The Haven in the Village at Carolina Place

The facility failed to ensure the Resident Register was completed and signed within 72 hours of admission. Based on record reviews and interviews, the facility did not meet the requirements for maintaining updated resident identification, care needs, and preferences within the register.

The facility failed to ensure the Resident Register was properly completed, signed, and dated by the Administrator and the resident or their representative. Specifically, for three sampled residents, the Resident Register lacked admission dates, Administrator signatures, and required signatures or dates from Power of Attorney representatives.

The facility failed to ensure that care plans for 2 out of 3 sampled residents were signed within 15 days of completion. Specifically, one resident's care plan completed on 04/16/23 was not signed by the Primary Care Provider until 06/06/23.

The facility failed to ensure that 2 of 3 sampled residents had care plans signed by a Primary Care Provider within 15 days of completion. Specifically, Resident #2's care plan completed on 04/16/23 lacked a required signature, and Resident #3's care plan completed on 04/08/23 was not signed until 06/06/23.

The facility failed to ensure physician orders were implemented for one resident regarding a medication used to treat depression and anxiety. Specifically, the Assistant Resident Care Director failed to fax the sertraline order to the pharmacy, resulting in a lack of medication administration documentation and no medication being available on the medication cart.

The facility failed to ensure physician's orders were implemented for a resident regarding a medication used to treat depression and anxiety. Specifically, a new order for sertraline was not faxed to the pharmacy, resulting in the medication being unavailable on the medication cart. Additionally, there was no documentation on the Medication Administration Record (MAR) explaining why the medication was not administered.

The facility failed to maintain a mattress in good repair for one resident. Specifically, the mattress had multiple black stains, the mattress pad was shredded in multiple places, and the pillow was provided without a pillowcase.