Lake James Lodge Assisted Living

The facility failed to clarify a medication order for a resident regarding albuterol prescribed every four hours for shortness of breath. There was no documentation that the facility verified or clarified the order with the prescribing practitioner to ensure it was clear and complete.

The facility failed to ensure referral and follow-up for a resident who had a referral for physical therapy (PT). Specifically, the Resident Care Coordinator did not follow up with the hospital or home health agency to ensure the PT referral was processed, and no process was in place to ensure all orders and referrals were implemented.

The facility failed to ensure proper referral and follow-up for a resident's physical therapy needs. Specifically, the Resident Care Coordinator did not verify if a PT referral from a hospital discharge summary had been sent to the home health agency, resulting in the agency never receiving the order.

The facility failed to maintain a matching therapeutic diet menu for all physician-ordered diets to guide food service staff. Specifically, there was no therapeutic menu available for a pureed diet or a mechanical soft ground meat diet for two sampled residents.

The facility failed to provide adequate supervision for 4 out of 6 sampled residents regarding smoking safety. Specifically, for Resident #5, the facility failed to manage risks associated with the resident's history of burning fingertips while smoking, despite documented needs for smoking restrictions and known poor smoking habits.

The facility failed to provide adequate supervision for 4 of 6 sampled residents regarding smoking safety. Specifically, Resident #5, who has a history of burning himself while smoking, was observed smoking unattended in a designated area without staff presence. This lack of supervision resulted in documented incidents where the resident's hair, beard, and clothing caught on fire.

The facility failed to provide adequate supervision for two residents who were observed smoking inside the building. This occurred despite the facility being a smoke-free community with posted 'No Smoking' signs.

The facility failed to maintain a safe environment by allowing a portable electric infrared space heater to be used in the back hall common area. This violates the prohibition of unvented fuel-burning and portable electric heaters.

The facility failed to comply with regulations prohibiting the use of portable electric heaters. An active, infrared portable space heater was observed in the back hall common area, and staff interviews indicated awareness of the device's presence despite knowing the prohibition.

The facility failed to maintain a North Carolina Division of Environmental Health sanitation score of 85 or above. A review of a previous report from 10/2/15 showed a score of 83, with noted issues including unclean floors, walls, and ceilings, as well as mold on the ceiling and furniture.