxative. -There was documentation on the back of the MAR indicating two tablets of Senokot-S were administered on 12/25/20 at 1:00pm and 7:00pm for constipation and did not help. -There was documentation on the back of the MAR indicating two tablets of Senokot-S were administered on 12/26/20 at 8:00am; there was no documentation about the effectiveness. -The documentation indicated one medication aide (MA) administered the Senokot-S on 12/25/20 and 12/26/20.

Review of Resident #3's MAR for January 2021 revealed: -There was no entry for a laxative. -There was no documentation a laxative had been administered to Resident #3 during January 2021.

Interview with Resident #3 on 01/14/21 at 9:32am revealed she experienced chronic constipation Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 44 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 44 C 330 and took an over the counter (OTC) laxative daily.

Interviews with Resident #3 on 01/19/21 at 9:27am and 11:31am revealed: -The MA gave her two Senokot tablets every morning. -The Senokot tablets were orange. -"That's what the doctor prescribed for me."

Interviews with a MA on 01/19/21 at 10:20am and 11:02am revealed: -Resident #3 was having a "little bit" of constipation. -Resident #3 did not get a laxative, including Senokot. -There was no Senokot available for administration in the facility. -There was not a laxative available for administration in the "house stock" (available for all residents who have an order for a laxative). -She did not administer a laxative to Resident #3 because there was not an order for it. -The documentation she entered on Resident #3's MAR was a mistake. -She advised Resident #3 to drink more water to get relief from constipation.

Telephone interview with a nurse practitioner from Resident #3's PCP's office on 01/20/21 at 12:20pm revealed: -She was not aware Resident #3 was receiving an OTC laxative. -She did not want staff to administer any medication, including OTC medication, without an order because it may cause an interaction with Resident #3's ordered medication.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:38am revealed: -His expectation was that all medication be Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 45 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 330 Continued From page 45 C 330 administered as ordered. -Resident #3 was receiving an OTC laxative. -Medication was not supposed to be administered without an order. ______The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner, resulting in a resident not receiving a medication correctly that was used as a cycle treatment for cancer (#1), a resident not receiving the full course of an antibiotic for cellulitis (#2), and a resident receiving an over the counter medication for constipation without an order (#3). This failure was detrimental to the health, safety, and welfare of the residents and constitutes a Type B Violation. ______The facility provided a plan of protection in accordance with G.S. 131D-34 on 01/21/21 for this violation.

CORRECTION DATE FOR THE TYPE B VIOLATION SHALL NOT EXCEED MARCH 8, 2021.

C 363 10A NCAC 13G .1007 (c) Medication Disposition C 363

10A NCAC 13G .1007 Medication Disposition

(c) Medications, excluding controlled medications, shall be destroyed at the facility or returned to a pharmacy within 90 days of the expiration or discontinuation of medication or following the death of the resident.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 46 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 363 Continued From page 46 C 363 This Rule is not met as evidenced by: Based on observations and interviews, the facility failed to return medication to the pharmacy or dispose of expired medications within 90 days of the date of expiration.

The findings are:

Observations of a current resident's medication on hand on 01/14/21 at 2:06pm revealed: -There were 4 medications and one cream that had expired dates on them. -There was a package of Meclizine 25mg dispensed on 05/14/19, with 27 tablets remaining in the package that expired on 05/13/20. -There was a package of Ondansetron HCL 8mg dispensed on 09/24/19, with 30 tablets remaining in the package that expired on 09/23/20. -There was a package of Ondansetron 4mg that had 00/00/00 for the dispense date, with 27 remaining in the package that expired on 05/13/20. -There was a package of Hyoscyamine 0.125mg dispensed on 03/01/19, with 27 tablets remaining in the package that expired on 02/29/20. -There was a jar of skin cream dispensed on 09/24/19; the jar was two-thirds full and had expired on 09/23/20.

