Terrabella Knightdale

The facility failed to maintain water temperatures in residents' rooms between 100 and 116 degrees Fahrenheit. Specifically, five out of ten tested fixtures showed temperatures ranging from 95.9 to 119.7 degrees Fahrenheit, including overheating in rooms A9, A10, and A18, and insufficient heat in rooms B3 and B12.

The facility failed to ensure proper referral and follow-up for a resident's acute health needs. Specifically, staff failed to contact the primary care provider regarding a resident who presented with a walnut-sized protrusion, redness, and swelling on her left foot and ankle. There was no documentation of the physician being notified of this condition.

The facility failed to ensure necessary medical follow-up for a resident with a physical ailment. Specifically, the facility did not contact the primary care provider regarding a resident who presented with a reddened, swollen, and bumpy left foot and ankle. There was no documentation showing that the physician was notified of this condition.

The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 4 out of 5 sampled residents. Specifically, medications for conditions such as dementia, vitamin D deficiency, stroke prevention, depression, anxiety, pain, and high blood pressure were not administered correctly.

The facility failed to ensure that 7 of 7 exit doors accessible by residents known to be disoriented were equipped with a functioning sounding device. Observations showed that when a door was opened, no audible alarm sounded, and staff did not receive alerts via pagers.

The facility failed to ensure that 7 of 7 exit doors accessible to a resident with known cognitive impairment and a history of elopement were equipped with functioning sounding devices. Observations revealed that several doors, including those on the A-Hall, B-Hall, and Media Room, did not trigger audible alarms or pager alerts when opened. Additionally, an exit door was found propped open with a wooden object without staff intervention.

The facility failed to ensure that seven out of seven exit doors accessible to a resident with known cognitive impairment and a history of elopement were equipped with functioning sounding devices. These devices are required to activate and alert staff when doors are opened to prevent unauthorized exits.

The facility failed to notify the primary care provider (PCP) regarding symptoms of a urinary tract infection and lab results for a resident. Despite the resident expressing discomfort and the family requesting an evaluation, the facility did not successfully coordinate follow-up care with the physician.