Inspection Report
Annual Inspection
Deficiencies: 7
Mar 18, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey on March 16-18, 2022 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in staff qualifications, food service cleanliness and snack provision, therapeutic diet adherence, medication administration, and infection control practices related to glucometer use.
Severity Breakdown
Type B Violation: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. | — |
| Failed to ensure 1 of 3 sampled staff had a criminal background check completed upon hire. | — |
| Failed to ensure the kitchen was clean and protected from contamination related to food particles and build-up substances on cooking equipment. | — |
| Failed to ensure snacks were offered to all residents between meals three times per day as required. | — |
| Failed to serve therapeutic diets as ordered for 2 of 2 sampled residents with nectar thickened liquid orders. | — |
| Failed to administer medications as ordered and in accordance with facility policies for 1 of 5 sampled residents, including improper medication observation and incomplete medication records. | — |
| Failed to implement infection control procedures for glucometers used for finger stick blood sugar testing, resulting in sharing of glucometers between residents and risk of bloodborne pathogen transmission. | Type B Violation |
Report Facts
Deficiencies cited: 7
FSBS readings: 23
FSBS readings: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for lack of criminal background check upon hire. | |
| Staff B | Licensed Practical Nurse (LPN) | Named in deficiency for lack of documented Health Care Personnel Registry check upon hire. |
| Administrator | Interviewed multiple times regarding staff qualifications, infection control, and dietary practices. | |
| Dietary Manager | Interviewed regarding kitchen cleanliness, snack provision, and therapeutic diet preparation. | |
| Medication Aide (MA) | Observed and interviewed regarding medication administration and finger stick blood sugar testing. | |
| Nurse in Charge (NIC) | Interviewed regarding medication administration and dietary concerns. | |
| RN Supervisor | Interviewed regarding medication administration and infection control policies. |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 29, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the Carolina Inn at Village Green on November 28-29, 2018 to assess compliance with regulations related to nutrition and food service, including therapeutic diet menus and serving therapeutic diets as ordered by physicians.
Findings
The facility failed to have matching therapeutic diet menus for 4 of 7 sampled residents and failed to serve 1 of 7 sampled residents (Resident #6) the physician-ordered mechanical soft diet. Interviews and record reviews revealed lack of updated therapeutic diet menus and communication gaps regarding diet orders.
Deficiencies (2)
| Description |
|---|
| Facility failed to have a matching therapeutic diet menu for 4 of 7 sampled residents, including no menu for Reduced Concentrated Sweets (RCS), mechanical soft diet, puree diet, and No Added Salt (NAS) diet. |
| Facility failed to serve Resident #6 the physician-ordered mechanical soft diet as evidenced by observations of meals served and interviews with staff. |
Report Facts
Sampled residents with therapeutic diet menu issues: 4
Sampled residents with therapeutic diet serving issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Interviewed regarding use of dietary lists and meal preparation | |
| Director of Dietary | Interviewed regarding lack of therapeutic diet menu and diet list updates | |
| Administrator | Interviewed regarding facility's reliance on clinical staff for orders and lack of awareness of diet issues | |
| Registered Dietician | Contracted to provide updated therapeutic diet menus and education | |
| Case Manager from Rehabilitation Center | Interviewed regarding Resident #6's mechanical soft diet order | |
| Dietary Assistant Manager | Interviewed regarding meal ticket process and diet substitutions | |
| Food Server | Interviewed regarding meal plating and use of diet menu list | |
| Nurse in Charge (NIC) | Interviewed regarding communication of new orders and diet changes |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 1, 2018
Visit Reason
Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies and outstanding corrective actions.
Findings
The facility has corrected most cited deficiencies; however, there remains an outstanding deficiency related to corridor doors not meeting code requirements for positive latching in certain areas without smoke detection.
Deficiencies (1)
| Description |
|---|
| Facility failed to meet code requirements for corridor doors to be positive latching in the 3rd floor Bistro and 1st floor Dining areas, where doors are equipped with roller latches and rooms lack smoke detection. |
Inspection Report
Capacity: 100
Deficiencies: 15
Oct 25, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for Licensing of Domiciliary Homes, the 1996 North Carolina State Building Code, and applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds.
Findings
Multiple deficiencies were identified related to building safety, physical plant conditions, fire safety, housekeeping, and equipment maintenance. These include issues with special locking arrangements on doors, lack of hand grips in tubs, improper door locks, poor housekeeping and maintenance, fire safety hazards, electrical system problems, and ventilation failures.