Interview with a medication aide (MA) on 01/19/21 at 10:28am revealed: -She called the pharmacy to replace any expired medication. -She and the other MA were responsible for calling the pharmacy and returning any expired medication. -She looked at the dates on the package when she administered medications. -The packages of expired medications were all PRN (as needed) so the resident had not used Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 47 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 363 Continued From page 47 C 363 them in a long time. -She tried to check all the medication every two weeks for expirations and send them back to the pharmacy; she "just let this go and did not mean to".

Telephone interview with the Administrator on 01/21/21 at 12:46pm revealed: -Expired medication was sent back to the pharmacy. -The Pharmacist that conducted the quarterly medication review was supposed to "take out" expired medication; she paid for that service from the pharmacy.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:51am revealed the MAs were responsible for identifying and sending expired medication to the pharmacy.

Telephone interview with a representative from the facility's contracted pharmacy on 01/21/21 at 1:17pm revealed they did not know what was done during the quarterly medication reviews because they subcontracted the medication reviews out to a consulting pharmaceutical company.

Telephone interview with a representative from the pharmacy's consulting pharmaceutical company on 01/21/21 at 1:21pm revealed she did not know what the consulting Pharmacist completed when he completed the medication reviews; the consulting Pharmacist would have to answer to what he did during a review.

Attempt to interview the Pharmacist from the consulting pharmaceutical company on 01/21/21 at 1:34pm was unsuccessful.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 48 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 415 Continued From page 48 C 415

C 415 10A NCAC 13G .1201 (a) Resident Records C 415

10A NCAC 13G .1201 Resident Records

(a) The following shall be maintained on each resident in an orderly manner in the resident's record in the adult care home and made available for review by representatives of the Division of Facility Services and county departments of social services: (1) FL-2 or MR-2 forms and the patient transfer form or hospital discharge summary, when applicable; (2) Resident Register; (3) receipt for the following as required in Rule .0704 of this Subchapter: (A) contract for services, accommodations and rates; (B) house rules as specified in Rule .0704(a)(2) of this Subchapter; (C) Declaration of Residents' Rights (G.S. 131D-21); (D) the home's grievance procedures; and (E) civil rights statement; (4) resident assessment and care plan; (5) contacts with the resident's physician, physician service or other licensed health professional as required in Rule .0902 of this Subchapter; (6) orders or written treatments or procedures from a physician or other licensed health professional and their implementation; (7) documentation of immunizations against influenza virus and pneumococcal disease according to G.S. 131D-9 or the reason the resident did not receive the immunizations based on this law; and (8) the Adult Care Home Notice of Discharge and Adult Care Home Hearing Request Form if the

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 49 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 415 Continued From page 49 C 415 resident is being or has been discharged. When a resident leaves the facility for a medical evaluation, records necessary for that medical evaluation such as Subparagraphs (1), (4), (5), (6) and (7) above may be sent with the resident.

This Rule is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to maintain resident records in an orderly manner at the facility for 3 of 3 (#1, #2, and #3) sampled residents.

The findings are:

1. Based on record review, the following documents were not readily available for Resident #2: current FL-2 (FL-2 was dated 07/19/19); all pages of the Resident Register (page 1 was missing); current care plan or statement of assessed need signed by the physician (care plan was dated 08/22/19); orders or written treatments or procedures from a physician or other licensed health professional and their implementation.

Attempted telephone interview with a second MA on 01/21/21 at 9:11am was unsuccessful.

Refer to the interview with the medication aide (MA) on 01/14/21 at 2:57pm.

Refer to the interview with the Assistant to the Administrator on 01/22/21 at 9:38am.

2. Based on record review, a completed Resident Register was not readily available for Resident #3. (Page 1 was minimally completed; all other pages were blank.)

Attempted interview with a second MA on Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 50 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 415 Continued From page 50 C 415 01/21/21 at 9:11am was unsuccessful.

Refer to the interview with the medication aide (MA) on 01/14/21 at 2:57pm.

Refer to the interview with the Assistant to the Administrator on 01/22/21 at 9:38am.

3. Based on record review, the following documents were not readily available for Resident #1: current FL-2 (FL-2 was dated 09/09/19); current care plan or statement of assessed need signed by the physician (care plan was dated 04/30/19 ); orders or written treatments or procedures from a physician or other licensed health professional and their implementation.

