House of Blessings at Sutton Rd.

The facility failed to notify the Division of Health Service Regulation that resident evacuation capabilities had changed. Specifically, four out of six sampled residents required different levels of assistance, including verbal prompting and physical assistance, than what was listed on the facility's license.

The facility failed to ensure that 2 of 3 sampled residents had their assessments and care plans updated annually. Specifically, one resident had a care plan that had not been updated since November 2020, and another resident had a care plan that was not signed by their Primary Care Provider.

The facility failed to ensure therapeutic diets were served as ordered for 2 of 3 sampled residents. For Resident #1, who was ordered a regular chopped diet, observations during dinner service showed the resident was served Salisbury steak cut into pieces instead of the ordered diet.

The facility failed to ensure that one of three sampled residents had completed required tuberculosis (TB) testing upon admission. Specifically, there was no documentation of a TB skin test for Resident #1, despite the resident's records indicating a possible diagnosis of latent tuberculosis.

The facility failed to maintain accurate records regarding physician visits and medication changes. Specifically, a resident's physician visit was not documented, and the facility failed to ensure all residents' records are reviewed monthly by the administrator.

The facility failed to train all staff on the importance of following the doctor's order regarding medication. This was evidenced by a resident being placed on a new medication without proper staff training or documentation of the order.

The facility failed to ensure that the physician's professional certification was up to date. The assessment of physician certification by the administrator was not performed within the required three-month interval.

The facility failed to monitor and provide adequate nutrition and food service. A resident with dysphagia was served a diet that was not appropriate for their condition, and the facility failed to ensure staff were trained to recognize such risks.

The facility failed to ensure that all staff changes were properly communicated. A communication error regarding staff changes was identified, and the facility failed to ensure that all new and old staff orders are reviewed and documented.

The facility failed to ensure that all medication errors are documented and corrected accurately. A medication error occurred because the resident does not have any doctor's orders for the specific medication, and the facility failed to include this on the physician's orders.

The facility failed to provide adequate training for staff and residents regarding infection prevention. Staff were not properly trained to check resident temperatures, and there was a lack of documented temperature logs for residents and staff.

The facility failed to ensure that one of three sampled residents was tested for tuberculosis disease upon admission in compliance with required control measures. Specifically, documentation showed a resident had a TB skin test placed in February 2016 but lacked documentation of the required second skin test.