NC State Veterans Home - Salisbury

In the surveyor’s words

From the most serious findings on record at NC State Veterans Home - Salisbury, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Dec 12, 2025

  Based on observation, record review, and interviews with staff and the Physician's Assistant (PA), facility staff used a shared blood glucose meter located in the medication cart without cleaning and disinfecting it before and after each use. This occurred while there were two residents identified with a known bloodborne pathogen in the facility with 1 of the 2 residents requiring blood glucose monitoring. Shared blood glucose meters can be contaminated with blood and must be disinfected after each use with an approved product and procedure. […]

• No harm, potential for more than minimal, patternF812Aug 8, 2024

  Based on observation and staff interviews, the facility failed to remove unlabeled items from 2 of 2 nourishment rooms. These practices had the potential to affect food served to residents. Findings included: An observation and interview conducted with Dietary [NAME] #1 on 08/05/24 at 11:10 AM revealed the nourishment room located on the second floor had a bottle of 12 fluid ounce (fl. oz) lactose free milk 20 fl. oz orange Gatorade, and an opened half full 20 fl oz. bottle of cherry coke located in the refrigerator that were unlabeled. Dietary [NAME] #1 further revealed they were not sure if the items belonged to a resident or nursing staff but should not have been located the refrigerator unlabeled. […]

• No harm, potential for more than minimal, isolatedF550Dec 12, 2025

  Based on observation, record review, and resident and staff interviews, the facility failed to honor a resident's request for a shower to be stopped when the resident told Nursing Assistant (NA) #3 to stop because he was man handling him. Resident #13 stated he was fearful of NA #3 and felt like no one was listening to him when he told staff about the incident. Additionally, the facility failed to maintain a resident's dignity by not placing a privacy/ dignity cover over his urine collection bag exposing his urine which was visible from the hallway to other residents, staff and visitors. This occurred for 2 of 3 residents reviewed for dignity (Resident #13 and Resident #3).The findings included: 1. […]

• No harm, potential for more than minimal, isolatedF605Dec 12, 2025

  Based on record review, and staff, Consultant Pharmacist and Physician interviews, the facility failed to ensure Resident #2 had a diagnosis for the use of antipsychotic medication and the as needed (PRN) antipsychotic medication, Haldol, used to regulate mood, behaviors, and thoughts, had a stop date of 14 days. The facility also failed to ensure Resident #1 had a diagnosis for the use of antipsychotic medication and antidepressant medication. This occurred for 2 of 5 residents reviewed for unnecessary medications (Resident #2, and Resident #1).The findings included:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included mild dementia with agitation, brief psychotic disorder and anxiety. […]

• No harm, potential for more than minimal, isolatedF607Dec 12, 2025

  Based on record review, staff, and resident, Resident Representative, Physician Assistant, and Psychiatric Nurse Practitioner interviews, the facility failed to follow and implement their abuse policy and procedures in the areas of protecting and reporting to the Administrator for 1 of 3 residents reviewed for abuse (Resident #13). Resident #13 told Nursing Assistant (NA) #3 that the NA was treating him roughly and man handling him and to stop care. NA #3 did not stop the care. NA #9 heard Resident #13 state that NA #3 treated him roughly and was man handling him during his shower. Neither NA #3 or NA #9 reported the incident to administration or the charge nurse on duty allowing NA #3 to finish his shift and to return to work the next day. […]