Inspection Reports for Carolina Reserve of Hendersonville
1820 Pisgah Dr, Hendersonville, NC 28791, United States, NC, 28791
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Inspection Report
Capacity: 61
Deficiencies: 9
Jun 25, 2019
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Biennial construction section survey to assess compliance with applicable physical plant, fire safety, and building code regulations for an adult care home.
Findings
The facility failed to meet several code and regulatory requirements including improper operation and knowledge of special locking arrangements, unsafe storage and handling of portable medical oxygen cylinders, obstructed exits, inadequate fire safety rehearsals, compromised fire-rated doors and walls, malfunctioning alarm devices, unsafe combustible storage, and lack of staff training on fire suppression system use.
Deficiencies (9)
| Description |
|---|
| Facility failed to have all required components and procedures to properly operate doors equipped with Special Locking Arrangements; staff unaware of emergency override switch location and use. |
| Building not maintained free of hazards due to improper handling and storage of portable medical oxygen cylinders and obstructed exterior exits. |
| Fire safety rehearsals not conducted quarterly on each shift as required, with multiple shifts missing rehearsals in recent quarters. |
| Building equipment including fire safety, electrical, mechanical, and plumbing not maintained in safe operating condition; corridor doors prevented from closing and latching properly. |
| Required one-hour fire rated walls and ceilings compromised by unsealed conduit sleeves and use of unrated foam. |
| Alarm sounding device covering emergency release switch near room 205 failed to sound when opened. |
| Large quantities of combustible storage kept in non-designated storage area (bedroom 117) risking fire spread beyond containment. |
| Improper storage too close to fire sprinkler heads, potentially negating sprinkler effectiveness. |
| Kitchen staff unaware of location or use of range hood fire suppression system pull; staff training needed. |
Report Facts
Licensed beds: 61
Portable medical oxygen cylinders: 3
Portable medical oxygen cylinders: 4
Mattresses stored: 14
Upholstered chairs stored: 2
Wood chairs stored: 2
Wood tables stored: 1
Wood chests of drawers stored: 2
Cardboard boxes stored: 8
Fire drill rehearsals missing: 1
Fire drill rehearsals missing: 1
Fire drill rehearsals missing: 2
Fire drill rehearsals missing: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 14, 2018
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The Adult Care Licensure Section conducted an annual survey from 12/12/18 to 12/14/18 to assess compliance with state regulations for Carolina Reserve of Hendersonville.
Findings
The facility failed to ensure that 2 of 6 sampled staff were tested for tuberculosis upon hire and failed to ensure proper labeling of hydromorphone medication for 1 of 5 sampled residents, which was detrimental to resident safety.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure 2 of 6 sampled staff (Staff A and C) were tested for tuberculosis disease upon hire. | — |
| Facility failed to ensure hydromorphone was properly labeled for 1 of 5 sampled residents (Resident #3), including missing required label information on prefilled syringes. | Type B Violation |
| Facility failed to ensure resident received care and services which are adequate, appropriate, and in compliance with relevant laws related to medication labeling. | — |
Report Facts
Number of sampled staff not tested for TB upon hire: 2
Number of sampled residents with medication labeling deficiency: 1
Quantity of hydromorphone prescribed: 60
Date range of annual survey: From 2018-12-12 to 2018-12-14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Named in tuberculosis testing deficiency |
| Staff C | Medication Aide | Named in tuberculosis testing deficiency |
| Business Office Manager | Responsible for personnel records and TB test audits | |
| Director of Clinical Services | Responsible for administering second step TB tests and monitoring compliance | |
| Administrator | Responsible for assuring new hires had required paperwork including TB tests | |
| Hospice Nurse | Prefilled hydromorphone syringes for Resident #3 | |
| Resident Care Coordinator | Involved in medication labeling issue for Resident #3 |
Inspection Report
Capacity: 61
Deficiencies: 4
May 10, 2017
Visit Reason
Biennial construction section survey to ensure compliance with the 1996 Regulations for Homes for the Aged and Disabled and applicable portions of the 2005 Regulations for Adult Care Homes of Seven or More Beds and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including failure to maintain ceilings free of dust and particulate on HVAC grilles, unsafe fire protection equipment with clogged AHU duct detectors and dropped sprinkler head escutcheons, and failure to provide adequate exhaust ventilation in specified areas.