Attempted telephone interview with a second MA on 01/21/21 at 9:11am was unsuccessful.

Refer to the telephone interview with the Administrator on 01/21/21 at 12:15pm.

Refer to the interview with the Assistant to the Administrator on 01/22/21 at 9:38am. ______Interview with a MA on 01/14/21 at 2:57pm revealed another MA was responsible for organizing the resident records.

Telephone interview with the Assistant to the Administrator on 01/22/21 at 9:38am revealed: -He was responsible for auditing the records and had done a complete audit in December 2020. -He instructed the MA to "thin" the resident records and remove old documents last week. -There was another MA working at the facility, but she did not know where to locate the documents that were removed from the resident's record. -All of the documents were in a box at the facility. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 51 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 450 10A NCAC 13G .1213 (f) Reporting Of Accidents C 450 And Incidents

10A NCAC 13G .1213 Reporting Of Accidents and Incidents

(f) When a resident is at risk that death or physical harm will occur as a result of physical violence by another person, the facility shall immediately report the situation to the local law enforcement authority.

This Rule is not met as evidenced by: Based on record reviews and interviews, the facility failed to notify law enforcement immediately of an incident in which 1 of 4 residents sampled (#1) was harmed by another resident.

The findings are:

Observation of Resident #1 on 01/19/21 at 9:22am revealed: -She had a mark on her face that was dark red and was from the corner of her right eyebrow to her hairline. -She had a second mark on the lower part of her neck just above her left shoulder that was dark red and brown and had a long red line and splotched area; the mark was about 2.5 inches long and a half of an inch wide.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 52 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 450 Continued From page 52 C 450

Interview with Resident #1 on 01/19/21 at 9:22am revealed: -The marks on her face and neck occurred when her roommate tried to choke her Sunday evening, 01/17/21, while they were seated in the resident living room. -The staff person that was working that night came into the room and broke up the fight. -The police were not called. -Her roommate "scared her to death" on 01/17/21 because the roommate had her throat and "cut her wind this time". -She was also concerned her roommate would pull on her colostomy and could possibly pull it off.

Interview with the Administrator on 01/19/21 at 10:51am revealed: -Resident #1 and her roommate fought; they would hit each other every day. -They never left marks on each other; she was not worried because "they were young, and they got over it and it does not last long". -She was aware of the fight that occurred on Sunday evening, 01/17/21, because the personal care aide (PCA) called to inform her. -The staff called her Sunday, 01/17/21 and reported the two residents had hit each other and pushed each other in the hallway; she did not know about either residents' hands on the others throat because staff did not say anything about that. -She did not call for police intervention when the two residents fought. -She did not report the incidents to anyone because "you do not take everything to court or have the sheriff pick them up".

Attempted telephone interveiws with the PCA who Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 53 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 450 Continued From page 53 C 450 was on duty on 01/17/21 on 01/20/21 at 2:52pm and 4:51pm were unsuccessful.

C 611 10A NCAC 13G .1701 (b) Infection Prevention & C 611 Control Program (temp)

10A NCAC 13G .1701 INFECTION PREVENTION AND CONTROL PROGRAM (b) The facility shall assure the following policies and procedures are established and implemented consistent with the federal CDC published guidelines, which are hereby incorporated by reference including subsequent amendments and editions, on infection control that are accessible at no charge online at https://www.cdc.gov/infectioncontrol, and addresses the following: (1) Standard and transmission-based precautions, for which guidance can be found on the CDC website at https://www.cdc.gov/infectioncontrol/basics, including: (A) respiratory hygiene and cough etiquette; (B) environmental cleaning and disinfection; (C) reprocessing and disinfection of reusable resident medical equipment; (D) hand hygiene; (E) accessibility and proper use of personal protective equipment (PPE); and (F) types of transmission-based precautions and when each type is indicated, including contact precautions, droplet precautions, and airborne precautions; (2) When and how to report to the local health department when there is a suspected or confirmed reportable communicable disease case or condition, or communicable disease outbreak in

