Inspection Report
Annual Inspection
Deficiencies: 3
Feb 27, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 02/25/25 through 02/27/25 to assess compliance with regulations including tuberculosis testing, health care needs, and medication orders.
Findings
The facility failed to ensure 4 of 5 sampled residents were tested for tuberculosis upon admission, failed to ensure referral and follow-up for acute health care needs of one resident related to verbal aggression and intoxication, and failed to ensure clarification or verification of medication orders for one resident self-administering medications.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure 4 of 5 sampled residents were tested for tuberculosis disease upon admission. |
| Facility failed to ensure referral and follow-up to meet the acute health care needs of 1 of 5 sampled residents related to verbal aggression and intoxication. |
| Facility failed to ensure clarification or verification of medication orders for 1 of 5 sampled residents self-administering medications. |
Report Facts
Sampled residents with missed TB testing: 4
Sampled residents: 5
Medication orders: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for administering TB skin tests and ensuring completion of TB testing. |
| Sales Director | Sales Director | Responsible for administering the 1st step TB skin test on admission. |
| Administrator | Administrator | Responsible for ensuring TB tests were completed and oversight of reporting behaviors to physicians. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for auditing records for TB testing and ensuring medication orders are filed and accurate. |
| Primary Care Provider | Primary Care Provider | Notified of resident behaviors and medication orders; unaware of verbal threats and intoxication incidents. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Provided psychiatric care to Resident #7; unaware of verbal aggression and intoxication incidents. |
| Medication Aide | Medication Aide | Did not document self-administered medications on eMAR and did not verify medications taken by Resident #5. |
Inspection Report
Capacity: 82
Deficiencies: 3
May 1, 2024
Visit Reason
This report documents a Construction Section Biennial Survey conducted to ensure the facility meets applicable building and safety codes and regulations.
Findings
Deficiencies were cited related to electrical outlets not being ground fault circuit interrupter (GFCI) protected in wet locations, damaged building equipment including a door with a temporary repair, and fire safety equipment deficiencies such as unsealed penetrations in fire resistant ceilings that could allow fire and smoke to spread.
Deficiencies (3)
| Description |
|---|
| Electrical outlets in the laundry room are not GFCI protected. |
| The right leaf door going into the Bistro is damaged and temporarily repaired. |
| Holes or gaps at penetrations in fire resistant rated ceilings in mechanical rooms are not properly sealed, risking fire and smoke spread. |
Report Facts
Licensed bed capacity: 82
Inspection Report
Annual Inspection
Deficiencies: 1
Aug 30, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on 08/30/22 - 08/31/22 to assess compliance with health care regulations.
Findings
The facility failed to ensure that a physician's order for a urinalysis for Resident #1 was implemented. Interviews revealed that the order was overlooked due to staff absence and miscommunication, resulting in no urinalysis being completed as ordered.
Deficiencies (1)
| Description |
|---|
| Failed to ensure physician's orders were implemented for 1 of 5 sampled residents related to an order for a urinalysis. |
Report Facts
Sampled residents: 5
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for following up on all orders; was out of the facility when the urinalysis order was received |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for sending orders to home health agency and following up on orders; missed the urinalysis order |
| Physician's Assistant | Physician's Assistant | Contracted PA who ordered the urinalysis due to increase in confusion in Resident #1 |
| Administrator | Administrator | Confirmed responsibility of HWD and RCC for ensuring all orders were complete |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 31, 2018
Visit Reason
Biennial Follow Up Construction Survey conducted to assess compliance with physical plant and safety regulations.
Findings
The smoke tight corridor doors were found not to be maintained in a safe and operating condition, specifically the inactive leaf of the corridor doors in the Left Activity Room did not automatically latch. New hardware has been ordered to correct this.
