Roxboro Assisted Living Opcp LLC

The facility failed to ensure one of five exterior exit doors was equipped with a sounding device that is audible throughout the facility. This is required because the facility has residents who are disoriented or exhibit wandering behavior. Specifically, the main entrance alarm did not sound when the survey team entered or exited the facility.

The facility failed to ensure one of five exterior exit doors was equipped with a sounding device that is audible throughout the facility. This is required because the facility has residents who are disoriented or exhibit wandering behavior. Specifically, the main entrance alarm did not sound when the survey team entered the facility on multiple occasions.

The facility failed to ensure that all staff members had a completed criminal background check available in their personnel files. Specifically, a review of sampled staff revealed that 2 of 6 employees, including one personal care aide, lacked both the required signed consent and documentation of a completed criminal background check.

The facility failed to ensure that all staff members had a completed criminal background check in their personnel files. Specifically, a review of sampled staff revealed that two out of six employees, including a personal care aide, lacked both the required criminal background check documentation and signed consent forms.

The facility failed to meet required aide duty hour requirements for 30 out of 35 shifts between 05/10/24 and 05/21/24. Specifically, staffing levels for first and second shifts did not meet the mandated hours based on the resident census, resulting in significant shortages of aide hours.

The facility failed to ensure the environmental storage room containing hazardous materials, such as bleach and aerosol glass cleaner, was locked and inaccessible to residents. Observations confirmed the storage room door remained unlocked during the day to allow staff access, despite the presence of residents who were intermittently disoriented.

The facility failed to provide supervision according to a resident's assessed needs for a resident with a history of falls. Specifically, the resident's bedroom was located far from the front desk with the door closed, which did not align with the required frequent checks and monitoring measures outlined in the facility's fall policy.

The facility failed to properly manage fall prevention and monitoring. Specifically, there were deficiencies in the implementation of fall policies, including the use of bed/chair alarms and post-fall monitoring protocols.

The facility failed to ensure proper management of continuous oxygen orders and blood pressure documentation. There were issues with ensuring sufficient oxygen tanks were available and that blood pressure readings were accurately documented on the EMAR.

The facility failed to provide a required therapeutic diet for a resident. The facility was unable to follow specific dietary recommendations, necessitating a plan for resident discharge to a higher level of care.

The facility failed to maintain adequate medication cart audits and pill count documentation. There was a lack of consistent verification that medications on the cart matched the EMAR and that pill counts were being performed.

The facility failed to ensure proper documentation and auditing of narcotics. There were inaccuracies in the narcotic count sheets and a lack of consistent oversight to ensure all narcotics were signed off on both the count sheet and the EMAR.

The facility failed to maintain standard COVID-19 protocols, including daily temperature checks for staff and residents, visitor questionnaires, and proper masking requirements for visitors and service providers.