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 54 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 54 C 611 accordance with Rule .1702 of this Section; (3) Resident care when there is suspected or confirmed communicable disease in the facility, including, when indicated, isolation of infected residents, limiting or stopping group activities and communal dining, and based on the mode of transmission, use of source control as tolerated by the residents. Source control includes the use of face coverings for residents when the mode of transmission is through a respiratory pathogen; (4) Procedures for screening visitors to the facility and criteria for restricting visitors who exhibit signs of illness, as well as posting signage for visitors regarding screening and restriction procedures; (5) Procedures for screening facility staff and criteria for restricting staff who exhibit signs of illness from working; (6) Procedures and strategies for addressing staffing issues and ensuring staffing to meet the needs of the residents during a communicable disease outbreak; (7) The annual review and update of the facility ' s IPCP to be consistent with published CDC guidance on infection control; and (8) a process for updating policies and procedures to reflect guidelines and recommendations by the CDC, local health department, and North Carolina Department of Health and Human Services (NCDHHS) during a public health emergency as declared by the United States and that applies to

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 55 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 55 C 611 North Carolina or a public health emergency declared by the State of North Carolina.

This Rule is not met as evidenced by: TYPE B VIOLATION

Based on observations, record reviews, and interviews, the facility failed to ensure recommendations and guidance established by the Centers for Disease Control (CDC) and the North Carolina Department of Health and Human Services (NC DHHS) were implemented and maintained to provide protection of the residents during the global coronavirus (COVID-19) pandemic regarding recommended infection prevention and control practices to reduce the risk of transmission and infection as related to staff not wearing surgical facemasks, staff and residents not maintaining a social distance of 6 feet, no signage for visitor restrictions and cough and respiratory hygiene and no screening of staff and visitors.

Review of the Center for Disease Control (CDC) guidelines for the prevention and spread of the Coronavirus (COVID-19) disease in long-term care facilities dated 11/20/20 revealed personnel should always wear a facemask while in the facility.

Review of the CDC guidelines for use of facemasks revealed COVID-19 is transmitted through droplet, therefore the mouth and nose are to be completely covered when wearing a facemask to prevent contamination and transmission of COVID-19.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 56 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 56 C 611 Review of the CDC guidelines for Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities updated on 05/29/20 revealed: -Personnel should always wear a facemask while they are in the facility. -Designate one or more facility employees to actively screen all visitors and personnel, including essential consultant personnel, for the presence of fever and symptoms consistent with COVID-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) before starting each shift/when they enter the building. -Designate one or more facility employees to ensure all residents have been asked daily about fever and symptoms consistent with COVID-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). -Educate residents and personnel about COVID-19.

Review of the facility's COVID-19 Infection Control policy dated 01/01/21 revealed: -Under the policy for PPE for droplet precautions a surgical mask should be used. -All staff will be screened at the beginning of each shift for fever and respiratory symptoms; they would have their temperatures taken and the absence of shortness of breath, new or change in a cough and sore throat would be documented. -All visitors will enter through the front door or main entrance only. -Signs regarding visitation policies and screening and restrictions procedures will be posted at the visitor entrance. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 57 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 57 C 611 -All visitors will be screened for the presence of fever and symptoms consistent with COVID-19. -Conduct facility wide surveillance to identify opportunities to prevent or reduce the rate of infection in our residents, employees and visitors. -There were no policies for social distancing or communal dining or screening for fever or symptoms of residents.

1. Observation of the facility on 01/14/21 at 9:00am revealed: -There was no signage posted outside or inside of the entrance for guidance for visitors or staff regarding visitation or screening for COVID-19. -There was one staff working and she had on a cloth facemask. -The survey team was allowed to enter the facility by the staff and were not screened with a questionnaire or had their temperatures checked.

Observation of the medication aide (MA) on 01/14/21 at 9:38am revealed: -She left the facility and went to the facility less than 500 feet away to retrieve a box off the porch; the box held a touchless thermometer. -She took the temperatures of all the residents and said the temperatures out loud; she did not document the temperatures.