Deficiencies (1)
| Description |
|---|
| Smoke tight corridor doors not maintained in a safe and operating condition; inactive leaf equipped with manual flush bolt that does not automatically latch. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Conducted the Biennial Follow Up Construction Survey. | |
| Maintenance Director | Interviewed regarding the condition of smoke tight corridor doors. |
Inspection Report
Capacity: 82
Deficiencies: 17
Sep 12, 2018
Visit Reason
Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety standards for the facility.
Findings
Multiple deficiencies were cited related to building safety, including delayed egress locking system issues, missing exit signs, corridor obstructions, housekeeping hazards, fire safety rehearsal deficiencies, malfunctioning emergency equipment, fire and smoke barrier door problems, sprinkler system issues, electrical hazards, prohibited portable electric heaters, and inadequate exhaust ventilation.
Deficiencies (17)
| Description |
|---|
| Delayed egress doors did not initiate irreversible release process when force applied, though they unlocked on fire alarm activation. |
| Missing exit signs on required exits or exit access doors. |
| Corridors obstructed by equipment and objects, impeding emergency egress. |
| Oxygen cylinders not physically secured, posing projectile hazard. |
| Broken toilet paper holder bracket with sharp edges in restroom. |
| Fire safety rehearsals not performed regularly on each shift quarterly and records lacked short descriptions. |
| Emergency exit signs failed to illuminate on backup power; directional indicators on exit signs were misleading. |
| Exit door could not open fully to required 90 degrees. |
| Smoke barrier doors did not latch properly to restrict fire and smoke spread. |
| Corridor doors had gaps or did not latch, compromising smoke tightness. |
| Fire sprinkler escutcheon plates missing or dropped, allowing smoke and heat spread. |
| Fire safety compromised by unsealed holes and improperly fitted fire collars in fire-resistance-rated ceilings. |
| Fire sprinkler heads obstructed by stored items. |
| Electrical panels blocked and unsafe multiple plug adaptors used. |
| Doors required excessive force to open, exceeding code limits. |
| Use of portable electric heaters prohibited but found in facility. |
| Exhaust ventilation systems in soiled linen area and employee restrooms not functioning, causing odors. |
Report Facts
Total licensed beds: 82
Corridor length: 43
Hole size: 18
Hole size: 48
Required clear working space: 36
Required clear working space: 30
Door opening force: 30
Heating temperature: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Construction Section Biennial Surveyor | |
| Dennis Harrell | Construction Section Biennial Surveyor | |
| Executive Director | Interviewed regarding fire safety rehearsals and documentation | |
| Maintenance Technician | Interviewed regarding fire safety rehearsals and documentation |
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 24, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on August 23-24, 2017 to assess compliance with medication administration and infection prevention requirements.
Findings
The facility failed to assure medications were administered as ordered for one resident due to insufficient medication supply and missing medication administration records. Additionally, two medication aides did not receive the required yearly state-approved infection control training.
Deficiencies (2)
| Description |
|---|
| Failed to assure medications were administered as ordered for 1 of 5 sampled residents due to lack of medication supply and missing June 2017 MAR. |
| Failed to assure 2 of 5 medication aides received yearly state-approved infection control training. |
Report Facts
Medication doses ordered: 9
Medication doses dispensed: 4
Medication doses administered: 7
Staff sampled: 5
Staff not trained: 2
Inspection Report
Capacity: 82
Deficiencies: 7
Nov 15, 2016
Visit Reason
Biennial Construction Survey conducted to ensure compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 Edition of the North Carolina State Building Code.
Findings
The facility was found to have multiple deficiencies including improper storage near fire sprinkler heads, incorrect exit signage, lack of detailed fire safety rehearsal records, and fire safety issues such as corridor doors not closing or latching properly, compromised fire-rated walls and ceilings, and unsealed penetrations that could allow fire and smoke to spread.
