Inspection Report
Follow-Up
Deficiencies: 0
Nov 1, 2024
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Follow up construction survey by documentation to verify correction of previously cited deficiencies.
Findings
Based on documentation received on November 1, 2024, all previously cited deficiencies have been corrected and no further action is required at this time.
Inspection Report
Capacity: 72
Deficiencies: 9
Jun 13, 2024
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Report of a Construction Section Biennial Survey conducted on June 13, 2024, to assess compliance with applicable physical plant standards and regulations for an adult care home licensed for 72 beds.
Findings
Multiple deficiencies were cited related to physical plant conditions including obstructions in corridors, unsafe outside premises, inadequate outdoor lighting, poor housekeeping and maintenance, unsafe storage of compressed gas cylinders, malfunctioning fire safety and emergency equipment, electrical hazards, improper fire sprinkler maintenance, use of prohibited portable electric heaters, hot water temperature issues, and lack of exhaust ventilation in required areas.
Deficiencies (9)
| Description |
|---|
| Doorways were not free of obstructions, blocking emergency egress. |
| Outside grounds were not maintained in a clean and safe condition with disassembled beds and unstable sidewalks. |
| Outdoor walkways and drives lacked required illumination of five foot-candles. |
| Floors and ceilings were not kept clean and in good repair; water heater leaking and vinyl soffit missing. |
| Building was not free of obstructions and hazards; compressed gas cylinders improperly stored. |
| Building and fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition; fire sprinkler pressure gauge at 0 psi; exit signs improperly marked or not illuminated; commercial kitchen hood suppression system improperly maintained; combustible materials improperly stored; smoke barrier doors propped open; fire alarm system not maintained; fire safety holes not firestopped; electrical receptacles without ground fault protection; smoke tight corridor doors damaged; sprinkler escutcheon plates incomplete; fire extinguishers not properly maintained; no spare fire sprinkler heads available. |
| Use of portable electric heaters found in facility, which is prohibited. |
| Hot water temperature at resident fixtures exceeded maximum allowed temperature. |
| Exhaust ventilation system not functioning in required areas. |
Report Facts
Licensed bed capacity: 72
Fire extinguisher maintenance interval: 1
Hot water temperature: 120
Hot water temperature: 118
Inspection Report
Annual Inspection
Deficiencies: 1
Sep 9, 2021
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The Adult Care Licensure Section conducted an annual and follow-up survey on 09/08/21 to 09/09/21 to assess compliance with medication administration regulations.
Findings
The facility failed to ensure the electronic Medication Administration Record (eMAR) was accurate for one resident who self-administered medications, with missing entries and lack of proper review of physician orders in the eMAR.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the electronic Medication Administration Record (eMAR) was accurate for Resident #2 who self-administered medications, including missing medication entries and lack of dosage information. |
Report Facts
Units of Novolog insulin: 40
Units of Novolog insulin: 45
Dosage of hydrocodone-acetaminophen: 5
Dosage of coumadin: 3
Dosage of coumadin: 5
Dosage of Basaglar insulin: 110
Dosage of vitamin D3: 5000
Dosage of vitamin C: 500
Dosage of zinc: 66
Dosage of omega-3: 1000
Dosage of gabapentin: 100
Inspection Report
Capacity: 72
Deficiencies: 12
Jul 17, 2019
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The report documents a biennial construction section survey conducted to assess compliance with physical plant, fire safety, and building code regulations for an adult care home licensed for 72 beds.
Findings
The facility was found to have multiple deficiencies including uncorrected sprinkler system issues, poor housekeeping and maintenance hazards, inadequate fire safety rehearsals, malfunctioning electrical outlets, compromised fire-rated walls and doors, non-functional emergency lighting and exit signs, lack of fire extinguisher inspection documentation, improper storage blocking electrical panels, and prohibited use of portable electric heaters.
Deficiencies (12)
| Description |
|---|
| Most recent sprinkler system inspection report listed several deficiencies with no documentation of correction. |
| HVAC exhaust grill and radiation damper had excessive dust/lint accumulation. |
| Portable medical oxygen cylinders stored unsafely in unapproved plastic crates. |
| Trip and fall hazards on exterior decks, steps, and porches including scattered debris, loose step tread, loose handrail, and foam cushions on steps. |
| Fire drill rehearsals not conducted regularly on all shifts each quarter and records lacked adequate descriptions. |
| GFCI electrical outlets at exit near room 34 and beverage counter in dining room would not reset, posing electrical shock hazard. |
| One-hour fire rated walls and ceilings compromised by holes and unsealed penetrations in multiple locations including smoke detector areas and electrical room. |
| Corridor doors and fire doors failed to close and latch properly, including double doors to dining room and pantry door tied open. |
| Battery powered emergency lights and exit signs in kitchen and corridor would not operate on battery power. |
| No documentation of required monthly fire extinguisher inspections for May and June. |
| Improper storage blocking access to electrical panel in kitchen. |
| Portable electric heaters found in prohibited areas: Business Office Coordinator and Community Sales Rep. |
Report Facts
Licensed bed capacity: 72
Portable oxygen cylinders: 13
Fire drill rehearsals missing: 5
Foam seat cushions: 7
Air transfer grill size: 64
Inspection Report
Capacity: 72
Deficiencies: 7
Jul 6, 2017
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The report documents a biennial construction section survey conducted to assess compliance with physical plant requirements, fire safety, sanitation, and building codes for an adult care home licensed for 72 beds.
