Terrabella Lincolnton

The facility failed to ensure that one of five sampled residents had a completed annual medical examination (FL2). Specifically, Resident #2's last medical exam was dated 02/21/24, which exceeded the required annual frequency.

The facility failed to ensure an annual medical examination was completed for one of five sampled residents. Specifically, Resident #2 did not have an updated FL2 form, as the last one on file was dated February 21, 2024.

The facility failed to ensure that a resident assessment was completed within the required timeframe. Specifically, the assessment for Resident #3 was not completed within 30 days of admission.

The facility failed to employ a qualified Activity Director, instead utilizing a part-time activities assistant. Additionally, the facility failed to provide current activity calendars in the assisted living units and failed to maintain a consistent activity program, as evidenced by residents reporting a lack of scheduled crafts, games, or outings.

The facility failed to have a qualified Activity Director. Observations showed a lack of activity calendars on assisted living units, and interviews revealed that the facility lacked an AD, relying instead on an activities assistant and personal care aides to provide occasional games.

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, high blood pressure, and high cholesterol were not administered according to physician orders.

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, anxiety, and pain were not administered according to orders.

The facility failed to ensure that three sampled staff members had a North Carolina Health Care Personnel Registry (HCPR) check completed upon hire. Personnel records for these medication aides lacked documentation of the required HCPR checks at their respective hire dates.