Inspection Reports for Cadence Mooresville by Cogir
198 E Waterlynn Rd, Mooresville, NC 28117, United States, NC, 28117
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Deficiencies: 0
Jan 14, 2025
Visit Reason
Report of a Biennial Construction Follow Up Survey conducted on January 14, 2025.
Findings
Deficiencies have been corrected. No further action is needed.
Inspection Report
Annual Inspection
Deficiencies: 4
Aug 22, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 08/20/24 through 08/22/24 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to have a resident care plan signed by the Primary Care Provider within 15 days, failure to administer medications as ordered for residents, inaccuracies in electronic medication administration records, and inadequate accounting for controlled substances.
Deficiencies (4)
| Description |
|---|
| Failure to ensure 1 of 3 sampled residents had a completed care plan signed by the Primary Care Provider within 15 days of assessment. |
| Failure to administer medications as ordered for 1 of 5 sampled residents related to not administering a medication used to treat anxiety related to dementia. |
| Failure to ensure the electronic medication administration records (eMAR) was accurate for 1 of 5 sampled residents related to a medication used to treat high blood sugar levels. |
| Failure to ensure accurate accounting for the receipt, administration, and disposition of controlled medications for 1 of 4 sampled residents related to medications to treat pain. |
Report Facts
Residents sampled: 5
Residents sampled: 4
Residents sampled: 3
Medication administrations missed: 100
Hydrocodone-acetaminophen tablets dispensed: 90
Hydrocodone-acetaminophen tablets dispensed: 90
Hydrocodone-acetaminophen tablets dispensed: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Responsible for faxing care plans to PCP, approving medication orders, and auditing controlled substance records. |
| Administrator | Administrator | Responsible for oversight of care plan completion and medication order verification. |
| Special Care Coordinator | Special Care Coordinator | Had access to approve or decline medication orders and was responsible for verifying orders. |
| Medication Aide | Medication Aide | Administered medications and was expected to verify medication labels to eMAR. |
| Behavioral Health Nurse Practitioner | Nurse Practitioner | Ordered continuation of medication for Resident #2. |
| Hospice Nurse | Hospice Nurse | Responsible for handling Resident #3's hospice plan of care including medication orders. |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 19, 2019
Visit Reason
Biennial Follow Up Construction Survey conducted to assess compliance with fire safety and building equipment maintenance requirements.
Findings
The facility failed to maintain fire safety components in a safe and operating condition, specifically emergency lights at the 'C' Hall-Courtyard exit gate did not illuminate when tested.
Deficiencies (1)
| Description |
|---|
| Emergency lights at the 'C' Hall-Courtyard exit gate do not illuminate when tested. |
Inspection Report
Follow-Up
Deficiencies: 1
May 15, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 05/13/19 to 05/15/19 to verify correction of a previous Type B Violation related to therapeutic diets.
Findings
The facility failed to assure therapeutic diets were served as ordered for 2 of 2 sampled residents with orders for nectar thickened liquid diets, placing residents at risk for aspiration pneumonia. Staff were unaware that ice cream and certain liquids were contraindicated for these diets, and training did not cover foods not allowed on thickened liquid diets.
Severity Breakdown
Type B Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to serve therapeutic diets as ordered for residents with nectar thickened liquid diet orders, including serving thin liquids and ice cream which could lead to aspiration. | Type B Violation |
Report Facts
Dates of survey: 05/13/2019 to 05/15/2019
Number of residents sampled with diet issues: 2
Dates of speech therapy visits for Resident #2: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Speech Language Pathologist (SLP) | Provided education to staff regarding aspiration risk and therapeutic diets for Resident #2 | |
| SCU Coordinator | Provided oversight to PCAs and was interviewed about meal service and diet knowledge | |
| Personal Care Aide (PCA) | Interviewed regarding serving residents and knowledge of therapeutic diets | |
| Medication Aide (MA) | Interviewed about resident diets and medication administration | |
| Dining Services Coordinator | Interviewed about food preparation and delivery to SCU dining room | |
| Administrator | Interviewed regarding staff training and facility policies on therapeutic diets |
Inspection Report
Capacity: 96
Deficiencies: 4
Apr 17, 2019
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 2005 Rules for the Licensing of Adult Care Homes and the 2009 N.C. State Building Code for Institutional - I-2.
Findings
The facility was found to have multiple deficiencies related to building equipment maintenance, including non-operational emergency lights, improperly supported plumbing components, lack of proper air gap in the kitchen condensate line, and a non-operational mechanical exhaust fan in the kitchen janitor sink closet.
Deficiencies (4)
| Description |
|---|
| Emergency lights at 'C' Hall-Courtyard exit gate and 'D' Hall-Screen Porch Exit do not illuminate when tested. |
| Newly installed circulator pump adjacent to the water heaters in the Mechanical Room is not properly supported. |
| Condensate line from the ice-maker is recessed into the floor drain in the Kitchen not providing a 2" air gap. |
| Mechanical exhaust fan is not operational in the Kitchen Janitor Sink Closet. |
Report Facts
Licensed capacity: 96
Inspection Report
Annual Inspection
Deficiencies: 4
Feb 28, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Carillon Assisted Living of Mooresville from February 26-28, 2019 to assess compliance with health care regulations and resident care standards.
