Inspection Reports for The Canterbury House

The report documents a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies identified in a prior Biennial Construction Survey.

The facility was found to have unresolved deficiencies including lack of a wiring diagram and system components map at the fire alarm panel, fire safety equipment not maintained in operating condition with corrosion observed on riser room heads, and inadequate exhaust ventilation in specified spaces with fans blowing air out instead of pulling it in.

This was a complaint follow-up construction survey conducted to verify correction of previously identified deficiencies.

Deficiencies identified in the prior complaint survey have been corrected and no further action is required at this time.

Complaint follow-up survey conducted; deficiencies corrected.

This is a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies identified in a prior Biennial Construction Survey.

The facility has multiple unresolved deficiencies related to fire safety and physical plant requirements, including magnetic locks on exterior doors re-locking prematurely, absence of wiring diagrams at the fire alarm panel, holes and gaps in fire-resistant ceilings, fire doors not latching properly, corroded fire sprinkler heads, and non-functioning resident bathroom exhaust fans.

The visit was a Complaint Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to the facility's fire sprinkler system.

The facility's fire sprinkler equipment was found not to be maintained in operating condition due to debris in the sprinkler piping and the system not being flushed after repairs, indicating that not all cited deficiencies have been corrected and further action is required.

This was a complaint follow-up survey. Not all cited deficiencies have been corrected, requiring further action.

The Adult Care Licensure Section and the Person County Department of Social Services conducted an annual and follow-up survey on 06/28/23 to 06/29/23.

The facility failed to administer medications as ordered for 1 of 5 sampled residents related to a medication for bone health, specifically alendronate 70mg once weekly. Medication audits were not consistently performed, leading to medication errors and extra medication remaining unadministered.

The Adult Care Licensure Section and the Person County Department of Social Services conducted an annual survey on 01/05/22 - 01/06/22 to assess compliance with health care, medication administration, infection control, and other regulatory requirements.

The facility was found deficient in ensuring timely referral and follow-up for a resident's endocrinologist appointment, administering medications as ordered by continuing to give a discontinued medication, and maintaining proper infection control practices related to staff facemask use during the COVID-19 pandemic.

This report documents a Construction Section Biennial Survey conducted to assess compliance with the 1996 Regulations for Homes for the Aged and Disabled, applicable 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code for Institutional Unrestrained Occupancy.

The facility was found to have multiple physical plant deficiencies including unsafe and unmaintained outside premises, furnishings in disrepair, hazards such as unsecured oxygen tanks, incorrectly oriented evacuation plans, fire safety equipment not maintained properly including gaps in corridor doors and doors held open with unapproved devices, electrical safety issues, gaps in fire resistant ceilings, dust accumulation on mechanical equipment, and non-functioning exhaust ventilation in several areas.

This document is a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, fire safety, and building codes for the facility.

The facility failed to meet several code requirements including improper emergency release switches on magnetically locked doors, lack of staff training on these doors, outdated and deficient sprinkler system inspections, fire safety hazards such as difficult to open exit gates, improper storage near sprinkler heads, inadequate fire drill rehearsals, and multiple fire safety door deficiencies including doors not latching properly and compromised fire-rated walls and ceilings.

An Annual Survey was conducted by the Adult Care Licensure Section on 1/20/16 and 1/21/16 to assess compliance with regulatory requirements.

The facility failed to report an allegation of abuse against a health care staff member within the required 24 hours and did not conduct a timely investigation within 5 working days. The allegation involved a staff member hitting a resident, which was not reported to the Health Care Personnel Registry due to lack of awareness of reporting requirements.

Biennial Construction Survey conducted to assess compliance with the 1996 Regulations for Homes for the Aged and Disabled, 2005 Rules 10A NCAC 13F for Adult Care Homes, and the 1996 North Carolina State Building Code for Institutional Unrestrained Occupancy.

Multiple deficiencies were cited related to physical plant maintenance including damaged resident room furniture, broken ceramic tiles, water-damaged ceilings, exterior construction damage, breaches in smoke barrier walls, improperly installed HVAC components, non-latching fire doors, unsealed fire-rated penetrations, improperly supported vent pipes, excessive particulate buildup in HVAC grilles, missing electrical box covers, removed sprinkler heads, obstructed kitchen fire suppression systems, and non-operational mechanical exhaust fans in various areas.