Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2024
Visit Reason
Follow up construction survey conducted by documentation review to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected based on documentation received, and no further action is required at this time.
Inspection Report
Capacity: 50
Deficiencies: 9
Oct 16, 2024
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 w/ '98 revision of the North Carolina State Building Code.
Findings
Multiple deficiencies were cited including obstructions in corridors, unmaintained outside premises, poor housekeeping and furnishings, unsafe storage of oxygen bottles, failure to maintain fire safety systems and equipment, blocked or malfunctioning fire doors, electrical hazards, excessive storage in mechanical rooms, and lack of exhaust ventilation in specified areas.
Deficiencies (9)
| Description |
|---|
| Corridors were obstructed by wheelchairs and walkers reducing clearance to less than six feet. |
| Outside grounds were not maintained in a clean and safe condition; window screens were ripped and torn. |
| Ceilings and floors were not kept in good repair; water stains on ceiling tiles and carpet unraveling creating trip hazards. |
| Oxygen bottles were improperly stored unsecured in rooms 1101 and 1112. |
| Fire safety systems had holes and gaps at penetrations allowing potential spread of fire and smoke. |
| Fire doors did not close properly or were blocked open, compromising smoke compartment safety. |
| Electrical equipment had missing or broken cover plates creating injury hazards. |
| Excessive storage in mechanical rooms blocked access to equipment and created fire hazards. |
| Facility did not maintain exhaust ventilation in specified spaces; fans in rooms 1107 and 1213 baths were disconnected. |
Report Facts
Licensed bed capacity: 50
Inspection Report
Annual Inspection
Deficiencies: 1
Jul 18, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on July 17-18, 2024.
Findings
The facility failed to implement a physician's order for blood pressure checks every morning for seven days for one sampled resident (Resident #4). The order was missed and not entered into the electronic Medication Administration Record (eMAR) system.
Deficiencies (1)
| Description |
|---|
| Failed to implement physician's orders for blood pressure checks daily for seven days for Resident #4. |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for ensuring orders were entered into eMAR; unaware of missed order for Resident #4 |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for ensuring orders were entered into eMAR |
| Administrator | Administrator | Responsible for ensuring orders were entered into eMAR; unaware of missed order for Resident #4 |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 8, 2022
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County DSS conducted an Annual Survey on September 7-8, 2022 to assess compliance with health care and regulatory standards for the facility.
Findings
The facility failed to assure contact with a medical professional for one resident, resulting in missed administration of levothyroxine sodium for hypothyroidism. Additionally, the facility failed to maintain an accurate and current list of residents requiring physician-ordered therapeutic diets, leading to incorrect diet information for one resident.
Deficiencies (3)
| Description |
|---|
| Facility failed to assure contact with a medical professional for Resident #4, resulting in missed administration of levothyroxine sodium for hypothyroidism over multiple months. |
| Facility failed to maintain an accurate and current list of residents with physician-ordered therapeutic diets, resulting in Resident #4 being listed incorrectly as on a regular diet instead of a low cholesterol, low fat diet. |
| Facility failed to administer medications as ordered for Resident #4, missing levothyroxine sodium doses 19 times in July, 18 times in August, and 5 times in September 2022. |
Report Facts
Missed medication doses: 19
Missed medication doses: 18
Missed medication doses: 5
Therapeutic diet list date: Jul 14, 2022
Therapeutic diet list date: Sep 2, 2022
TSH lab value: 3.82
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 31, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey on July 30 and 31, 2019 to assess compliance with state regulations for the facility.
