Heart to Heart Family Care Home

The facility failed to ensure that two sampled staff members had a documented Health Care Personnel Registry (HCPR) review completed upon hire. Personnel records for both medication aides lacked evidence of the required background check, and the employees were unaware of the HCPR process.

The facility failed to ensure therapeutic diets were served as ordered for three sampled residents. Specifically, the facility did not provide the required 1800 calorie diet or low sodium diet as prescribed by the residents' physicians.

The facility failed to ensure that therapeutic diets, including nutritional supplements and thickened liquids, were served as ordered by the resident's physician. This was evidenced by observations, record reviews, and interviews during the survey.

The facility failed to ensure that one of three sampled residents had completed the required two-step tuberculosis (TB) testing upon admission. Specifically, there was no documentation of a TB skin test available in the medical record for Resident #2.

The facility failed to ensure that the resident's physician authorizes personal care services and certifies the care plan by signing and dating it within 15 calendar days of the assessment completion.

The facility failed to ensure that 2 of 3 sampled residents had completed the required two-step tuberculosis (TB) testing. Specifically, for Resident #1, there was no documentation that a TB skin test was read and no evidence of a second skin test was provided.

The facility failed to ensure that 1 of 3 sampled residents had completed the required two-step tuberculosis (TB) testing in compliance with established control measures. Specifically, there was no documentation of a TB skin test for Resident #2 despite their recent admission.

The facility failed to ensure that 2 of 3 sampled residents had a care plan signed and dated by a physician within 15 days of the completion of assessments. For Resident #2, the care plan dated 06/11/21 lacked the required physician authorization and assessor certification signatures.

The facility failed to maintain adequate infection control documentation and screening procedures for COVID-19. Specifically, there was no documentation of resident temperatures for several months, and staff/visitor screening protocols were not consistently followed or documented. Additionally, observations showed residents were not consistently wearing facemasks correctly as required by infection control guidelines.

The facility failed to implement and maintain COVID-19 safety protocols as recommended by the CDC and NC DHHS. Specifically, the facility failed to properly screen visitors and staff for symptoms, post required signage, use appropriate PPE, and maintain necessary infection control procedures to reduce transmission risks.