Inspection Report
Follow-Up
Deficiencies: 8
Mar 12, 2025
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies identified in a prior Biennial Construction Survey.
Findings
The facility failed to submit required construction plans for review and approval related to fire alarm panel replacement. Additionally, multiple fire safety and electrical equipment deficiencies were observed, including a fire alarm control panel in trouble mode, smoke barrier doors not closing properly, unapproved fire-resistant sealing materials, holes in fire-rated doors and ceilings, and broken electrical equipment covers.
Deficiencies (8)
| Description |
|---|
| Failure to submit plans to DHSR/Construction for review and approval when performing construction or remodeling, specifically for fire alarm panel replacement. |
| Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; fire alarm control panel in trouble mode. |
| Failure to maintain fire safety equipment; smoke barrier doors on B Hall did not close completely due to door facing separation. |
| Failure to maintain fire safety systems; holes or gaps at penetrations through fire resistant rated ceilings or walls allowing potential fire and smoke spread. |
| Use of orange foam product to seal cable penetrations and data sleeves that does not meet required fire resistant rating. |
| Presence of two 1/4" diameter holes through a door above and below door hardware compromising fire resistance. |
| Peeling ceiling finishing tape leaving holes in fire resistant rated ceiling. |
| Electrical equipment not maintained safely; broken cover for heater control in C-7 Bathroom with no replacement part found. |
Report Facts
Date of survey: Mar 12, 2025
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 5
Nov 14, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and a follow-up survey on August 13-14, 2024, to assess compliance with state regulations for the facility.
Findings
The facility failed to maintain hot water temperatures within the required range, ensure tuberculosis testing compliance for residents, maintain updated medical examinations and care plans, and provide water at each meal as required by regulations.
Deficiencies (5)
| Description |
|---|
| Hot water temperatures exceeded the maximum allowed 116°F in 10 of 10 resident bathroom sinks and common bathroom sinks before adjustment. |
| Two of five sampled residents (#1, #3) were not tested for tuberculosis disease in compliance with control measures. |
| One of five sampled residents (#1) did not have an updated medical examination (FL2) completed annually. |
| Two of five sampled residents (#1, #2) did not have accurate care plans signed by a provider within 15 days of assessment or updated annually. |
| The facility failed to serve water to residents at each meal; water was not served at breakfast unless requested by residents. |
Report Facts
Residents in dining rooms: 40
Residents sampled: 5
Residents with TB testing noncompliance: 2
Residents with care plan noncompliance: 2
Hot water temperature readings: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Responsible for ensuring water temperatures were within the correct range; was on vacation during inspection | |
| Health and Wellness Director | Responsible for ensuring tuberculosis testing, medical exam updates, and care plan compliance; conducted weekly chart audits | |
| Executive Director | Responsible for oversight of compliance with care plans and medical documentation | |
| Dietary Aide | Prepared and served beverages during meals; acknowledged water was not served at breakfast unless requested | |
| Personal Care Aide (PCA) | Assisted residents with meals and hygiene; acknowledged water was served only upon request at breakfast | |
| Administrator | Aware of water serving requirements and responsible for ensuring compliance |
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 12, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 12 and 13, 2023 to evaluate compliance with medication administration competency, licensed health professional support tasks, and medication administration regulations.
Findings
The facility failed to ensure medication administration competency validation for 2 of 3 sampled staff, failed to ensure competency validation for licensed health professional support tasks for 1 of 3 medication aides, and failed to administer medications as ordered for multiple residents, resulting in a 22% medication error rate during observed medication passes.
Deficiencies (3)
| Description |
|---|
| Failed to ensure 2 of 3 sampled staff who administered medications had completed a Medication Clinical Skills Competency Validation. |
| Failed to ensure 1 of 3 medication aides had been competency validated for licensed health professional support tasks including urinary catheter care. |
| Failed to ensure medications were administered as ordered for 3 of 4 residents observed during medication passes, including errors with urinary tract infection supplements, constipation medications, antidepressants, anti-inflammatory medications, topical pain relievers, mineral supplements, antifungal powder, prescription strength fluoride toothpaste, and glaucoma eye drops. |
Report Facts
Medication error rate: 22
Medication administration days documented for Staff A: 26
Medication administration days documented for Staff C: 11
Catheter care shifts documented for Staff C: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide/Medication Aide | Failed to have documented Medication Clinical Skills Competency Validation but administered medications independently |
| Staff C | Medication Aide | Failed to have documented Medication Clinical Skills Competency Validation and Licensed Health Professional Support validation but administered medications independently |
| Health and Wellness Director | Former employee responsible for ensuring competency validations and medication cart audits; left employment prior to survey | |
| Health and Wellness Coordinator | New employee responsible for processing medication orders and developing monitoring systems | |
| Administrator | Unable to locate competency validations for Staff A and Staff C; responsible for facility oversight | |
| Medication Aide | Observed administering medications with errors during medication passes | |
| Primary Care Provider | Contracted provider expressing concern about medication administration errors |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Mar 23, 2023
Visit Reason
The inspection was conducted due to complaints and elopements at the facility.
