Carmel Hills

The facility failed to ensure medication orders were clarified for one resident regarding oxygen use. Specifically, the order lacked clear direction on how often to check oxygen saturation levels and whether the oxygen was to be administered only at bedtime or as needed throughout the day.

The facility failed to ensure medication orders were clarified with a physician or prescribing practitioner. Specifically, for one resident, oxygen orders lacked direction on how frequently to check oxygen saturation levels to determine when supplemental oxygen was required.

The facility failed to ensure all medication orders were clear and specific. Specifically, an order for aloe vera juice did not specify an amount to be administered, leading staff to follow the product label instead of a precise physician-ordered dose.

The facility failed to clarify medication orders with a physician when orders were not clear or complete. Specifically, for one resident, the order for aloe vera juice did not specify a precise amount to be administered, leading the staff to use the manufacturer's label instructions instead of a verified medical order.

The facility failed to ensure a functional assessment was developed annually for Resident #2. The most recent care plan for this resident was dated 07/08/16, and no updated assessment had been completed since that time.

The facility failed to ensure that participation by a licensed health professional in the review and evaluation of resident health status and care plan updates was completed within 30 days of admission or change in condition. Specifically, there was no documentation of a care plan being completed for Resident #2 since July 2016, despite a decline in the resident's functional status.

The facility failed to ensure a functional assessment was developed annually for one of three sampled residents. Specifically, Resident #2 did not have a current care plan or assessment completed since July 2016, despite changes in their functional status and needs.

The facility failed to ensure that 4 out of 5 sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR). Specifically, personnel records for Staff A, B, D, and E lacked documentation of required HCPR checks.

The facility failed to ensure that 4 out of 5 sampled staff members had documentation of a North Carolina Health Care Personnel Registry (HCPR) check. Specifically, personnel records for Staff A, B, and E lacked evidence of required HCPR screenings upon hire.