Kingsbridge House

The facility failed to ensure that all staff members have no substantiated findings listed on the North Carolina Health Care Personnel Registry upon hire, as required by G.S. 131E-256.

The facility failed to ensure that two out of three sampled staff members had documented North Carolina Health Care Personnel Registry (HCPR) checks upon their hire. Specifically, personnel records for a personal care aide and a medication aide lacked evidence of these required background checks at the time of employment.

The facility failed to ensure walls, floors, and furnishings were kept clean in a resident's bathroom. Observations revealed a dried, brown-colored substance on the commode, sink, floor, and wall, as well as a strong odor of urine in a resident's room.

The facility failed to maintain clean walls, floors, and furnishings in a resident's bathroom, as evidenced by dried brown-colored substance on the commode, sink, floor, and wall. Additionally, a strong odor of urine was noted in the resident's room, and staff interviews indicated the facility had been without a housekeeper for approximately three months.

The facility failed to ensure the minimum required number of staff members were present in the Special Care Unit (SCU) on the third shift. Specifically, during a sample of 14 third shifts between 11/01/21 and 11/14/21, the facility was short of required staff hours on 9 of those shifts. This resulted in significant staffing deficits, with some shifts lacking up to 17.6 required staff hours.

The facility failed to ensure the minimum required number of staff were present in the Special Care Unit (SCU) on the third shift. Specifically, for several dates in November 2021, the staff hours provided were significantly lower than the hours required based on the resident census.

The facility failed to provide adequate supervision for a resident in the special care unit, resulting in two separate incidents where the resident eloped through a window. This failure occurred despite the resident's assessed need for a higher level of care due to a dementia diagnosis.

The facility failed to provide adequate supervision for a resident with dementia, resulting in two separate elopement incidents where the resident climbed out of a window to leave the building. Additionally, there was no documentation of an elopement risk assessment for the resident, and staff members reported a lack of training regarding elopement procedures.