Findings
The facility was found to have multiple deficiencies including chronic urine odors in a resident's room, failure to ensure medication aides received required diabetic training, failure to implement physician orders for oxygen for a resident, and failure to administer medications as ordered for another resident.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain the environment free of chronic urine odors in resident room #1222. | — |
| Facility failed to ensure 2 of 2 medication aides received training on care of diabetic residents prior to insulin administration. | — |
| Facility failed to assure implementation of physician orders for oxygen for Resident #2. | Type B Violation |
| Facility failed to administer medications as ordered for Resident #4 related to constipation and diabetes medications. | — |
| Resident #4 self-administered insulin (Lantus) without a current physician's order. | — |
Report Facts
Deficiencies cited: 5
Dates of inspection: 2
Medication administration opportunities: 30
Medication administration documented: 9
Medication administration documented: 2
Medication administration documented: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete required diabetic training prior to insulin administration. |
| Staff B | Medication Aide | Failed to complete required diabetic training prior to insulin administration. |
| Resident Care Director | Aware of urine odor issue in resident room #1222 and planned corrective actions. | |
| Housekeeper | Responsible for cleaning resident rooms; noted urine odor remained after cleaning. | |
| Regional Health and Wellness Nurse | Observed urine odor and soiled conditions in resident room #1222. | |
| Administrator | Responsible for oversight; unaware of some medication and oxygen order issues. | |
| Health and Wellness Director | Responsible for scheduling diabetic training and following up on physician orders; failed to ensure training and oxygen order implementation. | |
| Resident Care Coordinator | Responsible for medication order processing and communication; aware of medication availability issues. | |
| Corporate Nurse | Responsible for ensuring medication aides received diabetic training. |
Inspection Report
Capacity: 50
Deficiencies: 8
Aug 30, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 w/ '98 revision of the North Carolina State Building Code.
Findings
Multiple deficiencies were identified including failure to meet building code requirements for special locking system doors, obstructions in exit corridors, housekeeping hazards, inadequate fire safety rehearsals, and fire safety equipment and building maintenance issues such as fire doors not latching properly and compromised fire rated ceilings.
Deficiencies (8)
| Description |
|---|
| Facility failed to have all required components for doors with Special Locking System, including missing emergency release switches and central emergency release switch. |
| Exit path was obstructed by equipment including a ladder and furniture reducing corridor clear width below required 6 feet. |
| Automatic roll-down fire screen pathway obstructed by gloves and food condiments, preventing complete closure. |
| Ice machine drain line in direct contact with floor drain, risking contamination. |
| Fire drill rehearsals not conducted regularly on all shifts quarterly; records incomplete or missing key details. |
| Many corridor fire doors do not close completely or latch, including trash storage room doors, laundry door, stairway doors, meeting room doors, and dining room doors. |
| Mechanical 'kick-down' devices on multiple office and meeting room doors prevent proper latching. |
| Fire rated ceiling compromised by unsealed conduit sleeves in the Communication room. |
Report Facts
Licensed bed capacity: 50
Number of unsealed conduit sleeves: 4
Required corridor clear width: 6
Reduced corridor clear width: 4
Inspection Report
Follow-Up
Deficiencies: 3
Jun 20, 2018
Visit Reason
The Adult Care Licensure Section and Mecklenburg County DSS conducted a follow-up survey on June 19-20, 2018 to verify correction of previous deficiencies.
Findings
The facility failed to notify Resident #1's physician regarding increased pain and depression symptoms, failed to ensure physician clarification for nutritional supplement orders for Resident #2, and had inaccuracies in the medication administration record for Resident #2 related to Aricept dosage. These failures were detrimental to resident care and compliance.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assure physician notification regarding Resident #1's increased risk of depression and increased pain levels. | Type B Violation |
| Failed to ensure contact with prescribing physician for clarification of orders related to nutritional supplements for Resident #2. | — |
| Failed to ensure accurate electronic medication administration record (eMAR) for Resident #2 related to Aricept dosage. | — |
Report Facts
Medication administrations: 45
Medication administrations: 44
Weight: 150
Weight: 134
Missing medication count: 17
Inspection Report
Annual Inspection
Deficiencies: 7
Mar 22, 2018
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on 3/20/18 to 3/22/18.