Observation of the facility on 01/14/21 at 12:54pm revealed: -Two men came into the facility with groceries; they were not screened and did not have their temperatures taken. -One of the men wore his facemask under his nose. -A woman came into the facility and began to put away groceries; she was not screened and did not have her temperature taken. -The woman had her facemask under her nose. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 58 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 58 C 611 -The Administrator came into the facility and was not screened and did not have her temperature taken. -The Administrator had on a cloth facemask under her nose.

Interview with a resident on 01/14/21 at 10:28am revealed: -She went to a physician's appointment the week before. -Her temperature was taken at the physician's office, but it was not taken at the facility when she returned from the appointment. -Her temperature was taken every day, but she did not know if anyone wrote it down anywhere.

Interview with the MA on 01/14/21 at 9:39am and 11:45am revealed: -The thermometer belonged in the facility; the building next door was a sister facility and they had borrowed the thermometer that morning. -The Administrator had told her to take residents' temperatures once a day since the pandemic. -She did not document the temperatures anywhere. -She took the temperatures of the residents before they left the facility for a physicians' appointment but not when they returned from the appointments. -The physicians' office took the residents temperatures while they were at the office. -She took her own temperature at the beginning and end of her shift, but she did not write it down anywhere. -She stayed overnights at the facility and worked two to three days in a row. -She knew to look for increased temperatures of 100 degrees Fahrenheit or higher; if anyone had a high temperature the Administrator wanted to be called. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 59 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 59 C 611 -She knew the symptoms for COVID-19 to look for were headache, fever, fatigue, and no taste or smell. -She asked the residents everyday if they had symptoms of COVID-19; she did not document anything anywhere. -Visitors were not allowed to come into the facility; family stayed on the porch to visit the residents. -The facility's primary care physician (PCP) came inside about once a week to see the residents; she took the PCP's temperature but did not document it anywhere. -She did not ask the PCP any questions or if she had symptoms because she was the physician. -She chose to wear her own cloth facemask because she could wash it; no one had provided guidance regarding surgical verses cloth facemask. -The Administrator came to the facility two to three times a week and she always wore a cloth facemask. -She took the Administrator's temperature when she came to the facility. -No one had ever told her to document any of the temperatures she took. -The Administrator told them about COVID-19 in March 2020; no visitors were allowed. -The Administrator told her to wear a facemask, not have contact with residents and to take residents' temperatures since April 2020.

Second interview with the MA on 01/14/21 at 2:28pm revealed: -She had not been given guidance for wearing a facemask other than the Administrator told her to wear one. -There were surgical facemasks provided by the facility for staff to wear but she had decided to wear her own cloth facemask; no one had told her not to wear a cloth facemask. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 60 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 60 C 611 -She was not aware of a policy or recommendation for staff to wear surgical facemasks while working.

Observation of the facility on 01/19/21 at 9:00am revealed: -There was no signage posted on the entrance or inside of the facility giving guidance to visitors and staff for screening or guidance for COVID-19. -The survey team was not screened and did not have their temperatures taken upon entry to the facility.

Observation of the facility on 01/19/21 at 9:16am revealed: -The survey team had their temperatures taken by the medication aide (MA); she did not document the temperatures. -She did not ask the team any pre-screening questions.

Telephone interview with the facility's contracted PCP on 01/21/21 at 2:00pm revealed: -She thought the facility took the residents' temperatures, but she did not know how often. -She told the staff about COVID-19 precautions like handwashing, facemask wearing, social distancing at meals and to separate if a resident was confirmed positive. -She took her own temperature when she went to the facility; staff did not take her temperature or ask her about symptoms.

