Inspection Reports for Avendelle at Lazy River

The Division of Health Service Regulation conducted a biennial survey to ensure compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and applicable portions of the 2012 North Carolina Building Code for small non-ambulatory care facilities.

Multiple deficiencies were cited including lack of current sanitation and fire safety approvals on site, a non-working over-the-range microwave, corridor obstructions, locked exit doors blocking egress, smoke detectors initially untestable but later verified operational, incorrect fire evacuation plan signage, various building equipment maintenance issues, and inadequate night lighting in resident areas.

The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation on 05/25/23.

The facility had multiple deficiencies including failure to maintain hot water temperatures within required limits, medication staff qualifications not met, inadequate supervision of a resident with wandering and inappropriate behaviors, failure to ensure health care referrals and follow-up for residents, failure to serve therapeutic diets as ordered, failure to protect resident rights, and medication administration errors including failure to administer prescribed medications and administering incorrect inhaler strength.

Complaint investigation included a male resident wandering into a female resident's room multiple times, attempting to get in bed with her, and inappropriate touching. The female resident was fearful and uncomfortable, and reported fear of retaliation from the Resident Care Coordinator.

The Adult Care Licensure Section conducted an annual and follow-up survey on 07/14/2021 to assess compliance with infection prevention and control programs and medication administration training requirements.

The facility failed to implement CDC COVID-19 guidance for daily resident temperature screening, instead taking temperatures monthly. Additionally, three sampled medication aides did not complete the required 15 hours of mandated medication administration training prior to administering medications.

The Division of Health Service Regulation conducted a Biennial Survey to ensure compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and applicable portions of the 2012 North Carolina Building Code for small non-ambulatory care facilities.

The survey identified deficiencies including improperly oriented fire evacuation plans and unsafe building equipment conditions such as a loose toilet, lint buildup behind the dryer, and a missing escutcheon in the riser room.

The Adult Care Licensure Section conducted an annual and follow-up survey on January 3, 2019, to assess compliance with medication aide training and competency requirements.

The facility failed to assure that 2 of 3 staff had completed the required 5, 10, or 15 hour medication training or had verification of prior work as a medication aide within the previous 24 months. Documentation and interviews revealed missing training and verification for Staff B and Staff C.