Henderson Care Center

The facility failed to ensure proper referral and follow-up for resident health needs. Specifically, the facility failed to send blood sugar log results to a physician's assistant for a resident with orders for insulin and blood sugar monitoring.

The facility failed to ensure that all staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) upon hire. Specifically, two out of three sampled Personal Care Aides lacked documentation of an HCPR check being completed at the time of their employment.

The facility failed to ensure all residents received care and services that were adequate, appropriate, and in compliance with relevant state laws and regulations. Specifically, the failure to properly vet staff qualifications through HCPR checks violated the standards required for appropriate care delivery.

The facility failed to ensure that 2 of 3 sampled Personal Care Aides (Staff B and E) had North Carolina Health Care Personnel Registry (HCPR) checks completed upon hire. This lack of documentation meant the facility could not verify that these staff members had no substantiated findings on the registry, potentially impacting resident safety.

The facility failed to ensure that therapeutic diets, including thickened liquids, were served as ordered by the resident's physician. Specifically, one resident ordered nectar-thickened liquids was served a liquid with a water-thin consistency. The Dietary Manager admitted to difficulty achieving the proper thickness and failed to verify the consistency before service.

The facility failed to ensure that therapeutic diets, including thickened liquids, were served as ordered by the resident's physician. Specifically, Resident #1 was served nectar-thickened liquids when the physician's order required a different consistency, and the facility's diet list was undated and lacked specific consistency details.

The facility failed to ensure that physical restraints, specifically bed rails and a geri-chair with a table top, were used only after a physician's order was obtained and an assessment and care planning process was completed. This failure resulted in Resident #5 falling out of bed over the bed rails. Documentation for the use of these restraints was absent in the resident's record.

The facility failed to ensure that physical restraints were used only after alternatives had been tried and documented. This was identified as a Type A2 violation based on observations, record reviews, and interviews.