The Bluefields

The facility failed to maintain hot water temperatures within the required range of 100°F to 116°F. Specifically, 6 of 6 sampled fixtures in the Special Care Unit were found to have temperatures ranging from 123.4°F to 135.5°F, posing a significant burn risk to residents.

The facility failed to ensure necessary referral and follow-up to address the acute healthcare needs of a resident in the Special Care Unit following an unwitnessed fall. Although the resident reported pain and mental status changes, the facility did not follow up with the primary care physician regarding the need for x-rays.

The facility failed to ensure proper referral and follow-up to address the acute healthcare needs of a resident following an unwitnessed fall. Although the resident reported leg weakness and hip pain, and exhibited increased confusion, there was no evidence of physician notification or follow-up documentation for these changes in condition. Furthermore, no after-visit summary was available for the physician's visit occurring the day after the resident reported symptoms.

The facility failed to ensure that one staff member (Staff A) had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR). There was no documentation of an HCPR check completed upon hire for this employee, who had been performing medication administration duties.

The facility failed to provide enough staff on the assisted living side to meet the personal care and health care needs of residents. Specifically, insufficient staffing was observed during 1 of 2 observed shifts.

The facility failed to provide enough staff on the assisted living side to meet the personal care and health care needs of residents. Specifically, insufficient staffing was observed during 1 of 2 observed shifts.

The facility failed to maintain required aide duty hours on each 8-hour shift. Specifically, the home did not meet the minimum staffing requirements for residents based on its capacity or census.