Findings
The facility failed to assure physician notification for residents with blood pressure readings outside ordered parameters, failed to implement physician orders for thromboembolic deterrent hose application and removal, and failed to serve therapeutic diets as ordered for residents with swallowing and dysphagia issues, placing residents at risk for aspiration and choking.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to assure physician notification for 2 of 5 sampled residents with blood pressure measurements outside ordered parameters. | — |
| Failed to implement physician's orders for 1 of 5 sampled residents regarding application and removal of thromboembolic deterrent hose. | — |
| Failed to serve therapeutic diets as ordered for 2 of 3 sampled residents with diet orders for blender prepared meals and nectar thickened liquids, and ground meats. | Type B Violation |
| Failed to assure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to serving therapeutic diets as ordered. | — |
Report Facts
Blood pressure readings outside ordered parameters: 11
Blood pressure readings outside ordered parameters: 5
Blood pressure readings outside ordered parameters: 7
Blood pressure readings outside ordered parameters: 3
Deficiency correction date: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Responsible for overseeing medication aides and reviewing MARs for blood pressure readings and follow-up with physicians. |
| Administrator | Administrator | Expected medication aides to notify physicians of blood pressure readings outside parameters and to document contacts. |
| Morning shift medication aide | Medication Aide | Responsible for obtaining blood pressure readings and notifying physicians if readings were outside ordered parameters. |
| Night shift medication aide | Medication Aide | Responsible for applying TED hose to residents. |
| Evening shift medication aide | Medication Aide | Responsible for removing TED hose from residents. |
| Dining Services Coordinator | Dining Services Coordinator | Responsible for training and oversight of dietary staff and ensuring therapeutic diets are served as ordered. |
| SCU Coordinator | Special Care Unit Coordinator | Maintains therapeutic diet list and communicates diet orders to staff. |
| Breakfast cook | Cook | Prepared meals for residents including those on therapeutic diets. |
| Primary Care Physician | Physician | Ordered blood pressure parameters and therapeutic diets for residents. |
| Home Health Nurse | Home Health Nurse | Provided wound care and instructed staff on TED hose application for Resident #4. |
Inspection Report
Plan of Correction
Capacity: 96
Deficiencies: 6
Jun 23, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with the 2005 Rules for the Licensing of Adult Care Homes and the 2009 N.C. State Building Code for Institutional - I2, Section 308.3.
Findings
Multiple deficiencies were identified related to physical plant safety and maintenance, including lack of hand grips in bathrooms, exit door locks not operable by single hand motion, non-functioning wanderer alarms, plumbing hazards, fire safety issues, and ventilation system failures.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide commodes, tubs, and showers accessible to residents with hand grips, affecting resident safety. |
| Exit door locks were not easily operable by a single hand motion from the inside without keys, potentially delaying emergency egress. |
| Exit doors accessible by residents lacked functioning sounding devices (wanderer alarms) to alert staff when opened. |
| Building plumbing equipment was not maintained safely; commode connection loose and lack of vacuum breaker on shower wand hose risking backflow contamination. |
| Building fire safety was compromised by a dropped light fixture exposing gaps in fire-resistance rated ceiling and incomplete coverage of fire sprinkler escutcheon plate. |
| Exhaust ventilation systems in multiple areas (soiled utility, janitors, mechanic room, kitchen, laundry, bathrooms) were not working, causing odor buildup. |
Report Facts
Licensed capacity: 96
Special care unit residents: 36
Inspection Report
Census: 96
Capacity: 96
Deficiencies: 9
May 21, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 2005 Rules for the Licensing of Adult Care Homes and the 2009 N.C. State Building Code for Institutional - I2, Section 308.3.
Findings
Multiple physical plant deficiencies were identified including issues with special locking arrangements on exit doors, lack of single hand motion door hardware at exits, unclean conditions and equipment in disrepair, breaches in fire-resistance-rated construction, impaired fire sprinkler escutcheon plates, lack of maintenance and documentation for the commercial kitchen hood's fire extinguishing system, presence of prohibited portable electric heaters, and failure to maintain exhaust ventilation in specified areas.
Deficiencies (9)
| Description |
|---|
| Exit doors in the Special Care Unit (SCU) have magnetic locks with emergency release switches requiring keys, but 2 of 3 staff did not have keys to operate them. |
| Patio exit door in the SCU required multiple hand motions to operate due to deadbolt and lockset door handle, not meeting single hand motion requirement. |
| Ice machine drain in the kitchen was piped directly onto the floor receptor, risking contamination. |
| Sconce outside the SCU laundry was missing its globe. |
| Breaches through fire-resistance-rated ceiling construction including holes and unsealed metal sleeves, compromising fire containment. |
| Fire sprinkler escutcheon plates were impaired or dropped, exposing openings that could allow passage of smoke and heat. |
| Commercial kitchen hood's fire extinguishing system lacked required inspections, maintenance, and documentation since January 2015. |
| Portable electric heater found in the Marketing Director's office, which is prohibited. |
| Exhaust ventilation was not working in multiple areas including A Hall Solid Utility, SCU Clean Laundry, and both Public Toilet Rooms. |
Report Facts
Residents served: 96
Special care unit residents: 36
Hole size: 2
Hole size: 3
Number of metal sleeves: 5
Inspection Report
Annual Inspection
Deficiencies: 2
Apr 30, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 04/29/15 and 04/30/15 at Carillon Assisted Living of Mooresville.
Findings
The facility failed to implement infection control measures ordered by the physician for one resident diagnosed with Clostridium difficile (C. diff.), including failure to maintain proper contact precautions and hand hygiene practices among staff.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement infection control measures ordered by the physician for Resident #4 with Clostridium difficile (C. diff.). | Type B Violation |
| Failure to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant federal and state laws and rules related to infection control. | — |
Report Facts
Dates of survey: Annual survey conducted on 04/29/15 and 04/30/15
Correction deadline: Correction date for Type B violation shall not exceed June 6, 2015
Loading inspection reports...
