Inspection Report
Annual Inspection
Deficiencies: 5
Jul 24, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on July 23 - 24, 2024 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including medication staff qualifications, tuberculosis testing upon admission, health care referral and follow-up, medication administration documentation, and medication storage security for residents who self-administer medications.
Deficiencies (5)
| Description |
|---|
| Failed to ensure 2 of 7 sampled medication aides completed state approved medication aide training and clinical skills validation. |
| Failed to ensure 1 of 5 residents was tested for tuberculosis disease upon admission with proper documentation. |
| Failed to ensure health care referral and follow-up for 1 of 5 residents related to not scheduling a gastroenterology referral for swallowing difficulties. |
| Failed to ensure medication administration was documented immediately following administration by the staff who administered the medication for 2 of 4 residents observed. |
| Failed to ensure medications were stored in a safe and secure manner for 3 of 3 residents who self-administered medications, including failure to lock doors or secure medications properly. |
Report Facts
Sampled medication aides: 7
Medication aides deficient: 2
Sampled residents for TB testing: 5
Residents deficient in TB testing: 1
Sampled residents for health care referral: 5
Residents deficient in referral: 1
Residents observed for medication administration: 4
Residents with medication administration documentation issues: 2
Residents sampled for medication storage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Aide | Named in deficiency for missing medication clinical skills validation documentation |
| Staff F | Medication Aide | Named in deficiency for missing medication training and clinical skills validation documentation |
| Staff G | Medication Aide | Named in deficiency for missing medication training documentation |
| Administrator | Interviewed regarding medication aide training deficiencies and referral responsibilities | |
| Health and Wellness Director | Interviewed regarding tuberculosis testing, medication administration, and medication storage deficiencies | |
| Resident Care Coordinator | Interviewed regarding referral scheduling and medication administration documentation | |
| Third shift Medication Aide | Medication Aide | Observed and interviewed regarding medication administration and documentation errors |
| First shift Medication Aide | Medication Aide | Observed and interviewed regarding medication administration and documentation errors |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 3, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey to verify correction of deficiencies identified in a prior Biennial Construction Survey.
Findings
The facility remains non-compliant with physical plant requirements including lack of automatic smoke detection in certain rooms, failure to maintain fire safety systems such as sprinkler heads, and inadequate exhaust ventilation in specified areas.
Deficiencies (3)
| Description |
|---|
| Rooms open to the corridor are required to be protected by automatic smoke detection; the Employee Breakroom door to the corridor has been removed and lacks smoke detection. |
| Failure to maintain building's fire safety systems in a safe condition; loose escutcheon ring on sprinkler head in Multi-Purpose Room and gaps in ceiling around sprinkler head in Kitchen. |
| Facility did not maintain exhaust ventilation in specified spaces; exhaust fans in Men's Guest Bathroom, C Hall Spa, and utility areas are not working. |
Inspection Report
Capacity: 70
Deficiencies: 10
Jan 24, 2024
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant and safety code compliance including missing signage on delayed egress doors, lack of automatic smoke detection in certain rooms, poor housekeeping and maintenance issues such as water damage and excessive lint accumulation, failure to maintain fire safety rehearsals quarterly on each shift, malfunctioning fire alarm and emergency lighting systems, gaps and holes in fire resistant ceilings and walls, and inadequate exhaust ventilation in specified utility areas.
Deficiencies (10)
| Description |
|---|
| Delayed egress doors missing required signage indicating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS'. |
| Rooms open to corridor lack required automatic smoke detection. |
| Walls, ceilings, and floors not kept clean and in good repair; water damage and excessive lint accumulation observed. |
| Facility not maintained free from hazards; electrical breaker panels obstructed by service carts. |
| Fire safety rehearsals not conducted quarterly on each shift; missing rehearsals on third shift in second and third quarters of 2023. |
| Failure to maintain emergency fire alarm system devices in safe operating condition; fire alarm control panel in trouble mode and missing smoke detector head due to water damage. |
| Holes and gaps in fire resistant rated ceilings and walls that could allow fire and smoke to spread beyond area of origin. |
| Failure to maintain electrical emergency/safety lighting; several exit signs/lights not illuminated or removed. |
| Fire safety doors do not completely close and latch, potentially allowing spread of smoke or fire. |
| Exhaust ventilation not maintained in specified spaces including bathrooms, utility rooms, and laundry areas; fans not working. |
Report Facts
Licensed bed capacity: 70
Special Care Unit beds: 22
Inspection Report
Follow-Up
Census: 37
Deficiencies: 2
Jun 29, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on June 28-29, 2022 to verify correction of previous deficiencies related to medication administration.