Findings
The facility failed to provide adequate supervision for 2 of 5 residents in the Special Care Unit, resulting in serious physical harm and neglect, constituting a Type A1 Violation. Multiple falls and injuries were documented, including a resident who suffered a traumatic brain injury and subsequent death.
Complaint Details
The visit was complaint-related, triggered by concerns about supervision failures and elopements. The report documents detailed findings related to Resident #2's multiple falls, injuries, and eventual death, as well as Resident #1's elopement incidents.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision for 2 of 5 residents in the Special Care Unit, leading to multiple falls, injuries, and death of a resident. | Type A1 Violation |
Report Facts
Total census: 44
Residents with supervision failure: 2
Falls documented for Resident #2: 9
Correction date deadline: Correction date for the Type A1 Violation shall not exceed 2023-04-23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charisse Fair | Area Nurse Manager | Signed as Administrator/Designee receiving the Corrective Action Report on 3/23/23 |
Inspection Report
Annual Inspection
Deficiencies: 7
Sep 2, 2021
Visit Reason
The Adult Care Licensure Section completed an annual survey from August 31, 2021 to September 02, 2021.
Findings
The facility failed to ensure competency validation for licensed health professional support tasks for medication and personal care aides, failed to provide adequate supervision resulting in multiple falls for a resident, failed to ensure physician notification and documentation for blood sugar checks, failed to clarify medication orders for acid reflux and pain medications, failed to administer medications as ordered for an antidepressant, and failed to ensure medication aides completed required infection control training and medication competency validations.
Deficiencies (7)
| Description |
|---|
| Failed to ensure competency validation for licensed health professional support tasks for medication and personal care aides. |
| Failed to provide supervision for a resident resulting in multiple falls and injury. |
| Failed to ensure physician notification and documentation for finger stick blood sugar checks with parameters. |
| Failed to clarify medication orders for pantoprazole and tylenol resulting in medications not administered as ordered. |
| Failed to ensure medications were administered as ordered for an antidepressant medication; documentation of refusals was lacking. |
| Failed to ensure medication aides completed required annual infection control training. |
| Failed to ensure medication aides completed medication clinical skills competency validation and passed the written medication aide examination. |
Report Facts
Falls: 5
Medication administration days: 10
Medication administration days: 13
Medication administration days: 9
Medication administration days: 15
Medication overage: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete medication clinical skills competency validation; administered medications observed on 09/02/21. |
| Staff B | Medication Aide | Had not completed state approved annual infection control training since 07/25/19. |
| Staff C | Personal Care Aide | No documentation of competency validation for licensed health professional support tasks. |
| Staff D | Personal Care Aide/Medication Aide | No documentation of passing written medication aide exam; documented medication administration days. |
| Staff E | Personal Care Aide | No documentation of competency validation for licensed health professional support tasks. |
| Staff F | Personal Care Aide | No documentation of competency validation for licensed health professional support tasks. |
| Area Nurse Manager | Provided information on competency validation and staff training processes. | |
| Business Office Manager | Responsible for maintaining staff records; acknowledged lack of audits and checklists. | |
| Administrator | Provided information on staff responsibilities and facility policies. |
Inspection Report
Follow-Up
Deficiencies: 6
Dec 6, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to the physical plant and building maintenance.
Findings
The facility had multiple outstanding deficiencies including damaged and unsafe outside premises, unclean and unrepaired housekeeping and furnishings, and failure to maintain building fire safety systems and plumbing equipment in safe and operating condition. Repairs were in progress but not completed at the time of inspection.
Deficiencies (6)
| Description |
|---|
| Outside premises not maintained in a clean and safe condition; damaged overhead latticework at A Hall exit. |
| Floors not kept clean and in good repair; damaged weatherstripping allowing pests inside; base loose in A Hall Exit vestibule. |
| Walls and furnishings not kept in good repair; bathroom doors in rooms D3 and D5 do not close properly. |
| Failure to maintain building fire safety systems; holes or gaps at penetrations through fire resistant ceilings in multiple locations including Men's Den Workshop and Furnace Rooms. |
| Fire safety equipment not maintained in safe operating condition; door latch plate screws not flush causing door to drag in E6. |
| Plumbing equipment not maintained in safe and operating condition; missing tank cover and stained toilet seat in E/F Hall Spa Restroom. |
Inspection Report
Capacity: 50
Deficiencies: 10
Oct 4, 2018
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules, 2005 Rules for Licensing of Adult Care Homes, and the 1996 NC State Building Code for a Home for the Aged serving 50 residents in a Special Care Unit.
