Carolina Reserve of Durham

The facility failed to ensure that 3 of 5 sampled staff members who administered medications had completed the required state-approved 5-hour, 10-hour, or 15-hour medication aide training courses. Specifically, for one staff member, there was no documentation of training completion or a medication aide verification form available for review.

The facility failed to ensure that three out of five sampled medication aides (Staff B, C, and E) had completed the required state-approved 5-hour, 10-hour, or 15-hour medication aide training courses. While some staff had passed written exams and clinical validations, there was no documentation of the required training course completion for these individuals.

The facility failed to meet requirements related to tag D310. This deficiency was part of the Statement of Deficiencies dated March 11, 2022, and was addressed in a Plan of Correction addendum.

The facility failed to meet requirements related to tag D358. This deficiency was part of the Statement of Deficiencies dated March 11, 2022, and was addressed in a Plan of Correction addendum.

The facility failed to meet requirements related to tag D375. This deficiency was part of the Statement of Deficiencies dated March 11, 2022, and was addressed in a Plan of Correction addendum.

The facility failed to meet requirements related to tag D377. This deficiency was part of the Statement of Deficiencies dated March 11, 2022, and was addressed in a Plan of Correction addendum.

The facility failed to ensure therapeutic diets were served as ordered for 2 of 4 sampled residents. Specifically, one resident was not served ordered orange juice, and the kitchen lacked necessary low fat/low cholesterol eggs and skim milk for resident dietary needs.

The facility failed to ensure that 8 ounces of milk was served to residents in the secured unit twice daily. Observations and interviews revealed that residents were not offered or served milk during dinner on 08/15/18 and breakfast on 08/16/18, and no milk was available in the unit's refrigerator.

The facility failed to ensure that therapeutic diets were served as ordered by the resident's physician. Specifically, for one sampled resident, the facility failed to provide a low fat/low cholesterol diet despite a physician's order for that specific diet.

The facility failed to ensure that 8 ounces of milk was served to residents in the secured unit twice daily. Observations and interviews revealed that residents were served water and tea instead of milk, and there was no milk available in the kitchen refrigerator for service.

The facility failed to ensure that exit door sounding devices were loud enough to be heard by staff when providing showers to residents. Specifically, the alarm could not be heard in a resident's bathroom when the door was closed and the shower was running. This poses a risk for residents identified with exit-seeking behavior and disorientation.

The facility failed to ensure that all nine exit door sounding devices were loud enough to be heard by staff during resident care. This deficiency specifically impacted a resident identified as disoriented and having exit-seeking behavior, as evidenced by an incident where the resident was found outside the building alone.