Interview with the Administrator on 01/14/21 at 1:30pm revealed: -Visitors were not allowed into the facility. -She was not familiar with any questionnaire recommendations; she did not allow visitors in the facility anyway. -The PCP and her assistant came into the facility Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 61 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 61 C 611 to see residents. -The PCP took her own temperature so there was no need for the facility staff to take their temperatures. -She did not ask the PCP any screening questions because "she was a physician and she knew what to look for already". -She knew the symptoms of COVID-19 included sneezing, coughing, body aches and pains. -She had instructed the MA to take temperatures of the survey team and then to call her. -She did not know why the MA did not take the survey teams' temperatures other than they were from the state and knew the rules and regulations. -The staff checked each other's temperatures when they changed shifts; nothing was documented. -None of the residents were going to physicians' appointments or out for treatments; all appointments were done virtually. -She did not require staff to document temperatures for anyone because she figured it was not needed. -The MA did not take the temperatures of the survey team because she figured state workers would not visit the facility if they had an elevated temperature. -She did not know that anyone coming into the facility was required to have a temperature screening. -There were no screening questionnaires at the facility because no one was coming into the facility. -She did not know the PCP should have been screened whenever she visited the facility.

Telephone interview with the Administrator on 01/20/21 at 12:49pm revealed: -The facility was taking the temperature of Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 62 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 62 C 611 anyone that was not employed by the facility; visitors were not allowed inside the facility, so their temperatures were not taken. -She would ask visitors and staff if they had been in a crowd or if they had been in contact with anyone known to have COVID-19 but did not have a pre-screening questionnaire for her staff or for visitors prior to the survey teams' visit. -She was not documenting pre-screening questions or temperatures prior to the survey teams' visit; she did not know she should have been documenting the information. -She got her information for COVID-19 from the television, the PCP, and general search information on her computer but she could not name a specific website or source. -She thought she and the facility staff could wear cloth facemasks; the facility had no problem getting surgical facemasks and there were plenty on hand at the facility. -The facility staff stayed at the facility for a two to three-day shift; they were required to take their own temperatures once a day and to call her if they had a fever of 101 degrees Fahrenheit. -There was a sign on the front door that announced visitors were not allowed; there was no other signage in the facility because the residents would take it down. -Residents' temperatures were taken once a week and documented in the medication administration record (MAR).

2. Observation of the resident living room on 01/14/21 at 11:11am revealed: -There were five residents sitting in the living room. -There were two residents sitting on a loveseat and were less than one foot apart. -There were two residents sitting on the sofa and were less than three feet apart; the sofa was less Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 63 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 63 C 611 than two feet away from the love seat. -There was a third resident sitting in a recliner sitting five to six feet away from the sofa.

Observation of the lunch meal on 01/14/21 at 1:00pm revealed: -There were six residents seated at the dining room table together. -There were two residents seated side by side on two sides of the table and one residents at each end.

Interview with the MA on 01/14/21 at 9:39am and 11:45am revealed: -She kept up to date on COVID-19 by watching the news. -The Administrator told her when she went home from work "to try to stay in as much as possible". -She had not seen a policy for COVID-19 infection control or prevention. -The Administrator had not shown her any paperwork or information related to COVID-19.

Second interview with the medication aide (MA) on 01/14/21 at 2:28pm revealed: -She had not been provided any guidance in reference to social distancing related to COVID-19 -The Administrator had told her there was no need to stop communal dining because the facility did not have residents that had tested positive.

Interview with the Administrator on 01/14/21 at 1:30pm revealed: -She had the facility's COVID-19 policy in her car. -She told the staff to call her if they were exposed. -The PCP gave the staff updates on COVID-19 when she came. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 64 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 64 C 611