Findings
The facility failed to ensure medications were administered within one hour before or after the prescribed times for 4 of 5 sampled residents, involving medications for seizures, blood thinners, pain, and mental health. Additionally, one medication aide had not passed the required state medication aide test within 60 days of clinical skills evaluation.
Deficiencies (2)
| Description |
|---|
| Medications were not administered within one hour before or after the prescribed times for 4 of 5 sampled residents (#4, #5, #6, & #7), including medications for seizures, blood thinner, pain, and mental health. |
| One medication aide (Staff B) administering medications had not taken and passed the state approved medication aide test within 60 days of completing the medication clinical skills evaluation. |
Report Facts
Residents in census: 24
Residents in census: 13
Late medication administrations: 12
Late medication administrations: 24
Late medication administrations: 18
Late medication administrations: 18
Late medication administrations: 16
Late medication administrations: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Failed to take and pass the state approved medication aide test within 60 days of clinical skills evaluation; administered medications without required certification. |
| Medication Aide | Interviewed on 06/28/22 at 3:00pm; responsible for medication administration on assisted living side; reported delays due to meetings and workload. | |
| Resident Care Coordinator (RCC) | Responsible for monitoring medication aides; unaware of late medication administration; planned to address medication timing. | |
| Health and Wellness Director (HWD) | Supervised medication aides and RCC; unaware of late medication administration; conducted trainings on medication timing. | |
| Administrator | Expected medications to be administered within one hour before or after scheduled times; responsible for oversight of medication administration and audits. |
Inspection Report
Annual Inspection
Deficiencies: 4
Apr 13, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey to assess compliance with health care, medication administration, and resident safety regulations.
Findings
The facility failed to ensure referral and follow-up for elevated blood sugar and delayed insulin administration for Resident #1 and failed to seek emergency treatment after an unwitnessed fall with head injury for Resident #4. Medication administration errors were found for Residents #1, #3, and #5 involving insulin, narcotic pain patches, and hypotensive medication. Additionally, medication administration times were frequently outside prescribed windows, and documentation of medication aide training was incomplete.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure referral and follow-up for elevated blood sugar and delayed insulin administration for Resident #1 and failure to seek emergency treatment after an unwitnessed fall with head injury for Resident #4. | Type A2 Violation |
| Failed to administer medications as ordered for Residents #1, #3, and #5 including insulin, narcotic pain patches, and hypotensive medication. | Type B Violation |
| Failed to ensure medications were administered within one hour before or after the prescribed time for Resident #1, resulting in delayed insulin administration. | — |
| Failed to maintain documentation of 15-hour medication administration training for medication aide Staff E. | — |
Report Facts
FSBS results: 497
FSBS results: 572
FSBS results: 600
FSBS results: 540
Medication administration delay count: 17
Medication administration delay count: 15
Medication administration delay count: 3
Midodrine administration count: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Aide | Failed to maintain documentation of required 15-hour medication aide training |
| Health and Wellness Director | Supervised medication aides and acknowledged lack of training and oversight on insulin administration and medication timing | |
| Resident Care Coordinator | Waiting for medication aide training documentation for Staff E |
Inspection Report
Capacity: 70
Deficiencies: 10
Aug 22, 2018
Visit Reason
This facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited including lack of hand grips at commodes, failure to maintain outside premises and interior walls in good condition, trip hazards, and failure to maintain fire safety components such as sprinkler systems, emergency lighting, and fire-rated doors in a safe and operating condition.
