Avendelle Assisted Living on Lazy River

The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit. Specifically, 9 out of 9 sampled fixtures were found to have temperatures ranging from 118 to 127.9 degrees Fahrenheit, posing a burn risk to residents.

The facility failed to maintain hot water temperatures at all resident-accessible fixtures between 100 and 116 degrees Fahrenheit. Specifically, 9 out of 9 sampled fixtures were found to have temperatures ranging from 118 to 127.9 degrees Fahrenheit, posing a burn risk to residents.

The facility failed to implement CDC recommendations and its own infection control policy regarding resident temperature screening during the COVID-19 pandemic. While policy required daily fever screening, records and interviews revealed temperatures were only being taken monthly or weekly. This failure to maintain daily surveillance increased the risk of undetected infection transmission among residents.

The facility failed to implement CDC guidance regarding COVID-19 prevention. Specifically, residents' temperatures were being taken monthly instead of daily as required by the facility's infection control policy and CDC recommendations.

The facility failed to ensure that all staff members administering medications had completed the mandated 15 hours of medication administration training. A review of sampled staff records showed that some employees had not completed the required training hours prior to administering medications.

The facility failed to ensure that 2 out of 3 sampled staff members had completed the required 5-hour, 10-hour, or 15-hour medication training or provided verification of working as a medication aide within the previous 24 months. Personnel records for Staff B and Staff C lacked documentation of the necessary training or prior employment verification required to perform unsupervised medication aide duties.

The facility failed to provide documentation that Staff B had completed the required competency evaluation for medication administration. There was no evidence of the required clinical skills evaluation or training components being documented for this staff member.

The facility failed to ensure that all staff members were checked against the North Carolina Health Care Personnel Registry (HCPR) for substantiated findings prior to working. Specifically, a review of personnel records for Staff C revealed substantiated findings on the HCPR.