Findings
Multiple deficiencies were cited including failure to meet delayed egress locking system requirements, lack of current sanitation and fire safety inspection reports, housekeeping hazards, improperly maintained fire extinguishers, incomplete fire safety rehearsals, unsafe building equipment and fire safety conditions, and malfunctioning exhaust ventilation systems.
Deficiencies (7)
| Description |
|---|
| Building does not meet code requirements for Delayed Egress Locking System; force greater than 15 pounds applied to door releasing device did not initiate irreversible release. |
| Facility failed to maintain current annual sanitation and fire safety inspection reports; last fire marshal inspection was over a year old. |
| Facility failed to maintain building in an uncluttered, clean, and orderly manner; excessive dust/lint on exhaust fan radiation damper and unsecured portable medical oxygen cylinder. |
| Fire extinguishers and associated equipment not properly maintained; last maintenance check was over a year old. |
| Fire safety rehearsals not conducted quarterly on each shift; missing rehearsals on 2nd and 3rd shifts in certain quarters; incomplete documentation of rehearsals. |
| Building fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition; multiple firestopping penetrations missing or compromised; interior doors not latching properly and door wedge found. |
| Exhaust ventilation system failed to operate properly in bathrooms of multiple bedrooms; system intermittently working. |
Report Facts
Licensed bed capacity: 72
Date of last fire marshal inspection: May 18, 2016
Date of last fire extinguisher maintenance: Mar 1, 2016
Inspection Report
Annual Inspection
Deficiencies: 1
May 24, 2017
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The Adult Care Licensure Section conducted an annual survey of the facility on May 23-24, 2017 to assess compliance with medication administration regulations.
Findings
The facility failed to ensure that staff administered Humalog insulin as ordered by a licensed prescribing practitioner for one of three sampled residents. Multiple instances were documented where Humalog was not administered despite blood sugar levels exceeding the threshold, and the medication was not available on site at the time of inspection.
Deficiencies (1)
| Description |
|---|
| Failure to administer Humalog insulin as ordered for Resident #1 when blood sugar was greater than 250, with multiple documented missed administrations and lack of medication availability. |
Report Facts
Missed medication administration opportunities: 6
Missed medication administration opportunities: 14
Missed medication administration opportunities: 9
Blood sugar range: 342
Blood sugar range: 371
Blood sugar range: 381
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | First shift MA unaware of Humalog order and resident's blood sugar status | |
| Health and Wellness Director | Denied knowledge of Humalog not being given or available | |
| Executive Director | Denied knowledge of Humalog not being given or available | |
| Physician Assistant | Not aware Resident #1 had not been receiving Humalog as ordered; notified on day of inspection | |
| Second shift Medication Aide | Aware of Humalog order and had administered it in the past but may have failed to document | |
| Second shift Medication Aide | Reported Humalog had been unavailable recently and sent fax request to pharmacy |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 19, 2015
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The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to staff qualifications and resident care.
Findings
The facility failed to ensure that a staff member had a completed Health Care Personnel Registry check prior to hiring and failed to assure follow-up with residents' primary care physician, speech therapist, and dialysis center regarding residents' refusal of therapeutic diets for two sampled residents.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 1 of 6 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hiring. |
| Facility failed to assure follow-up in contacting residents' primary care physician, speech therapist, and Dialysis Center regarding residents' refusal of therapeutic diets ordered for 2 of 5 sampled residents. |
Report Facts
Staff sampled: 6
Residents sampled: 5
Non-compliance entries for Resident #1: 10
Non-compliance entries for Resident #2: 27
Non-compliance days for Resident #2: 15
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 11, 2015
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The Adult Care Licensure Section and the Forsyth County Department of Social Services conducted an annual and follow-up survey on 08/11/15 and 08/12/15 to assess compliance with regulations.
