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Source: NC Division of Health Service Regulation
The facility failed to ensure that annual medical examinations (FL2) were updated for residents. Specifically, record reviews of two sampled residents revealed that their medical examinations had not been updated since early 2024, despite their admission dates requiring annual updates.
The facility failed to ensure that the results of medical examinations were properly documented on the required North Carolina Medicaid Adult Care Home FL-2 form. The documentation lacked the necessary updated information and physician signatures required by the regulation.
The facility failed to ensure that annual medical examinations (FL-2 forms) were updated for 2 of 3 sampled residents. Specifically, Resident #2 and Resident #3 had medical examinations that had not been updated since early 2024.
The facility failed to administer medications as ordered by the prescribing practitioner for one resident. Specifically, the resident's medication for seizures (clobazam) was not administered as prescribed, with documentation gaps and missed doses due to awaiting a refill.
The facility failed to administer medications as ordered by the prescribing practitioner for a resident. Specifically, the facility failed to properly manage orders for clobazam, resulting in incorrect dosages being documented on the eMAR and medications being unavailable for administration due to lack of refills and pharmacy order discrepancies.
The facility failed to administer medications as ordered by the prescribing practitioner for one resident. Specifically, the resident's medication for seizures (clobazam) was not administered as prescribed, with documentation gaps and missed doses occurring between July and August 2022 due to awaiting a refill.
The facility failed to administer medications as ordered by the prescribing practitioner for one resident. Specifically, the resident was not receiving prescribed doses of clobazam for seizure management, and the facility lacked the necessary medication on hand to administer the ordered doses. Discrepancies were also noted between pharmacy records and the electronic medication administration record (eMAR).
The facility failed to administer medications as ordered by the prescribing practitioner for one resident. Specifically, the resident's medication for seizures (clobazam) was not administered as prescribed, with documentation gaps and missed doses due to awaiting a refill.
The facility failed to maintain a matching therapeutic diet menu for all physician-ordered therapeutic diets. Specifically, there was no menu available for a resident required to be on a pureed diet, and a resident on a mechanical altered/ground diet was not properly accommodated via a matching menu.
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