Peak Resources - Charlotte

In the surveyor’s words

From the most serious findings on record at Peak Resources - Charlotte, in the surveyor’s own words.

• Immediate jeopardy, patternF760Apr 19, 2021

  Based on staff interviews, nurse practitioner interview, physician interview, hospital record review and facility record review, the facility failed to administer 16 doses of an anticoagulant used to lower the risk of stroke or blood clot for 1 of 3 residents sampled for medication errors (Resident #1). The resident was hospitalized and diagnosed with a small area of acute infarction (stroke). Immediate jeopardy began on 3/15/21 when facility staff modified the anticoagulant order for Resident #1 which subsequently resulted in the 16 missed doses of the medication. The immediate jeopardy was removed on 4/9/21 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. […]

• Immediate jeopardy, isolatedF689Mar 21, 2024

  Based on observations, record review and staff interviews, the facility failed to prevent a resident with severe cognitive impairment, who wore an elopement alarm device due to known wandering and exit-seeking behaviors, from exiting the facility unsupervised and without staff knowledge by leaving an unalarmed exit door propped open for 1 of 4 residents reviewed for accidents (Resident #212). On 06/09/23, Resident #212 was noticed by staff at approximately 5:30 PM wandering the halls with her purse and was last seen in the facility at 6:35 PM sitting in the activity room by herself. At approximately 7:30 PM, Resident #212 was observed outside the building in the back parking area by a visitor and staff. […]

• Actual harm, isolatedF600Mar 22, 2023

  Based on observations, record reviews, resident and staff interviews, the facility failed to protect a resident's right to be free from mistreatment when 1 of 1 Nurse Aide (NA) #1 and 1 of 1 Treatment Nurse continued to hold a resident on her side, clean her from a bowel movement and continue providing pressure ulcer care after the resident yelled at them to stop and told them to let her turn over onto her back because her left leg was hurting and dangling off the bed. This was for 1 of 3 residents reviewed for abuse (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included hypertension, quadriplegia, and anxiety disorder. […]

• Actual harm, isolatedF600Mar 8, 2023

  Based on observations, record reviews, and staff, Nurse Practitioner and Physician interviews the facility failed to protect the resident's right to be free of a suspicious injury for 1 of 3 residents reviewed for abuse, Resident #3. Resident #3 was discovered to have a red area below her right eye with facial swelling on 1/22/2023 at 6:46 am which progressed to bruising under both eyes and bruising in left ear on 1/23/2023. Findings included: Resident #3, a Spanish speaking resident, was admitted to the facility on [DATE] and her diagnoses included chronic pain, arthritis, heart disease and dementia. […]

• Actual harm, isolatedF610Mar 8, 2023

  Based on observations, record review, and staff, Nurse Practitioner, and Physician interview the facility failed to complete a thorough investigation to determine the possible cause of a suspicious injury for 1 of 3 residents reviewed for abuse (Resident #3). A red area below Resident #3's right eye and facial swelling was identified on 1/22/2023 at 6:46 am which progressed to black and blue bruising under both eyes and left ear on 1/23/2023. Findings included: The facility's Abuse, Neglect, Misappropriation of Resident Property, and Exploitation Policy revised on 1/19/2023 stated the Administrator is responsible to ensure complaints of abuse, including injuries of unknown origin are investigated. […]