Deficiencies (15)
| Description |
|---|
| Facility failed to have all required components to properly operate doors equipped with special locking arrangements. |
| Corridor doors were not positive latching as required by code. |
| Tubs accessible to residents lacked required hand grips. |
| Medication preparation sink faucet did not have wrist type lever handles. |
| Exit door locks were not easily operable by a single hand motion from inside. |
| Walls, ceilings, floors, and furniture were not kept clean and in good repair, including holes in walls and deteriorated carpets. |
| Building was not maintained free of hazards; oxygen cylinders were stored unsecured. |
| Interior doors were not maintained in a safe and operating condition; several doors did not latch properly. |
| Fire safety was compromised due to missing or damaged fire sprinkler escutcheon plates, missing ceiling panels, and unsealed penetrations in fire-resistance-rated assemblies. |
| Commercial kitchen hood fire suppression system lacked required inspections and maintenance documentation; nozzles not properly aimed. |
| Emergency exit signs were not properly illuminated or correctly marked. |
| Electrical system was unsafe due to blocked electrical panel access, non-functioning GFCI outlets, and falling light fixtures. |
| Fire sprinkler heads were obstructed with debris, potentially delaying fire response. |
| Egress from some areas required keys or special knowledge due to locked doors without proper override. |
| Required exhaust ventilation system was not working in specified areas. |
Report Facts
Total licensed capacity: 100
Oxygen cylinders unsecured: 4
Recessed can light fixtures falling: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor conducting the Construction Section Biennial Survey. | |
| Suzanna Fay | Surveyor conducting the Construction Section Biennial Survey. | |
| Executive Director | Interviewed regarding failure to meet code requirements for special locking arrangements. | |
| Maintenance Director | Interviewed regarding failure to meet code requirements for special locking arrangements. |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 19, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from November 17 to November 19, 2015, to assess compliance with state regulations including hot water system requirements.
Findings
The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit in multiple resident areas across all floors. Observations and interviews revealed excessively high and low water temperatures, lack of adequate signage, and inconsistent monitoring and documentation of water temperatures. Maintenance had been addressing boiler and mixing valve issues, with plans to install new valves and improve monitoring.
Severity Breakdown
Type B Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit in resident areas on Terrace Level, First, Second, and Third Floors. | Type B Violation |
| Facility failed to assure residents received adequate and appropriate care related to hot water temperature compliance. | Type B Violation |
Report Facts
Hot water temperature: 120
Hot water temperature: 130
Hot water temperature: 124
Hot water temperature: 92
Hot water temperature: 96
Hot water temperature: 80
Hot water temperature: 99
Hot water temperature: 88
Hot water temperature: 122
Hot water temperature: 118
Correction deadline: Jan 3, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed multiple times regarding boiler problems, water temperature monitoring, and corrective actions | |
| Administrator | Interviewed regarding awareness of hot water issues, sanitation inspections, and corrective plans | |
| Nurse In Charge | Interviewed about staff notification and resident safety measures related to hot water issues |
Inspection Report
Capacity: 100
Deficiencies: 10
Oct 29, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 1996 Rules for the Licensing of Domiciliary Homes, the 1996 North Carolina State Building Code, and applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds.
Findings
The facility was found to have multiple deficiencies including failure to provide lever handles on medication room sinks, poor housekeeping and maintenance issues such as damaged trim and stained carpets, unsafe storage of oxygen containers, malfunctioning emergency exits and fire safety components, electrical hazards including missing circuit blanks and non-tripping GFCI receptacles, improper hot water temperatures, and non-working exhaust ventilation in resident bathrooms.
Deficiencies (10)
| Description |
|---|
| Med Prep Area sink faucet lacks wrist type lever handles, using knobs instead, risking cross contamination. |
| Facility failed to maintain buildings in good repair and clean; includes missing trim, stained carpet, peeling and stained vinyl wallcovering. |
| Oxygen containers stored in unapproved containers in multiple locations, risking falling and damage. |
| Emergency exit doors difficult to open requiring special knowledge; corridor door does not close or latch properly. |
| Missing circuit blank in electrical panel posing electrocution hazard. |
| GFCI receptacles beside sinks in serving and main kitchens do not trip when tested, risking electrocution. |
| Damaged or missing one-hour rated ceiling tiles in sprinkler riser room compromising fire resistance. |
| Condensate pipe for ice machine extended into floor drain, risking bacterial contamination. |
| Hot water temperature in resident rooms not maintained within required range (94°F and 124°F found). |
| Exhaust fan in bathroom of Resident Room 121 not working, preventing proper ventilation. |
Report Facts
Total licensed capacity: 100
Hot water temperature: 124
Hot water temperature: 94
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