Mecklenburg Heath and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mecklenburg Heath and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 4, 2022

  Based on record review and interviews with staff, family, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to administer the correct medications to a resident when Nurse #1 administered medications prescribed for Resident #8 to Resident #4. Resident #4 received 5 medications which included long-acting insulin, muscle relaxer, blood pressure medication, antidepressant, and a dietary supplement/sleep aid. This resulted in Resident #4 becoming unresponsive and she had a critically low blood pressure (BP) of 70/40 that required intravenous fluid (IVF) resuscitation upon Emergency Medical Services (EMS) arrival. Resident #4 was transferred to the emergency room (ER) for evaluation of altered mental status (AMS). […]

• Immediate jeopardy, isolatedF622Jan 19, 2021

  Based on record review, legal guardian interview, facility staff and hospital staff interviews, the facility failed to communicate Resident #1's guardianship status to the hospital and failed to arrange for a supervised transfer and handoff of Resident #1 who was deemed incompetent and had a legal guardian. The nursing home provided confidential guardianship information to a contracted van driver in a sealed envelope. The van driver reportedly provided the sealed envelope to hospital staff and left the resident alone at the hospital. Hospital staff denied receiving any resident documentation in written, scanned, or telephonic format. This was evident for 1 of 3 residents reviewed for hospital discharges and transfers. […]

• No harm, potential for more than minimal, patternF812Jun 4, 2021

  Based on observations, record review and staff interviews, the facility failed to label, and date opened food items stored for use in 1 of 1 walk in refrigerator and 1 of 2 nourishment rooms. Findings included: 1. An observation of the kitchen conducted with the Food Service Supervisor on 06/01/21 at 11:30 AM revealed the following items were not labeled or dated upon opening: a. An undated and unlabeled package of opened sliced turkey breast was observed in the walk-in refrigerator. b. An undated and unlabeled opened plastic bag of lettuce was observed in the walk-in refrigerator. c. An undated and unlabeled opened plastic bag of cheese cubes was observed in the walk-in refrigerator. 2. […]

• No harm, potential for more than minimal, patternF880Jun 4, 2021

  Based on observations, record review and interviews with staff, pharmacy and construction workers the facility failed to follow The Centers for Disease Control (CDC) guidelines for personal protective equipment (PPE) with Enhanced Droplet Precautions (EDP) in 3 of 6 staff/construction workers observed and failed to wear masks that covered the mouth and nose in 3 of 10 staff/construction workers observed during the COVID-19 pandemic. Findings included 1. An observation was done on 06/01/21 at 12:14 PM of Patient Care Assistant (PCA) #1 on the 100 hall. PCA #1's mask was below the nose for several minutes when she was talking at the desk. […]

• No harm, potential for more than minimal, isolatedF550Jul 23, 2026

  Based on observations, record review, and staff interviews, the facility failed to maintain a resident's dignity when Nurse Aide (NA) #1 and NA #2 transferred Resident #67 in a mechanical lift out of her room into the common area hallway to a shower bed on the other side of the hallway with the front of her nude body covered with a bath sheet, exposing her bare hips and the bare sides of her buttocks for 1 of 2 sampled residents reviewed for dignity. Resident #67 stated the NAs would cover the front part of her body with a sheet and would leave her sides exposed, but she really didn't like that. […]