Mildred's Family Care

The facility failed to ensure that 2 of 3 sampled staff members were tested for tuberculosis in compliance with required control measures. Specifically, one staff member had no documentation of a negative TB test since being hired, and another staff member had outdated test results from 2018 with no recent documentation.

The facility failed to ensure that 1 of 1 sampled staff member had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR). There was no documentation indicating that an HCPR check had been completed for the staff member since they were hired at the facility.

The facility failed to ensure that exit doors accessible to disoriented residents had working, continuously sounding alarms that were audible throughout the facility. Observations revealed that alarms on both the front and side entrance doors did not sound when the doors were opened, posing a safety risk for residents exhibiting wandering behavior.

The facility failed to ensure all hired staff records contained current Tuberculosis (TB) test results. The Administrator and SIC are responsible for reviewing files twice a year to ensure compliance.

Required Health Care Practitioner Registry (HCPR) checks were not current for all staff members. The facility must ensure these checks are completed prior to hire and maintained through semi-annual reviews.

Criminal background checks for hired staff were not up to date or completed prior to employment. The Owner and Administrator are responsible for ensuring these checks are completed and reviewed twice annually.

The facility failed to ensure that drug screenings were current and completed for all staff prior to hire. All required paperwork must be verified to ensure compliance during bi-annual file reviews.

Required paperwork for specific staff positions was not maintained in a current state. The Administrator and SIC must ensure all position-specific documentation is completed before staff begin working.

The facility failed to ensure that exit doors accessible to disoriented residents had working alarms with sufficient volume. Specifically, storm doors lacked alarms, and the wooden exit doors had alarms that did not sound when opened or closed. This failure prevents staff from being alerted to potential wandering behavior.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit for resident use. Observations revealed water temperatures as high as 124 degrees Fahrenheit, and the facility lacked a temperature log or a thermometer to monitor and document these levels.

The facility failed to provide matching therapeutic menus for food service guidance for 2 out of 3 sampled residents who had physician orders for a ground/chopped diet. During the lunch meal observation on May 12, 2021, residents were served whole chicken legs instead of the required modified texture.

The facility failed to ensure a current Environmental Health Sanitation Inspection had been completed. Records and interviews revealed the last sanitation inspection occurred on October 23, 2013, and the facility had not received a subsequent inspection for nearly five years.