Deficiencies (7)
| Description |
|---|
| Improper storage too close to a fire sprinkler head in the clean linen room. |
| Exit sign near bedroom 27 indicating incorrect direction of travel to the exit. |
| 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 ceilings compromised by holes, unsealed penetrations, and inoperable or missing ceiling radiation dampers. |
| Hole in the wall in the housekeeping closet. |
| Sprinkler escutcheon not tightly fitted to ceiling in employee restroom, compromising one-hour fire protection. |
Report Facts
Total licensed capacity: 82
Inspection Report
Follow-Up
Deficiencies: 3
Feb 2, 2016
Visit Reason
Staff with the Adult Care Licensure Section and Caldwell County DSS conducted a follow-up survey on site to verify correction of previous deficiencies related to health care referrals and medication order clarifications.
Findings
The facility failed to assure referral and follow-up for 2 of 5 sampled residents: Resident #3 did not have a follow-up TSH lab completed after a physician order, and Resident #1 lacked a clarification order for Donepezil, resulting in delayed medication administration. The facility implemented a new order tracking system to address these issues.
Severity Breakdown
Type B Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assure referral and follow-up for Resident #3 related to a physician order for a Thyroid Stimulating Hormone (TSH) lab. | Type B Violation |
| Failed to obtain a clarification order for Donepezil for Resident #1, resulting in no administration of the medication until discontinuation. | Type B Violation |
| Failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to referral and follow-up for Residents #1 and #3. | — |
Report Facts
Sampled residents: 5
Residents with referral/follow-up issues: 2
TSH lab value: 8
Date of correction deadline: Mar 20, 2016
Inspection Report
Follow-Up
Deficiencies: 3
Dec 9, 2015
Visit Reason
The Adult Care Section and the Caldwell Department of Social Services conducted a follow-up survey on 12/9/15 and 12/10/15 to investigate resident rights violations and medication administration issues.
Findings
The facility failed to protect one resident (Resident #7) from mental and verbal abuse by another resident (Resident #5), including threats of harm. Additionally, the facility failed to administer the medication Seroquel as ordered for one resident (Resident #1), due to misinterpretation of the physician's order and inconsistent documentation.
Severity Breakdown
Type A2 Violation Unabated: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect Resident #7 from mental and verbal abuse by Resident #5, including threats to cut her throat with a razor. | Type A2 Violation Unabated |
| Failure to administer Seroquel medication as ordered by the licensed prescribing practitioner for Resident #1. | — |
| Failure to assure all residents were free from verbal abuse related to residents rights. | — |
Report Facts
Resident #5 falls: 2
Seroquel dosage change date: Oct 29, 2015
Seroquel administration times: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Assistant | Reported Resident #5's threats to Resident #7 and removed razors from Resident #5's room. |
| Staff B | Supervisor in Charge | Informed about threats on 12/04/15, instructed frequent checks on Resident #5. |
| Administrator | Instructed sending Resident #5 to emergency room and expected staff to intervene and notify family and MD. | |
| Health and Wellness Director | Registered Nurse | New to facility, aware of threats on 12/04/15, instructed sending Resident #5 to emergency room. |
| Medication Aide | Misinterpreted physician's order for Seroquel and implemented incorrect medication administration. |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 24, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on September 23-24, 2015 to assess compliance with health care and resident rights regulations.
Findings
The facility failed to assure physician notification for one resident with decreased cognition and aggressive behaviors, and failed to protect another resident from mental abuse by the aggressive resident who took personal items and exhibited verbal and physical aggression.
Severity Breakdown
Type B Violation: 1
Type A2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assure physician notification for Resident #5 related to decreased cognition, verbal and physical aggression, and need for higher level of care. | Type B Violation |
| Failed to assure Resident #4 was free from mental abuse by Resident #5 who took personal items and exhibited verbal and physical aggression. | Type A2 Violation |
| Failed to assure all residents were free from verbal and physical abuse and neglect related to residents' rights and health care. | — |
Report Facts
Number of sampled residents with noted issues: 5
Admission date: Nov 27, 2013
Admission date: May 1, 2001
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