Inspection Reports for Carolina Reserve of Durham
4523 Hope Valley Rd, Durham, NC 27707, United States, NC, 27707
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Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2024
Visit Reason
Report of a Biennial Follow Up Construction Survey conducted on December 18, 2024.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Capacity: 60
Deficiencies: 9
Jun 12, 2024
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the North Carolina Building Code(s) and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited related to physical plant conditions including failure to comply with code requirements for emergency release switch keys, unsafe and unmaintained outside premises, poor housekeeping and furnishings, unsafe and non-operating building equipment including fire safety and mechanical systems, plumbing issues, and inadequate exhaust ventilation in specified areas.
Deficiencies (9)
| Description |
|---|
| Staff responsible for evacuation did not carry emergency release switch keys for locked units. |
| Outside grounds were not maintained in a clean and safe condition, including bowed soffit and rotting fascia trim. |
| Walls and furnishings were not kept in good repair, including loose door hardware and detaching panels. |
| Mechanical equipment was not maintained in safe operating condition; dryer exhaust caps were broken or missing allowing pest entry. |
| Fire safety equipment was not maintained; doors did not close and latch properly, held open with magnets, and door hardware was loose or damaged. |
| Electrical emergency/safety lighting equipment was not maintained; exit signs and emergency lights failed to illuminate. |
| Fire resistant rated ceilings had holes or gaps at penetrations, missing sprinkler escutcheon rings, unsecured attic access panel, and ceiling cracks. |
| Plumbing equipment was not maintained; steady stream of water from sink faucet in SCU Dining. |
| Exhaust ventilation was inadequate or non-functional in specified spaces including resident bathrooms, laundry, and housekeeping areas. |
Report Facts
Licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 6
Nov 16, 2023
Visit Reason
The Adult Care Licensure Section and the Durham County Department of Social Services conducted an annual and follow-up survey from November 14, 2023 to November 16, 2023.
Findings
The facility failed to ensure medication staff completed required training, failed to implement physician orders for compression socks and TED hose for residents, failed to maintain accurate therapeutic diet listings and serve diets as ordered, and failed to administer medications as ordered for sampled residents, including issues with pain medication, inhalers, nasal sprays, and blood pressure medication.
Severity Breakdown
Type B Violation: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure 3 of 5 medication staff completed state-approved medication aide training courses as required. | — |
| Facility failed to ensure implementation of physician's orders for compression socks and TED hose for 2 of 5 sampled residents. | — |
| Facility failed to maintain an accurate listing of residents with physician-ordered therapeutic diets for guidance of food service staff. | — |
| Facility failed to serve therapeutic diets and supplements as ordered for 3 of 7 sampled residents. | — |
| Facility failed to clarify medication orders for 1 of 5 sampled residents for medication used to treat mild pain. | — |
| Facility failed to administer medications as ordered for 2 of 5 sampled residents for an inhaler, nasal spray, reflux medication, and blood pressure medication. | Type B Violation |
Report Facts
Medication administration frequency: 4
Medication administration duration: 3
Blood pressure readings: 4
Medication doses remaining: 16
Medication doses dispensed: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in medication aide training deficiency | |
| Staff C | Named in medication aide training deficiency | |
| Staff E | Named in medication aide training deficiency | |
| Administrator | Interviewed regarding multiple deficiencies and facility policies | |
| Director of Clinical Services | Interviewed regarding medication orders and implementation | |
| Director of staffing agency | Interviewed regarding medication aide training documentation | |
| Pharmacist | Interviewed regarding medication orders and pharmacy dispensing | |
| Dietary Manager | Interviewed regarding therapeutic diet implementation | |
| Resident Care Coordinator | Interviewed regarding therapeutic diets and medication administration | |
| Personal Care Aide | Interviewed regarding meal service and medication administration | |
| Medication Aide | Interviewed regarding medication administration and order processing |
Inspection Report
Annual Inspection
Deficiencies: 4
Mar 11, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Carolina Reserve of Durham from March 9, 2022 to March 11, 2022 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure therapeutic diets were served as ordered for 2 residents, failed to administer medications as ordered for 1 resident including errors with an oral rinse and eyelid cleanser, failed to ensure a resident had physician's orders for self-administered medications, and failed to store self-administered medications in a safe and secure manner.
