Suburban Guardianship

The facility failed to ensure that all current orders for medications and treatments were reviewed and signed by the resident's physician or prescribing practitioner at least every six months. This was evidenced by a review of 2 out of 3 sampled residents, specifically Resident #3, whose orders had not been updated since May 2023.

The facility failed to comply with regulations regarding the provision of pharmaceutical care services through a licensed pharmacist, prescribing practitioner, or registered nurse.

The facility lacked a fire suppression system and had only two entrances/exits. Evidence showed that a resident with significant physical limitations, including right-side paralysis, would be unable to exit the building without staff assistance during a fire. This creates a significant risk to resident safety during emergency evacuations.

The facility failed to ensure that one of three sampled residents had completed the required tuberculosis (TB) testing upon admission. Specifically, while a negative skin test was documented, the second step of the required testing was missing from the resident's record. Management acknowledged that the oversight occurred during their monthly record reviews.

The facility failed to ensure that one of three sampled residents had completed required tuberculosis testing upon admission. Specifically, Resident #3 did not have documentation of a completed second-step TB test in their medical record, and management had overlooked the missing requirement.

The facility failed to ensure that all staff members had no substantiated findings on the North Carolina Health Care Personnel Registry (HCPR) upon hire. Specifically, a Supervisor-in-Charge was working at the facility with substantiated findings on her registry check, and the Administrator's personnel file lacked documentation of an HCPR check at the time of hire.

The facility failed to ensure that staff members had completed required criminal background checks. A review of records showed that 5 out of 5 sampled staff members lacked the necessary background checks in accordance with state law.

The facility failed to keep floors in good repair in the kitchen, dining room, and den. Observations revealed gaps in the flooring, a missing transitional strip in a doorway, and damaged, peeling floor surfaces. Residents reported that the floor condition causes stumbling.