Jones Family Home #1

The facility failed to ensure that all exit doors had functioning alarms for residents identified as wandering risks. Observations showed a resident exiting through the back door at various times without an active alarm, and the Administrator confirmed the alarm was not properly functioning.

The facility failed to maintain documentation of drug screenings for all staff members. A review of Staff A's personnel record revealed no documentation that a drug screen for the presence of controlled substances had been completed prior to hire.

The facility failed to ensure that one of two exit doors accessible to a resident identified as intermittently disoriented had a working alarm. Observations showed that the back exit door lacked an alarm, allowing residents and staff to enter and exit without an audible alert. The Supervisor in Charge confirmed the alarm system had stopped working several days prior to the survey.

The facility failed to ensure that two exit doors accessible to a resident identified as a wanderer were equipped with working alarms of sufficient volume. Observations showed that residents and staff were able to enter and exit through the front and back doors without any alarms sounding.

The facility failed to ensure that 1 of 2 sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry prior to hire. Specifically, Staff A's personnel record lacked a documented date of hire and documentation that a registry check had been completed.

The facility failed to develop an individualized, written resident care plan for 3 of 3 sampled residents. This failure was identified through observations, record reviews, and interviews regarding the required assessment process.

The facility failed to ensure that one of two sampled staff members completed the required 5, 10, or 15-hour medication aide training and clinical skills validation. Personnel records for Staff B lacked a documented date of hire and proof of state-approved training. The staff member had been administering medications since 10/14/2022 without the necessary updated credentials.

The facility failed to ensure that the supervisor in charge conducts quarterly audits to verify minimum requirements are met and documented in client records. Additionally, the Director failed to perform unannounced reviews of records to ensure compliance with established processes.

The facility failed to ensure that the monthly calendar is posted monthly within the facility.

The facility failed to ensure that one of three sampled residents was properly tested for tuberculosis upon admission. Specifically, documentation was missing regarding when a TB skin test was placed, and there was no evidence that a subsequent skin test was read.

The facility failed to maintain the outside grounds in a clean and safe condition. Specifically, the front porch steps were blocked by a wooden caution sign, the porch lacked necessary banisters/railings, and a patio love seat was obstructing the ramp leading to the front porch.