Inspection Report
Annual Inspection
Deficiencies: 1
Aug 3, 2023
Visit Reason
The Adult Care Licensure Section and the Department of Social Services conducted an annual survey, follow-up, and complaint investigation from August 2, 2023 to August 3, 2023. The complaint investigation was initiated by the Department of Social Services on August 2, 2023.
Findings
The facility failed to hold a medication for 1 of 6 sampled residents related to a medication used to treat high blood pressure. Specifically, Resident #6 was administered metoprolol succinate ER 50mg despite physician orders to hold the medication if the resident's pulse was below 60. Interviews with staff and the primary care provider confirmed the medication should have been held according to the physician's parameters.
Complaint Details
The complaint investigation was initiated by the Department of Social Services on August 2, 2023 regarding medication administration concerns for Resident #6.
Deficiencies (1)
| Description |
|---|
| Failed to hold metoprolol succinate ER 50mg for Resident #6 when pulse was below 60 as per physician's order. |
Report Facts
Sampled residents: 6
Medication dose: 50
Pulse documented: 50
Pulse documented: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Coordinator | Administered medication to Resident #6 on June 27, 2023 and acknowledged medication should have been held | |
| Medication Aide | Administered medication to Resident #6 on July 3, 2023 and acknowledged medication should have been held | |
| Primary Care Provider | Confirmed medication should be held if pulse below 60 and expected staff to follow protocol | |
| Administrator | Stated staff should follow physician's orders including parameters of when to hold medication |
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 21, 2022
Visit Reason
The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual and follow up survey and complaint investigation on 04/21/22 and 04/22/22. The complaint investigation was initiated by the Buncombe County Department of Social Services on 04/20/22.
Findings
The facility failed to provide adequate supervision for a resident who eloped, failed to administer medications as ordered for two residents, and failed to ensure medication administration was properly observed for one resident. Multiple deficiencies related to supervision, medication administration, and documentation were identified.
Complaint Details
Complaint investigation was initiated by the Buncombe County Department of Social Services on 04/20/22 related to Resident #5 eloping from the facility.
Deficiencies (3)
| Description |
|---|
| Facility failed to provide supervision for Resident #5 which resulted in the resident eloping from the facility. |
| Facility failed to ensure medications were administered as ordered for Residents #3 and #4, including incorrect dosing and missing medications. |
| Medication aide failed to observe Resident #5 taking her morning medications, resulting in Resident #5 taking another resident's medications. |
Report Facts
Residents sampled: 5
Temperature: 21
Wind gust: 35.7
Medications dispensed: 30
Medications remaining: 10
Polyethylene glycol doses dispensed: 238
Polyethylene glycol doses dispensed: 510
Zofran tablets dispensed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Named in medication administration observation failure related to Resident #5 on 03/12/22 | |
| Personal Care Aide | Witnessed Resident #5 taking another resident's medication on 03/12/22 | |
| Administrator | Interviewed regarding supervision and medication administration deficiencies | |
| Health and Wellness Director | Responsible for medication order entry and care plan updates; unavailable for interview | |
| Nurse | Interviewed regarding medication order entry and administration | |
| Pharmacy Technician | Interviewed regarding medication orders and dispensing | |
| Nurse Practitioner | Interviewed regarding medication orders and resident follow-up |
Inspection Report
Capacity: 38
Deficiencies: 10
Jul 12, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a Construction Section Biennial Survey conducted on 7-12-2019 at Brookdale Asheville Walden Ridge.
Findings
The survey identified multiple deficiencies including a delayed egress door that would not release under required force, missing baseboard in the beauty salon, use of an extension cord through a doorway, presence of a wasp nest, a nurse call system showing a 'System Trouble' condition, compromised fire rated walls and ceilings with unsealed penetrations, corridor doors that do not close and latch properly, loose floor covering presenting a trip hazard, and a clogged condensate drain overflowing in the HVAC closet.
Deficiencies (10)
| Description |
|---|
| Delayed Egress exit door would not release and open when a force of not more than 15 pounds was applied; it required over 100 pounds. |
| Part of the baseboard was missing in the beauty salon. |
| Hose on the shower wand in the Beauty Salon was long enough to reach the sink basin without a vacuum breaker, risking siphoning contaminated water. |
| Extension cord used in place of permanent wiring, plugged inside a storage room and extended through a doorway to a refrigerator for employee use. |
| Presence of a wasp nest on the ceiling of the screened porch at the courtyard. |
| Nurse call system showing a 'System Trouble' condition, which may cause failure to operate properly. |
| Required one-hour fire rated walls and ceilings compromised with holes and unsealed penetrations in multiple locations including housekeeping closet, activity closet, HVAC closet, exterior storage room, and shower wall. |
| Many corridor doors prevented from closing quickly and latching properly, with holes at latchsets and loose latchset knobs on multiple doors. |
| Floor covering loosely attached in exit hallway from C Hall West, presenting a trip and fall hazard. |
| Condensate drain clogged and overflowing in the HVAC closet on A Hall. |
Report Facts
Licensed capacity: 38
Force applied to delayed egress door: 100
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 26, 2018
Visit Reason
The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual survey on 10/25/18 and 10/26/18 at Brookdale Asheville Walden Ridge.
