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Source: NC Division of Health Service Regulation
The facility failed to contact the physician for medication order clarification for two residents. Specifically, for Resident #2, a physician's order for carbamazepine 200mg was not properly entered on the Medication Administration Record (MAR), and the medication was not available for administration during the survey.
The facility failed to contact the physician for medication order clarification for two residents. Specifically, for Resident #2, a physician's order for carbamazepine 200mg was not properly entered on the Medication Administration Record (MAR), and the medication was not available for administration during the survey.
The facility failed to contact the resident's physician to verify or clarify medication orders for 2 of 3 sampled residents. Specifically, for Resident #2, the facility failed to identify that carbamazepine 200mg had been discontinued and failed to identify that there was no current order for Abilify 30mg, leading to incorrect medication administration records and unavailable medications.
The facility failed to ensure a resident was not left alone without staff supervision. On 04/29/21, the front door was found wide open, and a resident was observed sitting on the porch while the Supervisor-in-Charge was away from the building. The Supervisor-in-Charge admitted to leaving residents alone to run errands.
The facility failed to ensure a resident was not left alone without staff supervision. On 04/29/21, the front door was found wide open, and a resident was observed sitting on the porch while the Supervisor-in-Charge was away from the building. The Supervisor-in-Charge admitted to leaving residents alone to run errands.
The facility failed to ensure sufficient information for diagnoses, medications, diet, and resident care was documented on the FL-2 form for one resident. Specifically, the FL-2 lacked diagnoses, admission date, ambulatory status, assistive device information, bowel and bladder status, medication orders, and diet orders.
The facility failed to maintain walls, ceilings, and floors in good repair. Specific issues included a shattered front porch window, rusty air vents in the hallway, kitchen, and bathroom, and multiple dark brown ceiling stains indicating active or recent leaks in the living room, bedroom, kitchen, and bathroom.
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