Northlake House

The facility failed to properly document required medical examination information on the North Carolina Medicaid Adult Care Home FL-2 form. Specifically, for one of three sampled residents, the resident's medication records lacked the required frequency and dosage information.

The facility failed to ensure that resident medication information on the FL-2 form included the required frequency and route of administration. Specifically, for one sampled resident, multiple medications including aspirin, atorvastatin, and citalopram HBR lacked these necessary details.

The facility failed to ensure that 6 of 5 sampled residents had Special Care Unit (SCU) resident profiles updated on a quarterly basis. Additionally, the facility failed to ensure that a SCU resident care plan was updated and completed annually for 1 of 5 sampled residents.

The facility failed to ensure that 5 of 5 sampled residents had Special Care Unit resident profiles updated on a quarterly basis. Additionally, the facility failed to ensure that a resident care plan was updated and completed annually for 1 of 5 sampled residents.

The facility failed to provide adequate supervision for a resident in the Special Care Unit who had a history of exit-seeking and wandering behaviors. This resulted in the resident eloping from the facility unnoticed, reaching a nearby business across a busy street. Additionally, the resident's care plan lacked documented interventions to prevent future elopement.

The facility failed to provide adequate supervision for residents in the Special Care Unit, resulting in a resident with a history of exit-seeking and wandering behaviors eloping from the facility without staff knowledge. Additionally, the resident's care plan lacked documented interventions to prevent future elopement incidents.

The facility failed to ensure that the FL-2 medical examination forms for two sampled residents included complete information and were clarified by the primary care provider. Specifically, one resident's FL-2 lacked a documented medical diagnosis.

The facility failed to provide feeding assistance with dignity and respect for two of five sampled residents. Observations showed staff members were standing while providing feeding assistance to residents.

The facility failed to administer medications as ordered for 2 of 5 sampled residents. Specifically, for Resident #4, donepezil was not administered for 7 out of 30 opportunities in November 2019 because staff failed to request pharmacy refills in a timely manner, despite medication being available on hand.