Goldsboro Assisted Living & Alzheimer's Care

The facility failed to provide adequate supervision for a resident with a history of multiple falls resulting in serious injuries, including a fractured nose and head injury. Specifically, there was no documentation of interventions being implemented to ensure the resident's safety following these incidents.

The facility failed to provide adequate supervision for a resident with a history of multiple falls resulting in serious injuries, including a fractured nose and head injury. Specifically, there was no documentation of interventions put in place following falls on 03/03/24 and 03/22/24. The facility's failure to implement necessary safety measures left the resident at high risk for further injury.

The facility failed to establish and implement infection prevention and control policies and procedures consistent with CDC guidelines. Specifically, the program lacks adequate coverage for standard and transmission-based precautions, environmental cleaning, hand hygiene, and procedures for screening visitors and staff for signs of illness.

The facility failed to maintain infection control processes required by the CDC and facility policy to prevent the spread of pathogens. A personal care aide was observed providing incontinence care to a resident without gloves, resulting in feces being spread to the resident's bed, the bedspread, and the aide's bare hands.

The facility failed to provide adequate supervision for 2 of 5 sampled residents, which resulted in multiple falls and injuries. Specifically, residents experienced skin tears, a facial laceration requiring stitches, and being found on the floor.

The facility failed to provide adequate supervision for two residents, resulting in multiple falls, being found on the floor, and sustaining injuries including skin tears and a facial laceration requiring stitches. Specifically, for one resident, no fall interventions were implemented and the primary care provider was not notified following a fall.

The facility failed to implement a physician's order for the application of thrombo-embolic deterrent (TED) hose for one resident. Review of records and observations showed the resident was not wearing the required hose and there was no documentation of application or removal in the medication administration records.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for one resident. Specifically, the facility discontinued an anti-hypertensive medication without obtaining a physician's order.

The facility failed to implement a physician's order for the daily application of thrombo-embolic deterrent (TED) hose for a resident. A review of medication records showed no documentation of TED hose use, and an onsite observation confirmed the resident was not wearing the prescribed hose.