Hertford Manor

The facility failed to ensure that staff members responsible for preparing and serving food completed the required food service orientation program. An interview with a dietary aide revealed she had been working for two weeks without completing the orientation and was unaware of the requirement.

The facility failed to maintain proper kitchen cleanliness and staff training protocols. A staff member has been assigned to manage kitchen cleanliness, and the dietary manager will undergo training by a more experienced dietary aid to ensure proper food preparation and sanitation.

The facility failed to consistently follow up on resident appointments and document changes in status. The manager is now implementing a process to follow up on all appointments and ensure that any resident refusals or rescheduled appointments are documented in the patient record.

The facility failed to ensure that cleaning supplies, such as mop buckets and sanitizing buckets, were properly maintained and changed daily. Additionally, maintenance is required to ensure exterior doors are properly functioning to prevent flies from entering the kitchen area.

The medication aide failed to consistently review and follow up on all received medication orders and refills. The facility has implemented new documentation forms on medication carts to track refills and clarifications from pharmacies to ensure accuracy.

The facility failed to perform regular audits of the medication cart. A new weekly audit process has been established for the medication aide to ensure all refills and order clarifications are properly addressed and documented.

The facility failed to implement CDC and NC DHHS guidance regarding COVID-19 protections for newly admitted residents and those post-hospital discharge. Specifically, the facility did not properly utilize personal protective equipment (PPE), practice social distancing, or ensure the 14-day isolation/quarantine of residents to reduce the risk of infection transmission.

The facility failed to implement CDC and NC DHHS guidance regarding COVID-19 infection control for a newly admitted resident. Specifically, the facility did not post isolation signage on the resident's door and failed to maintain proper social distancing/quarantine protocols as the resident was observed walking through the facility hallway.

The facility failed to prohibit the use of portable electric heaters in resident bedrooms. Specifically, inspectors observed active portable electric heaters in rooms #13 and #14, including one instance where a staff member had provided a heater to a resident due to cold temperatures.

The facility failed to prohibit the use of portable electric heaters in resident bedrooms. Specifically, inspectors observed active portable electric heaters in rooms #13 and #14, including one instance where a staff member had provided a heater to a resident due to cold temperatures.

The facility failed to prohibit the use of portable electric heaters in resident bedrooms. Specifically, inspectors observed active portable electric heaters in rooms #13 and #14, with one resident reporting that staff had provided the heater to combat cold temperatures.

The facility failed to ensure that training on the care of residents with diabetes was provided to unlicensed staff prior to the administration of insulin. Specifically, two out of three sampled medication aides were found to have administered insulin without documented required training.