Waters of Dillsboro-Ross Manor, The

In the surveyor’s words

From the most serious findings on record at Waters of Dillsboro-Ross Manor, The, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 3, 2025

  Based on record review, and interview, the facility failed to ensure a maintenance staff removed lye-based chemical drain cleaner from the bathroom of vulnerable resident for 1 of 3 residents reviewed for accidents. (Resident C) This deficient practice resulted in the resident ingesting the chemical liquid and sustaining low-grade esophageal injury and moderate-grade gastric injury that required intensive care at an acute care hospital. Findings include: A Quarterly Minimum Data Set (MDS) assessment, dated 11/27/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations). […]

• No harm, potential for more than minimal, patternF565Mar 26, 2026

  Based on interview and record review, the facility failed to act promptly regarding residents' concerns voiced during the Resident Council meetings for 4 of 12 months of meeting minutes reviewed. (August, September, October, and December 2025) Findings include:During the Resident Council Meeting, on 03/24/2026 at 1:45 P.M., the residents indicated the call lights were not answered in a timely manner and sometimes it took up to an hour to get assistance. The Resident Council Meeting Minutes were reviewed and indicated issues related to call lights were concerns on the following months: -August 2025, Residents indicated nursing staff were sitting in the office discussing personal things instead of coming to help answer call lights when needed. […]

• No harm, potential for more than minimal, patternF761Mar 26, 2026

  Based on observation and interview, the facility failed to store medications appropriately for 3 of 5 medication carts observed. (Upstairs Medication Cart 3-2, Upstairs Medication Cart 3-1, and the Dementia Unit Medication Cart)Findings include:During an initial tour observation, on 03/22/2026 at 9:51 A.M., the Upstairs Medications Cart 3-2 was sitting in the hallway outside the nurse's station, unlocked, and unattended. Three staff members walked by the unlocked medication cart. At 9:52 A.M., a staff member walked by the cart and locked it. […]

• No harm, potential for more than minimal, patternF557Jul 18, 2025

  Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity related to Activities of Daily Living (ADL) care and monitoring inventory of personal belongings for 4 of 9 residents reviewed for resident rights. (Residents B, C, K, and L) Findings include:1. During an interview and observation, on 07/17/25 at 10:17 A.M., Resident B indicated she was bruised during ADL care a couple of weeks ago. Staff members had come into her room early in the morning, after breakfast, and said she was going to take a shower. The resident held onto the grab bar on the side of the bed and kept saying she refused. […]

• No harm, potential for more than minimal, patternF761Mar 6, 2025

  Based on observation, interview, and record review, the facility failed to store medications appropriately related to vials of insulin for 2 of 3 medication carts reviewed. (Station 3 Medication Cart 2 and Station 2 Medication Cart) Findings include: 1. Medication Cart 2 on Station 3 was observed on [DATE] at 9:23 A.M., with Licensed Practical Nurse (LPN) 2, and included the following: - A Fiasp/Aspart insulin vial for Resident 3, that was ,d+[DATE] full. The delivery date on the storage bottle was [DATE]. No open date was on the vial or the storage bottle. The LPN indicated the resident received the insulin four times a day per a sliding scale, but he had not received it yet that day. - A Lispro insulin vial for Resident 64, that was ,d+[DATE] full. […]