Inspection Report
Capacity: 30
Deficiencies: 7
Sep 13, 2023
Visit Reason
This report documents a Construction Section Biennial Survey conducted to assess compliance with the 2005 Rules 10A NCAC 13F for Adult Care Homes of Seven or More Beds and the 2012 North Carolina State Building Code for Institutional Unrestrained Occupancy.
Findings
Multiple deficiencies were cited including failure to maintain outside premises in a clean and safe condition, failure to maintain fire safety and emergency fire alarm systems in safe operating condition, issues with fire resistant doors not closing and latching properly, gaps allowing smoke spread, holes in fire resistant ceilings, and plumbing equipment not maintained safely such as loose toilet seats.
Deficiencies (7)
| Description |
|---|
| Outside premises were not maintained in a clean and safe condition; ceiling finish on courtyard porch damaged and peeling from water. |
| Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; FACP has a trouble signal due to lightning strike. |
| Failure to maintain fire safety equipment; cross corridor doors did not close and latch upon fire alarm activation. |
| Cross corridor doors leading into Assisted Living side have a 1/2 inch gap allowing smoke to spread. |
| Holes or gaps at penetrations through fire resistant rated ceilings; 1 inch diameter hole in bathroom ceiling of Room 1102. |
| Doors in Rooms 1115 and 1116 do not close and latch properly; rubbing on threshold and requiring excessive force or will not close. |
| Plumbing equipment not maintained safely; loose toilet seat on First Guest Toilet. |
Report Facts
Licensed bed capacity: 30
Inspection Report
Capacity: 30
Deficiencies: 8
Jan 11, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 2005 Rules 10A NCAC 13F for Adult Care Homes of Seven or More Beds and the 2012 North Carolina State Building Code for Institutional Unrestrained Occupancy.
Findings
Multiple deficiencies were cited including unclean and poorly maintained mechanical systems, unsecured oxygen cylinders posing hazards, failure to maintain fire extinguishers and associated equipment, obstructed emergency exit paths, uninspected automatic roll-down fire doors, gaps in fire-resistance-rated assemblies, and interior doors not latching properly.
Deficiencies (8)
| Description |
|---|
| Building mechanical systems are not kept clean and in good repair; ventilation grille in Bedroom 1104 Bathroom has excessive dust/lint. |
| Oxygen cylinders stored unsecured in Bedroom 2106, posing hazard if they fall and break valves. |
| Facility failed to properly maintain fire extinguishers and associated equipment; no documentation of monthly inspections since last annual maintenance in October 2017. |
| Exterior exit path obstructed by rocking chair at Exit 9, limiting door opening; deficiency corrected during survey. |
| Automatic roll-down fire doors in Second Floor Bistro and First Floor Bistro not inspected as required by NFPA 80. |
| Gap around cable near Bedroom 1111 not firestopped, compromising fire-resistance-rated ceiling assembly. |
| Fire sprinkler escutcheon plate dropped down in Bedroom 2109 Closet, exposing opening allowing spread of smoke and heat. |
| Corridor door in Bedroom 1111 did not latch into its frame when closed. |
Report Facts
Licensed bed capacity: 30
Number of oxygen cylinders: 8
Fire extinguisher inspection timeframe: 3
Inspection Report
Annual Inspection
Census: 12
Deficiencies: 5
Nov 21, 2017
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on November 20-21, 2017.
Findings
The facility failed to maintain fire safety equipment in a safe and operating condition related to 6 of 10 magnetic door locks in the memory care unit. Two sampled staff lacked timely Health Care Personnel Registry checks. The facility failed to assure referral and follow-up for a resident regarding physician notification of low blood pressure. The facility lacked a matching therapeutic diet menu for a resident with a low concentrated sweets diet order. Medication administration did not comply with physician orders for holding blood pressure medications under specified conditions.
Severity Breakdown
Type B Violation: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to assure all fire safety equipment was maintained in a safe and operating condition related to 6 of 10 magnetic door locks in the memory care unit, with emergency override switches padlocked and inaccessible. | Type B Violation |
| Failure to assure 2 of 4 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. | Type B Violation |
| Failure to assure referral and follow-up for 1 of 3 sampled residents regarding physician notification of blood pressure lower than 110/70 or pulse rate lower than 60. | — |
| Failure to have a matching therapeutic diet menu for 1 of 1 sampled residents with orders for a low concentrated sweets diet. | — |
| Failure to administer blood pressure medication as ordered for 1 of 3 sampled residents regarding holding metoprolol and lisinopril for blood pressure lower than 110/70 or pulse rate lower than 60, and awaiting new orders. | — |
Report Facts
Residents in Memory Care Unit: 12
Magnetic door locks not maintained: 6
Staff sample size: 4
Staff with missing HCPR checks: 2
Blood pressure readings less than 110/70: 10
Blood pressure readings less than 110/70: 13
Blood pressure readings less than 110/70: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Housekeeper | Sampled staff without timely Health Care Personnel Registry check |
| Staff B | Contract Chef | Sampled staff without timely Health Care Personnel Registry check |
| Maintenance Director | Named in findings related to fire safety equipment and magnetic door locks | |
| Business Office Manager | Business Office Manager | Responsible for Health Care Personnel Registry checks and staff employment records |
| Administrator | Administrator | Responsible for monitoring staff compliance and facility operations |
| Personal Care Aide | Personal Care Aide | Interviewed regarding memory care unit security and emergency override switches |
| Medication Aide | Medication Aide | Named as key holder for emergency override switches and involved in medication administration |
| Executive Chef | Executive Chef | Named in findings related to therapeutic diet menu |
| Registered Dietitian | Registered Dietitian | Contracted dietitian providing therapeutic menus |
| Resident Care Director | Resident Care Director | Responsible for reviewing medication orders and staff compliance |
Inspection Report
Original Licensing
Capacity: 30
Deficiencies: 3
Feb 4, 2016
Visit Reason
This is a biennial construction survey conducted as part of the initial licensing process for the facility, which was first licensed on 10/27/2015.
Findings
The facility was found to have deficiencies including unsecured grab bars in a bathing location, a smoke barrier door that did not close completely, and the absence of a required wiring diagram and system components location map near the fire alarm panel.
Deficiencies (3)
| Description |
|---|
| Facility has not maintained in a safe manner secured grab bars at bathing locations; loose grab bars in the walk-in shower for Room 2106. |
| Smoke barrier door on the second floor did not close completely to contain smoke and/or fire. |
| Facility neglected to post a layout floor plan of all electro-magnetic devices; no wiring diagram and system components location map under glass adjacent to the fire alarm panel. |
Report Facts
Licensed capacity: 30
Loading inspection reports...
