Soundview II #1

The facility failed to ensure necessary medical follow-up and referrals for residents. Specifically, two residents lacked documentation for scheduled or completed carotid duplex scans, sleep studies, and dental appointments despite existing physician orders.

The facility failed to ensure follow-up for necessary medical appointments for two residents. Specifically, Resident #2 did not receive a scheduled carotid duplex scan or sleep study despite physician orders, and Resident #1 did not receive a dental appointment that was ordered in February 2025.

The facility failed to maintain an adequate program of activities designed to promote the well-being of residents.

The facility failed to ensure medication was administered as ordered by a prescribing practitioner for one resident. A physician's order from February 14, 2018, to increase lisinopril dosage from once daily to twice daily was not transcribed to the medication administration record (MAR). Consequently, the resident continued to receive the incorrect dosage through March 2018.

The facility failed to ensure medications were administered as ordered by a prescribing practitioner for one of three sampled residents. Specifically, a physician's order from 2/14/18 to increase lisinopril dosage from once daily to twice daily was not transcribed to the Medication Administration Record (MAR). As a result, the resident continued to receive the incorrect dosage through March 2018.

The facility failed to ensure that one of two sampled staff members was tested for tuberculosis disease in compliance with required control measures. Specifically, while a first skin test was recorded, there was no documentation of the required second TB skin test for the employee.

The facility failed to ensure that one of two sampled staff members had no substantiated findings on the North Carolina Health Care Personnel Registry. A registry check performed in July 2015 revealed that the staff member had two substantiated findings entered on the registry in November 2013.

The facility failed to maintain a readily retrievable record documenting the receipt, administration, and disposition of controlled substances for accurate reconciliation.

The facility failed to ensure that one of two sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry. A review of Staff B's records revealed two substantiated findings entered on the registry on 12/14/13, which the Administrator was unaware of.

The facility failed to maintain accurate reconciliation and readily retrievable records for the receipt, administration, and disposition of controlled substances. This resulted in amounts ranging from 8 to 357 tablets of various controlled substances being unaccounted for across four sampled residents.