Your Loving Family Care Home I

The facility failed to implement physician orders for weekly blood pressure checks for one resident. Review of vital sign logs for March, April, and May 2025 showed only one check per month was documented, and specific dates for these checks were missing. The resident's physician confirmed that weekly checks are necessary to properly monitor for blood pressure elevations or drops.

The facility failed to ensure that 2 of 4 staff members (Staff C and Staff D) who were administering medications had completed the required medication aide training, clinical skills competency validation, and the medication aide examination.

The facility failed to ensure that all staff members had no findings listed on the North Carolina Health Care Personnel Registry, specifically noted for Staff D, for whom no personnel record or HCPR check was available on-site.

The facility failed to ensure that at least one staff member on duty at all times had successfully completed CPR training within the last 24 months, as evidenced by a lack of documentation for Staff C and Staff D.

The facility failed to ensure that 2 of 4 staff members administering medications had completed required medication aide training, passed the written examination, and completed clinical skills competency validation. Specifically, records for Staff C showed no documentation of training or exam completion, and Staff D's personnel record was not available on-site for review.

The facility failed to maintain a matching therapeutic diet menu for a resident requiring a cardiac (heart healthy) diet. While menus existed for other specific diets, there was no corresponding menu to guide food service staff for this resident's physician-ordered nutritional needs.

The facility failed to provide a matching therapeutic diet menu for a resident prescribed a cardiac diet. While the resident's medical records and care plan required a low-fat, low-cholesterol, and low-sodium diet, the facility's menu for the date of inspection did not include a specific cardiac diet option. Additionally, the Administrator was unaware of the resident's specific dietary requirements.

The facility failed to ensure that medication was administered as ordered by a licensed prescribing practitioner. Specifically, for one resident, the prescribed eye vitamin (PreserVision AREDS) was documented as administered on the MAR, but the medication was not available on hand for administration during the survey.

The facility failed to maintain furniture in a clean and good repair. Specific issues included dressers with scratches, missing handles, and non-functional drawers, as well as chairs and television stands that were scuffed or had cracked wood.

The facility failed to ensure that walls, ceilings, and floors were kept clean and in good repair. Observations revealed cracked and peeling paint on walls and ceilings, scuffed doors, rusted/bent floor vents, and vinyl flooring that was rolled up exposing the sub-flooring.

The facility failed to ensure quarterly Licensed Health Professional Support (LHPS) reviews for one of two sampled residents who required oxygen therapy. The review of the resident's records indicated a failure to meet the required assessment and evaluation frequency.

The facility failed to ensure that one of three sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) upon hire. The employee record for Staff C lacked both a listed hire date and documentation of their HCPR status.