Deficiencies (10)
| Description |
|---|
| Facility has not installed hand grips at all commodes, specifically in the 300 Hall SPA. |
| Facility failed to maintain the outside grounds in a clean and safe condition; overgrown tree limbs on roofs of 200 & 400 Halls. |
| Facility failed to maintain interior walls in good condition; hole in wall above sink at wet bar in Room 211. |
| Facility failed to maintain doors in good condition; exterior exit door in 400 Hall damaged at base near Room 403. |
| Facility failed to be maintained free of obstructions and hazards; garden hose adjacent to exit door threshold in 200 Hall near Room 212 presents trip hazard. |
| Facility failed to install all fire safety components; Linen Closet in 300 Hall SPA not sprinklered. |
| Emergency corridor light next to Dining Room in 300 Hall does not illuminate when tested. |
| One-hour fire rated doors were wedged open or blocked allowing passage of smoke or fire at 100 Hall Health & Wellness Director's Office and Laundry Room. |
| Door latching hardware is loose for Room 104. |
| Cross corridor door adjacent to Room 301 did not close fully to prevent passage of smoke and/or fire. |
Report Facts
Licensed capacity: 70
Special Care Unit beds: 22
Inspection Report
Follow-Up
Deficiencies: 5
Dec 1, 2016
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of deficiencies noted during the previous 09/29/2016 Biennial Construction Survey.
Findings
The facility was found to have ongoing deficiencies related to building safety and maintenance, including obstructed access to electrical panels, unlabeled circuit breakers, gaps in fire resistant ceilings, malfunctioning door latches, and a detached smoke detector.
Deficiencies (5)
| Description |
|---|
| Access to electrical panels obstructed by stored items in Health and Wellness Director Office. |
| Circuit breaker panel 'AA' lacked a schedule identifying electrical devices controlled. |
| Gaps between fire resistant rated ceiling and fire sprinkler head escutcheon in exterior patio areas. |
| Dining room double doors had latch issues preventing complete closing and latching; door coordinator removed preventing proper door coordination. |
| Ceiling mounted smoke detector in Activity Room detached from ceiling. |
Inspection Report
Annual Inspection
Capacity: 70
Deficiencies: 10
Sep 29, 2016
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules, as part of a biennial survey.
Findings
Multiple deficiencies were identified including failure to maintain current fire sprinkler inspection reports, unclean ceilings with dust and mold growth, obstructed electrical panel access, unlabeled circuit breakers, gaps in fire resistant ceilings, malfunctioning fire safety doors and devices, non-operational emergency lighting, detached smoke detector, and lack of required exhaust ventilation in storage areas.
Deficiencies (10)
| Description |
|---|
| Facility failed to have a current fire sprinkler inspection report available for review. |
| Ceilings were not kept clean; return air and exhaust fan grilles clogged with dust and evidence of mold growth at return air grille. |
| Access to electrical panels obstructed by stored items in Health and Wellness Director Office and Fire Sprinkler Room. |
| Circuit breakers in electrical panels were not labeled to identify which devices they control. |
| Gaps at penetrations or holes in fire resistant rated ceilings allowing potential spread of fire and smoke. |
| Common area and room doors failed to close completely and latch, including dining room doors contacting frame strike plate. |
| Doors held open with unapproved kick down hold open devices, impeding rapid door closure in fire. |
| Wall mounted emergency light at dining room entrance did not work on battery power. |
| Ceiling mounted smoke detector in Activity Room was detached from ceiling. |
| Facility failed to provide required exhaust ventilation in 300 Hall Storage Room where chemicals are stored. |
Report Facts
Licensed beds: 70
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 27, 2015
Visit Reason
The Adult Care Licensure Section and the Wake County Human Services conducted an annual and follow-up survey on 10/27/15 - 10/28/15 to assess compliance with regulations related to nutrition, food service, and therapeutic diet menus.
Findings
The facility failed to maintain cleanliness in the kitchen, dining, and food storage areas, with multiple observations of food debris, spills, and grime. Additionally, the facility did not have a gluten-free therapeutic diet menu for a resident with Celiac disease, and the dietary staff were unaware of a deep cleaning schedule or therapeutic diet requirements.
Deficiencies (2)
| Description |
|---|
| The kitchen, dining, and food storage areas were not clean or free from contamination, including dirty floors, sticky handles, food debris, and grime on equipment and surfaces. |
| The facility failed to provide a matching therapeutic gluten-free diet menu for a resident with a physician-ordered gluten-free regular diet. |
Report Facts
Dates of survey: 2
Resident count for gluten-free diet: 1
Meal consumption: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding kitchen conditions, dietary staffing, and therapeutic diet menu |
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