Findings
The facility failed to provide adequate supervision for residents resulting in serious injuries from falls, failed to assure contact with medical professionals for several residents leading to inappropriate care, failed to implement physician orders including therapeutic diets and treatments, and failed to monitor compliance with infection control policies, particularly for a resident in isolation for C-Diff. The Administrator failed to assure proper management and implementation of policies and procedures, resulting in substantial noncompliance with regulations.
Severity Breakdown
Type A1 Violation: 3
Type B Violation: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide supervision for 2 of 5 sampled residents related to falls and injuries including fractures and head injury. | Type A1 Violation |
| Failed to assure contact with medical professionals for 3 of 5 sampled residents resulting in inappropriate diet, isolation, and refusal of ordered treatments. | Type A1 Violation |
| Failed to implement physicians' orders for 3 of 5 sampled residents related to stool documentation, therapy services, and compression sleeve application. | — |
| Failed to assure therapeutic diets were served as ordered for 1 of 1 sampled resident with orders for texture modified diet with nectar thickened liquids. | Type B Violation |
| Failed to ensure contact with prescribing physician for verification or clarification of orders for 1 of 5 sampled residents and clarification for 2 of 5 sampled residents related to undated FL2, conflicting diet orders, and wound care instructions. | — |
| Failed to monitor compliance with infection control policy for 1 of 1 resident in isolation for Clostridium Difficile (C-Diff). | — |
| Failed to assure management, operations, and policies and procedures were implemented to maintain residents' rights and substantial compliance with regulations. | Type A1 Violation |
Report Facts
Falls: 4
Weight loss percentage: 14.5
Medication count: 25
Medication count: 9
Medication count: 14
Refused TED hose days: 8
Refused TED hose days: 7
Refused TED hose days: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for completing assessment pages on incident reports and reviewing physician orders. | |
| Health and Wellness Director | Responsible for infection control education, reviewing physician orders, and falls management. | |
| Executive Director | Facility administrator responsible for overall operations and regulatory compliance. | |
| Medication Aide | Involved in medication administration, incident reporting, and resident care. | |
| Dietary Services Coordinator | Responsible for dietary staff training and oversight, including therapeutic diet compliance. | |
| Licensed Professional Nurse | Primary care physician's office nurse providing information on resident care. | |
| Nurse Practitioner | Resident's healthcare provider involved in diet and isolation care decisions. |
Inspection Report
Capacity: 50
Deficiencies: 9
Nov 4, 2016
Visit Reason
Biennial Construction Survey conducted to ensure compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996/98 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including outdated fire safety inspection reports, corridors obstructed with equipment and storage, damaged bedroom doors needing repair, housekeeping hazards such as ice machine drain line contamination risk and dry waste traps, inadequate fire safety rehearsals documentation, fire alarm system trouble condition, and corridor doors failing to close and latch properly.
Deficiencies (9)
| Description |
|---|
| Facility did not have current sanitation and fire safety inspection reports; last Fire Marshal inspection dated 3-31-2015. |
| Corridors were not maintained free of obstructions, including combustible baskets and storage blocking exit corridors. |
| Doors to bedrooms 1211, 1216, and 1218 were badly scratched and in need of repair and paint. |
| Ice machine drain line was in direct contact with the floor drain, risking contamination. |
| Waste trap for the hopper was dry, allowing noxious odors and possibly harmful bacteria to enter the facility. |
| Fire safety rehearsal records lacked sufficient description of what the rehearsals involved. |
| Fire alarm system was showing a 'Trouble' condition, potentially failing to operate properly. |
| Multiple corridor doors failed to close completely and latch, including smoke barrier doors near rooms 1106 and 1206, stairway door near room 1121, bedroom 118 door, and doors held open mechanically or wedged. |
| No key was onsite to allow entry into the Director of Nursing and Assistant Director of Nursing offices, preventing survey of hazards in those rooms. |
Report Facts
Licensed capacity: 50
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