Deficiencies (4)
| Description |
|---|
| Facility failed to keep ceilings clean by allowing HVAC supply and return-air grilles to collect dust and particulate. |
| Facility fire protection equipment incorporated in the HVAC system was not maintained in a safe manner; sampling tubes clogged in all AHU duct detectors in Main Mechanical Room. |
| Exterior porch ceilings at each exit door have dropped sprinkler head escutcheons. |
| Facility failed to provide exhaust ventilation where odors are generated; mechanical exhaust fan not exhausting interior air in SCU/Laundry Room, Room 120, and Room 122. |
Report Facts
Licensed capacity: 61
Inspection Report
Follow-Up
Capacity: 61
Deficiencies: 4
Mar 19, 2015
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Follow-up survey conducted to verify compliance with the 1996 Regulations for Homes for the Aged and Disabled and applicable portions of the 2005 Regulations for Adult Care Homes, as well as the 1996 North Carolina State Building Code.
Findings
Deficiencies were found related to building equipment safety, specifically compromised one-hour fire rated walls and ceilings with unsealed holes and missing or inoperable ceiling radiation dampers, which could allow fire to spread quickly within the facility.
Deficiencies (4)
| Description |
|---|
| One-hour fire rated walls and/or ceilings were compromised in several locations with holes and penetrations not sealed with approved materials and missing or inoperable ceiling radiation dampers. |
| No radiation dampers provided in the High/Low combustion air inlets in the mechanical closet off the Activity room. |
| No radiation dampers provided in the High/Low combustion air inlets in the mechanical closet off the Living room. |
| Mechanical rooms with gas furnaces have High/Low combustion air inlets that penetrate the ceiling and terminate into the attic open space. |
Report Facts
Licensed bed capacity: 61
Inspection Report
Capacity: 61
Deficiencies: 11
Jan 22, 2015
Visit Reason
Biennial Construction Survey to ensure the facility meets applicable regulations including the 1996 Regulations for Homes for the Aged and Disabled, 2005 Regulations for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including non-compliance with building code requirements for magnetic locks and emergency release switches, housekeeping hazards related to plumbing fixtures, inadequate fire safety rehearsals, malfunctioning emergency lighting, fire safety door issues, compromised fire rated walls and ceilings, unsafe storage of portable medical oxygen cylinders, and plumbing equipment maintenance problems.
Deficiencies (11)
| Description |
|---|
| Locks on exit doors and exit gate from Special Care did not meet Building Code requirements for magnetic locks; staff did not carry emergency release keys and were unaware of their function. |
| Emergency release switch at nurse station was a momentary switch instead of the required ON/OFF switch. |
| Hoses on water fixtures were long enough to reach fixtures without vacuum breakers, risking siphoning contaminated water. |
| Fire drills were only conducted on 1st shift before lunch, not quarterly on each shift as required. |
| Battery powered emergency light near room 134 would not work when tested. |
| Fire rated door to laundry was wedged open, preventing proper closing. |
| Duct mounted smoke detectors were not properly maintained; sampling tubes were dirty or improperly installed. |
| Magnetic locks on Special Care Unit exit doors and gate re-locked after fire alarm was silenced, potentially delaying evacuation. |
| One-hour fire rated walls and ceilings were compromised by unsealed holes, unapproved sealants, missing radiation dampers, and fallen ducts. |
| Portable medical oxygen cylinders were improperly stored in unapproved containers or no containers in rooms 116 and 120. |
| Toilets in the Spa and bathrooms off rooms 214, 218, and 219 were coming loose from the floor. |
Report Facts
Licensed bed capacity: 61
Portable medical oxygen cylinders: 18
Portable medical oxygen cylinders: 5
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