L and C Family Care Home LLC

The facility failed to ensure a licensed pharmacist, provider, or registered nurse completed a quarterly onsite medication review for all sampled residents. Specifically, three out of three residents reviewed lacked documentation of a quarterly review that includes the reconciliation of current orders, medication administration records, and medications in the facility.

The facility failed to ensure that two out of three staff members were verified through the North Carolina Health Care Personnel Registry (HCPR) upon hire. Specifically, there was no documentation of an HCPR check for Staff B, and the administrator could not locate the required verification.

The facility failed to ensure that all current medication and treatment orders were reviewed and signed by a physician or prescribing practitioner at least every six months. This was evidenced by a failure to complete the required six-month review for 2 out of 3 sampled residents.

The facility failed to maintain hot water temperatures at a minimum of 100 degrees F and a maximum of 116 degrees F. Inspections of three fixtures, including sinks and a tub, revealed temperatures ranging from 94 to 96.5 degrees F. Additionally, a resident reported skipping showers because the water was too cold.

The facility failed to ensure the building was adequately equipped and maintained for a resident with physical impairments who could not evacuate independently. Specifically, the facility lacked a fire suppression system despite having a resident who required extensive assistance with transfers and ambulation.

The facility failed to ensure one of three sampled staff members received a tuberculosis test upon hire. While a second skin test was documented later, there was no record of an initial test performed at the time of employment.

The facility failed to ensure that one of three sampled staff members received a criminal background check upon hire. The background check for the staff member was not performed until several months after their start date.

The facility failed to ensure medications were administered as ordered to one of three sampled residents. Specifically, a medication used to treat anxiety was not administered according to the prescribed orders.

The facility failed to ensure that one of three sampled staff members received a tuberculosis test upon hire. While subsequent tests were documented, there was no record of an initial TB skin test being performed when the employee started employment in January 2021.