Telephone interview with the Administrator on 01/20/21 at 12:49pm revealed: -She had instructed her staff to practice social distancing with themselves and the residents; she had instructed staff to allow no more than four residents in the living room at a time. -She thought the residents were eating at separate meal times; she had instructed the staff to have no more than four residents eat at the table at a time. -She was not aware all six residents were eating around the dining room table at one time. -She was not aware of the temporary rule .1701 Infection control and preventions specifically dealing with COVID-19. -She got her information for COVID-19 from the television, the PCP, and general search information on her computer but she could not name a specific website or source. -She did not check her email for updated guidelines and recommendations from the NCDHHS or the LHD. -She did speak to the residents about COVID-19 when it first started but they do not understand how serious it is. ______The facility failed to implement and maintain the guidelines and recommendations established by the Centers for Disease Control (CDC), and the North Carolina Department of Health and Human Services (NC DHHS) for infection prevention and transmission during the COVID-19 pandemic in which staff did not wear surgical facemasks within the facility, practice social distancing with residents and communal dining and staff did not screen the residents, visitors, or themselves daily. The facility's failure to complete staff and visitor screenings and properly use facemasks placed the residents at increased risk for transmission Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 65 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 611 Continued From page 65 C 611 and infection from COVID-19, which was detrimental to the health and safety of the residents and constitutes a Type B Violation. ______A plan of protection was provided by the facility in accordance with G.S. 131D-37 on 01/15/21 for this violation.

CORRECTION DATE FOR THE TYPE A2 VIOLATION SHALL NOT EXCEED MARCH 3, 2021.

C 912 G.S. 131D-21(2) Declaration of Residents' Rights C 912

G.S. 131D-21 Declaration of Resident's Rights Every resident shall have the following rights: 2. To receive care and services which are adequate, appropriate, and in compliance with relevant federal and state laws and rules and regulations.

This Rule is not met as evidenced by: Based on observations and interviews, the facility failed to ensure adequate and appropriate care and services were provided to residents related to design and construction, housekeeping and furnishings, and medication administration.

The findings are:

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 66 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 912 Continued From page 66 C 912 and Construction (Type B Violation).]

3. Based on observations, record reviews and interviews, the facility failed to administer medications as ordered by a licensed prescribing practitioner for 3 of 3 sampled residents (#1, #2, and #3) related to a medication used to treat cancer (#1), an antibiotic (#2), and a laxative (#3). [Refer to tag C0030, 10A NCAC 13G .1004(a) Medication Administration (Type B Violation).]

C 914 G.S 131D-21(4) Declaration Of Resident's Rights C 914

Every resident shall have the following rights: 4. To be free of mental and physical abuse, neglect, and exploitation.

This Rule is not met as evidenced by: Based on observations, record reviews and interviews the facility failed to ensure a resident (#1) was free of physical abuse from her roommate.

1.The facility failed to ensure residents were treated with respect, consideration, dignity and the right to be free of physical abuse when Resident #1 was choked, scared and felt unsafe towards her roommate. [Refer to Tag 311 10A NCAC 13G .0909 Residents Rights Residents Rights (Type B Violation)]

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 67 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 922 Continued From page 67 C 922 C 922 G.S. 131D 21(12) Declaration of Resident's C 922 Rights

G.S. 131D-21 Declaration of Resident's Rights Every resident shall have the following rights: 12. To have and use his or her own possessions where reasonable and have an accessible, lockable space provided for security of personal valuables. This space shall be accessible only to the resident, the administrator, or supervisor-in-charge.

This Rule is not met as evidenced by: Based on observations, record reviews and interviews the facility failed to ensure every resident shall have the right to use his or her own possession where reasonable by the confiscation of Resident #1's personal cell phone as a punishment for fighting.

The findings are:

Interview with Resident #1 on 01/19/21 at 9:22am revealed: -The staff had to "get" on her and her roommate to stop arguing with each other; then the staff would take away their personal cell phones. -The Administrator would take her cell phone away from her for a few days to correct the behavior. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 68 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 922 Continued From page 68 C 922 -The Administrator had taken her cell phone away from her on Sunday, 01/17/21,and had not given it back to her after she and her roommate had a fight.

Telephone interview with Resident #1's family member on 01/19/21 at 2:56pm revealed: -She provided Resident #1 with a personal cell phone for her to use. -The Administrator told her it was a privilege for the residents to have a cell phone and it could be taken away from Resident #1 if the phone was misused. -She knew Resident #1 hit another resident and her cell phone was taken away from her for a week; she did not remember when.