Findings
The facility failed to ensure medication containers had correct labels for 1 of 3 sampled residents (Resident #2) related to allopurinol, mirtazapine, and fexofenadine. Medications were dispensed with outdated dosage labels without change in direction stickers, requiring medication aides to split tablets to administer correct doses.
Deficiencies (1)
| Description |
|---|
| Medication containers had incorrect labels for Resident #2 related to allopurinol, mirtazapine, and fexofenadine, with no change in direction stickers despite dosage changes. |
Report Facts
Tablets dispensed: 30
Tablets remaining: 22
Tablets dispensed: 30
Tablets remaining: 22
Tablets dispensed: 30
Tablets remaining: 22
Inspection Report
Capacity: 38
Deficiencies: 8
Jul 5, 2017
Visit Reason
This was a Construction Section Biennial Survey to assess compliance with physical plant, fire safety, and building code requirements for the licensed adult care home facility.
Findings
The survey found multiple deficiencies including lack of required signage on delayed egress doors, improper storage too close to fire sprinkler heads, inadequate fire drill rehearsals on each shift, corridor doors not closing and latching properly to resist fire and smoke, compromised fire rated walls and ceilings, exposed energized wires, and damaged doors posing safety hazards.
Deficiencies (8)
| Description |
|---|
| Delayed Egress exit door lacked required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.' |
| Improper storage too close to fire sprinkler heads, with items stacked within 5 to 9 inches of the ceiling in multiple locations. |
| Ice machine drain line extended into floor drain, risking contamination. |
| Fire drill rehearsals were not conducted quarterly on each shift as required, with multiple shifts missing rehearsals in various quarters. |
| Corridor doors failed to close completely and latch, including cross-corridor smoke barrier doors and various bedroom and service doors, compromising fire and smoke resistance. |
| One-hour fire rated walls and ceilings were compromised by holes and penetrations not properly sealed. |
| Light switch and plate missing in storage room exposing energized wires. |
| Closet door in Beauty Salon was badly damaged and in danger of falling. |
Report Facts
Licensed capacity: 38
Storage clearance: 18
Storage clearance observed: 5
Fire drill rehearsals missing: 5
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 5
Aug 28, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow-up survey on August 26, 2015 through August 28, 2015 to assess compliance with staffing, supervision, and resident care regulations.
Findings
The facility failed to assure sufficient personnel for housekeeping, food service, and direct resident care duties, and failed to provide adequate supervision for residents with assessed needs and symptoms of assaultive behavior. Multiple deficiencies were noted related to staffing, supervision, and resident safety.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Insufficient personnel employed to perform housekeeping and food service duties, resulting in direct care staff performing these duties during all shifts. | — |
| Management staff not routinely scheduled to provide direct care or medication administration duties. | — |
| Facility failed to assure staff provided supervision for 1 of 5 sampled residents with assessed needs and symptoms of assaulting staff and residents. | Type A2 Violation |
| Facility failed to assure minimum staffing was present at all times on third shift in the Special Care Unit. | — |
| Facility failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws and regulations related to personal care and supervision. | — |
Report Facts
Census: 35
Occupancy: 34
Staffing: 3
Medication aide and direct care staff: 1
Resident incidents: 6
Inspection Report
Capacity: 38
Deficiencies: 14
Aug 11, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable state rules and building codes for the licensed adult care home facility.
Findings
The survey identified multiple deficiencies related to physical plant safety and maintenance, including loose hand grips in bathrooms, trip hazards in exit corridors, improperly functioning fire safety doors, obstructed exit paths, non-working exit signs, compromised fire-rated walls and ceilings, and non-functioning exhaust ventilation in several areas.
Deficiencies (14)
| Description |
|---|
| Hand grip at the toilet in the bathroom off room C7 was loosely mounted to the wall. |
| Range hood fire suppression nozzles were pointed at the shelf above the cooking surface rather than the cooking surface itself. |
| Broken floor coverings presenting trip hazards in exit corridors near rooms A3 and D3. |
| Hair wash wand hose in Beauty Salon lacked a vacuum breaker, risking water contamination. |
| Cross-corridor door near room D2 failed to close completely when activated by fire alarm. |
| Exterior exit path near room B8 obstructed with chairs. |
| Exit corridors obstructed with stored items near rooms B8 and D3. |
| Many corridor doors not closing completely or fitting properly to resist fire and smoke passage, including doors to rooms C2, laundry near A8, D1, D2, D5, and D6. |
| Closer and latch removed from ¾ fire rated door separating kitchen from exit access corridor. |
| ¾ fire rated door between kitchen and serving kitchen obstructed from closing by slide bolt latch. |
| Fire rated glass missing from ¾ fire rated door separating kitchen from pantry. |
| Exit signs not working near rooms B8 and C8. |
| One-hour fire rated walls and ceilings compromised by holes, penetrations, missing cover plates, and inoperable ceiling radiation dampers in multiple locations including corridor near C7, employee lounge, mechanical/sprinkler riser room, maintenance room, business office, and mechanical closet near C8. |
| Exhaust ventilation not working in bathroom off room B5, mop closet off laundry, and mop closet near kitchen. |
Report Facts
Licensed capacity: 38
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