Findings
The facility failed to ensure that one staff member had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hiring. Additionally, the facility failed to serve therapeutic diets as ordered by physicians for 3 of 5 sampled residents, including renal, nectar thickened liquids, and carbohydrate control diets.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hiring. | — |
| Facility failed to assure therapeutic diets (Renal, Nectar Thickened liquids, Carbohydrate Control) were served as ordered by the physician for 3 of 5 sampled residents. | Type B Violation |
Report Facts
Date of survey completion: Aug 12, 2015
Potassium lab values: 5.2
Potassium lab values: 5.6
Potassium lab values: 5.5
Potassium lab values: 5.5
Potassium lab values: 4.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Resident Care Coordinator | Named in finding for failure to ensure no substantiated findings on Health Care Personnel Registry prior to hiring. |
| Dietary Manager | Interviewed regarding therapeutic diet preparation and training of kitchen staff. | |
| Business Office Manager | Interviewed regarding HCPR checks and meal service. | |
| Regional Support Nurse | Interviewed regarding HCPR checks and meal service. | |
| Executive Director | Interviewed regarding meal service and staff roles. | |
| Medication Aide | Interviewed regarding resident medication and diet compliance. | |
| Speech and Language Pathologist | Interviewed regarding resident swallowing and diet orders. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 12
Apr 14, 2015
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Complaint investigation initiated by Forsyth County Department of Social Services regarding multiple concerns including housekeeping, medication administration, staffing, and resident care.
Findings
The facility failed to provide clean and appropriate bedding, ensure staff had current CPR training, maintain adequate staffing levels, provide scheduled bathing assistance, ensure accurate medication administration and documentation, schedule physician referrals, and prevent neglect by staff. Multiple residents reported late or missed medications and inadequate personal care. Infection control procedures were not properly followed regarding glucometer use. Two medication aides administered medications without required competency validation.
Complaint Details
Complaint investigation initiated by Forsyth County Department of Social Services on 03/25/15 due to multiple resident and family complaints about housekeeping, medication administration, staffing shortages, personal care neglect, and staff mistreatment. Investigation conducted 04/08/15 through 04/14/15.
Severity Breakdown
Type A2: 3
Type B: 7
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide clean and appropriate bedding for 3 of 33 residents' rooms. | — |
| 31 of 69 shifts lacked staff with current CPR training within past 24 months. | — |
| Administrator failed to ensure total operation compliance including health care, medication administration, staffing, training, personal care, infection prevention, resident rights, housekeeping, and medication accuracy. | Type A2 |
| Failed to meet minimal staffing requirements for all shifts from 02/01/15 through 04/08/15. | Type B |
| Failed to provide bathing assistance for 4 of 9 sampled residents unable to attend to personal care independently. | Type B |
| Failed to implement infection control procedures consistent with CDC guidelines on use of glucometers for multiple residents; sharing labeled glucometers without proper disinfection. | Type B |
| Failed to administer medications as ordered for 2 of 7 residents observed and 5 of 10 sampled residents, including errors with vitamin supplementation, elevated lipids, allergies, skin disorders, convulsions, chest pain, pain, and insomnia medications. | Type A2 |
| Failed to administer medications within one hour before or after scheduled time for 6 of 7 residents observed during medication administration. | Type B |
| Medication Administration Records (MAR) were inaccurate including undocumented medication refusals and undocumented omissions for 3 of 3 sampled residents. | — |
| Failed to notify physician regarding non-compliance with self-administered medications for 1 resident. | — |
| Resident mistreatment and neglect by staff member (Staff A) including late and withheld medications, rude attitude, and retaliation concerns. | Type B |
| Two medication aides administered medications without completing required clinical skills validation prior to administration. | Type B |
Report Facts
Shifts without CPR trained staff: 31
Residents with unclean bedding: 3
Residents without scheduled bathing assistance: 4
Residents with medication administration errors: 7
Residents with medication timing errors: 6
Residents with MAR documentation errors: 3
Residents with missed physician referrals: 5
Residents with fall incidents: 3
Medication aides without clinical skills validation: 2
Facility census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Administered medications prior to clinical skills validation; personnel file lacked documentation of change from Resident Care Aide to Medication Aide. |
| Staff I | Medication Aide | Administered medications without clinical skills validation; instructed by Lead Supervisor to administer medications. |
| Lead Supervisor | Responsible for staff scheduling and medication aide oversight; instructed unvalidated staff to administer medications; instructed medication aides to use one glucometer for multiple residents; aware of medication administration and documentation issues. | |
| Executive Director | Facility administrator responsible for total operation; unaware of many compliance issues; approved unvalidated medication aides to administer medications. |
Report
May 21, 2015
File
20150521-statement-of-deficiency.pdf
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