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Source: NC Division of Health Service Regulation
The facility failed to ensure that residents' FL-2 forms were completed in their entirety. Specifically, the patient information section was incomplete for two out of three sampled residents, lacking critical details such as physician visit frequency, neurological status, and special care factors.
The facility failed to ensure that residents' FL-2 medical examination forms were completed in their entirety. Specifically, the patient information section was missing for 2 out of 3 sampled residents.
The facility failed to ensure that 3 of 3 sampled residents (#1, #2, and #3) had a resident assessment and care plan completed within 30 days of admission and updated annually. This includes failure to maintain updated functional assessments for the sampled residents.
The facility failed to ensure that 1 of 3 sampled residents had been tested for tuberculosis in compliance with required control measures. Specifically, Resident #2 had a single TB skin test on record but lacked documentation of the required second step test.
The facility failed to ensure that one of three sampled residents had completed the required two-step tuberculosis (TB) skin testing upon admission. While a record showed an initial skin test, there was no documentation of the required second step of the testing process.
The facility failed to administer medications as ordered for Resident #1, specifically regarding a cholesterol-lowering medication (Lipitor). A review of records showed the medication was ordered but not entered on the Medication Administration Record (MAR), and the medication was not physically present in the facility. The Supervisor in Charge admitted to overlooking the order on the resident's FL-2 form.
The facility failed to administer medications as ordered for one resident, specifically regarding a cholesterol-lowering medication (Lipitor). A review of medication administration records showed no entries for the medication, and an observation confirmed the medication was not present in the facility. The supervisor in charge admitted to overlooking the medication order on the resident's clinical record.
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