Deficiencies (4)
| Description |
|---|
| Failed to ensure therapeutic diet orders were served as ordered for 2 of 4 sampled residents (#1 and #6) with reduced carbohydrate and low fat/low cholesterol diets. |
| Failed to administer medications as ordered for 1 of 4 residents (#7), including errors with chlorhexidine oral rinse timing and omission of eyelid scrubs. |
| Failed to ensure 1 resident (#4) had physician's orders to self-administer acetaminophen, lidocaine patch, and eye lubricant. |
| Failed to assure that self-administered medications were stored in a safe and secure manner for 1 resident (#4). |
Report Facts
Medication error rate: 7.1
Number of residents sampled with diet deficiencies: 2
Number of residents sampled with medication administration deficiencies: 1
Number of residents sampled with self-administration deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Newly hired, responsible for ordering food and training kitchen staff; interviewed regarding diet deficiencies. |
| Administrator | Administrator | Interviewed regarding diet and medication administration deficiencies and facility policies. |
| Director of Clinical Services | Director of Clinical Services | Interviewed regarding medication administration errors and order processing. |
| Medication Aide | Medication Aide | Observed administering medications and interviewed regarding medication errors. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for self-administration assessments and obtaining physician orders; interviewed regarding medication storage and self-administration. |
Inspection Report
Capacity: 60
Deficiencies: 7
Feb 21, 2019
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant and safety issues including improper key control for emergency release switches on locked unit doors, lack of required bathroom fixtures and roll-in showers, obstructions in corridors and exit doorways, unsecured oxygen cylinders, electrical outlets without ground fault interrupters, and blocked fire sprinkler heads.
Deficiencies (7)
| Description |
|---|
| Facility failed to have all required procedures to properly operate doors equipped with Special Locking Arrangements; only the Med Tech had a key to emergency release switches and staff were unaware of their use and location. |
| Facility failed to provide a bathroom off a corridor with a minimum three feet door, a tub accessible on at least two sides, a three feet by three feet roll-in shower, toilet, and lavatory as required. |
| Exit doorways were obstructed by equipment, such as a table blocking the Sun Room exit door, preventing the required 42 inches clearance. |
| Oxygen cylinders were not physically secured, posing a hazard if they fall and break valves. |
| Electrical outlets in wet locations such as sinks, bathrooms, and outside the building lacked ground fault interrupters; a GFCI outlet at the exterior kitchen door failed testing. |
| Electrical system was not maintained in a safe and operating condition; a copy machine blocked access to an electrical panel limiting required clearance. |
| Fire sprinkler heads were obstructed by stored items in the Kitchen Pantry and Maintenance Closet, potentially affecting sprinkler discharge patterns. |
Report Facts
Total licensed beds: 60
Required clearance for exit door: 42
Minimum door width: 36
Minimum clearance for electrical panel: 36
Minimum clearance for electrical panel depth: 30
Minimum clearance below fire sprinkler: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor who conducted the Construction Section Biennial Survey |
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 3
Aug 16, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 08/15-16/18 to assess compliance with regulations related to nutrition, therapeutic diets, medication orders, and resident care.