Findings
The survey identified multiple deficiencies related to physical plant conditions including exit door locks not easily operable, unsafe and unclean outside premises, ceilings and floors not kept clean or in good repair, hazards such as unsecured oxygen bottles and trip hazards, inadequate fire safety rehearsals, mechanical and electrical equipment not maintained safely, fire safety system failures including doors not closing properly and holes in fire-rated ceilings, plumbing issues, and lack of required exhaust ventilation in certain areas.
Deficiencies (10)
| Description |
|---|
| Exit doors were not easily operable by a single hand motion; C Hall Exit door strikes the brick mold making it difficult to open. |
| Outside premises were not maintained in a clean and safe condition; damaged overhead latticework at A Hall exit. |
| Ceilings had mildew stains and damage; floors were not kept clean or in good repair; walls and furnishings were damaged or not in good repair. |
| Facility was not maintained free from hazards; unsecured oxygen bottles, trip hazards from uneven floors and clutter blocking electrical panels. |
| Fire safety rehearsals were not conducted quarterly on each shift as required; only one fire drill conducted in third quarter of 2018 on first shift. |
| Mechanical and electrical equipment not maintained in safe operating condition; dust accumulation, non-functioning GFCI outlets, scorch marks, and ants in outlets. |
| Fire safety equipment and building components not maintained; smoke doors not closing properly, holes and gaps in fire-rated ceilings, doors blocked open or dragging, sprinkler heads obstructed or missing escutcheon plates. |
| Plumbing equipment not maintained; missing toilet tank cover, leaking toilet causing floor stains. |
| Building not maintained in safe and operating condition; roof leak with temporary plastic tube drainage over icemaker. |
| Facility did not provide exhaust ventilation in required areas; bathroom exhaust fan not working. |
Report Facts
Licensed capacity: 50
Fire drills conducted: 1
GFCI outlets without power: 12
GFCI outlets observed: 12
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 1, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on February 1-2, 2017 and February 6, 2017 to assess compliance with state regulations.
Findings
The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit at multiple sinks in resident bathrooms and community areas, posing a risk of burns or discomfort. Additionally, the facility failed to provide adequate supervision for a resident with frequent falls, resulting in multiple injuries and lack of increased monitoring or interventions.
Severity Breakdown
Type B Violation: 1
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to assure hot water temperatures were maintained at a minimum of 100 degrees F to a maximum of 116 degrees F for 12 of 20 sinks in residents' bathrooms and 3 of 4 sinks in community spa rooms and restrooms. | Type B Violation |
| Failed to provide supervision for Resident #4 who required assistance with ambulation and had frequent falls, resulting in multiple injuries and no increased supervision documented. | Type A2 Violation |
Report Facts
Sinks with improper hot water temperature: 12
Sinks with improper hot water temperature: 3
Resident falls: 23
Fall incidents documented: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #4 | Resident with frequent falls | Subject of supervision deficiency and fall incidents |
| Medication Aide | Interviewed regarding fall procedures and supervision | |
| Health and Wellness Director | Responsible for fall incident reporting and care plan updates | |
| Executive Director | Interviewed regarding facility supervision policies and fall interventions | |
| Primary Care Provider | Resident #4's physician, aware of falls and medication adjustments | |
| Personal Care Aide | Provided care and supervision to Resident #4 | |
| Maintenance Staff | Responsible for monitoring and adjusting hot water temperatures | |
| Administrator-in-Training (AIT) | Interviewed about water temperature monitoring and policies |
Inspection Report
Capacity: 50
Deficiencies: 8
Nov 9, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Rules, 2005 Rules for Licensing of Adult Care Homes, and the 1996 NC State Building Code for a Home for the Aged serving 50 residents in a Special Care Unit.
Findings
Multiple deficiencies were identified including lack of current sanitation report, maintenance issues with doors and fire safety equipment, missing documentation of fire suppression system inspections, missing towel rack exposing sharp edges, inadequate fire safety rehearsals documentation, compromised fire rated walls and ceilings, and non-functioning exhaust fan in housekeeping closet.
Deficiencies (8)
| Description |
|---|
| Current sanitation report for the building was not available in the home for review. |
| Door to Bedroom C5 was difficult to open when latched closed, potentially trapping residents. |
| No documentation of monthly inspections on the range hood fire suppression system inspection tag. |
| Towel rack missing in the D Hall Spa exposing sharp edges on towel rack hangers. |
| Some fire safety rehearsal records lacked description of what the rehearsal involved. |
| Corridor doors prevented from closing quickly and latching or did not fit properly to resist fire and smoke passage. |
| Required one-hour fire rated walls and ceiling compromised in the Riser Room by tape and gypsum compound falling off. |
| Exhaust fan not working in the B-C housekeeping closet, failing to maintain required exhaust ventilation. |
Report Facts
Licensed capacity: 50
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