Interview with the Administrator on 01/19/21 at 10:51am revealed: -The personal care aide (PCA) called her Sunday, 01/17/21, and reported the two residents had hit each other and pushed each other in the hallway. Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 69 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C 922 Continued From page 69 C 922 -She took their cell phones away from them when they misbehaved; she did that to "let them know they need to behave" and not "put their hands on each other anymore". -The two residents do not complain about taking their cell phones away from them. -By taking their cell phones away from them it showed them that they did not hit anyone; showed them how to be responsible as adults.

Attempts to interview the personal care aide (PCA) on 01/20/21 at 2:52pm and 4:51pm were unsuccessful.

C935 G.S. § 131D-4.5B (b) ACH Medication C935 Aides;Training and Competency

G.S. § 131D-4.5B (b) Adult Care Home Medication Aides; Training and Competency Evaluation Requirements.

(b) Beginning October 1, 2013, an adult care home is prohibited from allowing staff to perform any unsupervised medication aide duties unless that individual has previously worked as a medication aide during the previous 24 months in an adult care home or successfully completed all of the following: (1) A five-hour training program developed by the Department that includes training and instruction in all of the following: a. The key principles of medication administration. b. The federal Centers for Disease Control and Prevention guidelines on infection control and, if applicable, safe injection practices and procedures for monitoring or testing in which bleeding occurs or the potential for bleeding exists.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 70 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C935 Continued From page 70 C935 (2) A clinical skills evaluation consistent with 10A NCAC 13F .0503 and 10A NCAC 13G .0503. (3) Within 60 days from the date of hire, the individual must have completed the following: a. An additional 10-hour training program developed by the Department that includes training and instruction in all of the following: 1. The key principles of medication administration. 2. The federal Centers of Disease Control and Prevention guidelines on infection control and, if applicable, safe injection practices and procedures for monitoring or testing in which bleeding occurs or the potential for bleeding exists. b. An examination developed and administered by the Division of Health Service Regulation in accordance with subsection (c) of this section.

This Rule is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to ensure 1 of 2 sampled staff (Staff B) who administered medications completed the state approved 10-hour medication aide training course and successfully passed the required state medication administration examination.

The findings are:

Review of Staff C's personnel records revealed: -Staff C was hired on 09/06/19 as a supervisor in charge (SIC). -There was documentation Staff C completed the 5-hour medication training on 09/09/19. -There was documentation Staff C completed the Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 71 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C935 Continued From page 71 C935 medication clinical skills competency validation dated on 09/09/19. -There was no documentation Staff C had completed a 10-hour or 15-hour medication training. -There was no documentation Staff C had passed the written medication aide (MA) exam.

Review of a resident's medication administration records (MAR) for December 2020 and January 2021 revealed Staff C administered medication four times.

Review of a second resident's MAR for December 2020 and January 2021 revealed Staff C administered medication four times.

Review of a third resident's MAR for January 2021 revealed Staff C administered medication two times.

Interview with a resident on 01/14/21 at 9:32am revealed: -There was a staff member who could not administer medication. -Whenever that staff member was on duty, a medication aide (MA) from the sister facility would administer medication to the residents. -Staff C sometimes came over from the sister facility to administer medication.

Telephone interview with the Assistant to the Administrator on 01/21/2 at 9:38am revealed: -There were three staff assigned to work at the facility. -Staff C did not work at the facility; she worked in another facility that was located next door and owned by the Administrator. -He did not know why her initials and name were on the MARs unless there had been an Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 72 of 73 PRINTED: 02/12/2021 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______

FCL079-102 B. WING ______01/22/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 149 GLENDALE DRIVE SAFE HAVEN ACH # 3 EDEN, NC 27288

C935 Continued From page 72 C935 emergency he did not know about. -Staff C should not be administering medications at the facility because she did not work there. -Staff C had passed the examination and was a MA; he thought her documentation for her medication administration training and MA exam were in her record. -Staff C provided transport to the residents; she did not administer medication.

Attempted interview with Staff C on 01/20/21 at 9:13am was unsuccessful.

Division of Health Service Regulation STATE FORM 6899 8UQN11 If continuation sheet 73 of 73