Findings
The facility failed to serve milk twice daily to residents in the secured unit as required, failed to serve a resident's therapeutic low fat/low cholesterol diet as ordered, and failed to clarify medication orders for a resident receiving crushed extended release medications contrary to physician and pharmacy instructions.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure 8 ounces of milk was served to residents twice daily in the secured unit. | — |
| Facility failed to assure a resident with physician's orders for a low fat/low cholesterol diet was served as ordered. | — |
| Facility failed to clarify medication orders for a resident with two extended release medications crushed prior to administration without orders to crush all medications. | Type B Violation |
Report Facts
Census: 14
Deficiencies cited: 3
Blood pressure reading: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (secured unit) | Interviewed regarding milk service and therapeutic diet compliance |
| Administrator | Facility Administrator | Interviewed regarding awareness of milk service and therapeutic diet issues |
| Dietary Manager | Dietary Manager | Interviewed regarding therapeutic diet preparation and plating |
| Medication Aide | Medication Aide | Interviewed regarding medication administration and crushing practices |
| Registered Nurse | Registered Nurse | Interviewed regarding medication order review and clinical operations |
| Contract Pharmacy Technician | Contract Pharmacy Technician | Interviewed regarding medication crushing orders and pharmacy reviews |
| Contract Pharmacist | Contract Pharmacist | Interviewed regarding medication effects and quarterly pharmacy reviews |
Inspection Report
Capacity: 60
Deficiencies: 3
Mar 3, 2017
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
Deficiencies were cited related to housekeeping and furnishings, including failure to maintain and clean HVAC air-distribution vents, damaged interior walls and doors due to wheelchair interactions, and breaches in the one-hour roof/ceiling assembly construction compromising its integrity.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain service and cleaning of HVAC air-distribution vents; return-air grille has excessive particulate build-up in Room 106. |
| Facility failed to maintain the finish surfaces of interior walls and doors; interior walls and doors of Resident Room 113B are damaged due to wheelchair interactions. |
| Facility was not maintained in a safe manner due to breaches of the one-hour roof/ceiling assembly construction; ceiling sheet-rock has taped joints that are cracked and not sealed in the 200 Hall Sunroom. |
Report Facts
Licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 23, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Spring Arbor of Durham from July 21, 2015 to July 23, 2015 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in several areas including inadequate volume of exit door alarms for a resident with exit-seeking behavior, failure to complete required criminal background checks for one staff member, and failure to provide required diabetes care training and medication aide training to one medication aide prior to insulin administration.
Deficiencies (4)
| Description |
|---|
| Exit door alarms were not loud enough to be heard by staff when showering a resident with exit-seeking behavior and disorientation. |
| One of four staff (Staff B) did not have a criminal background check in accordance with state requirements. |
| One medication aide (Staff B) had not completed required training on care of diabetic residents prior to administering insulin. |
| One medication aide (Staff B) had not completed the required 10-hour medication aide training within 60 days of hire. |
Report Facts
Number of exit doors with inadequate alarms: 9
Number of residents identified with exit seeking behavior: 1
Number of staff sampled without criminal background check: 1
Medication aide training hours completed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Supervisor/Medication Aide and Resident Assistant | Named in deficiencies related to missing criminal background check and incomplete medication aide and diabetic care training. |
Inspection Report
Capacity: 60
Deficiencies: 5
Jan 8, 2015
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code(s) as part of a Biennial Construction Survey.
Findings
Multiple deficiencies were cited including unsafe electrical wiring, compromised fire safety equipment, improper storage of oxygen cylinders, inadequate hot water temperatures, and insufficient exhaust ventilation.
Deficiencies (5)
| Description |
|---|
| Electrical equipment not maintained in a safe manner; junction box detached and exposed wiring in Main Laundry. |
| Fire safety equipment compromised; doors to corridors did not latch properly, gaps in fire resistant ceilings in Sprinkler and Water Heater Rooms. |
| Improper storage of oxygen cylinders; bottles unrestrained and stored insecurely in Room 206 and Med Room. |
| Hot water temperatures below minimum required levels (94°F to 98°F) except in kitchen. |
| Exhaust ventilation not provided as required; no exhaust fan in Biohazard Room and central exhaust fan not working on 100 Hall. |
Report Facts
Total licensed capacity: 60
Water temperature range: 94
Water temperature range: 98
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