Inspection Report
Capacity: 66
Deficiencies: 3
Apr 10, 2024
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code Section 409.1- Group I-2.
Findings
Deficiencies were cited related to unsafe and non-operating building equipment including plumbing without proper air gap, emergency lights that did not illuminate, and multiple exhaust fans not working in various rooms and hallways.
Deficiencies (3)
| Description |
|---|
| The ice machine drain in the Dining Room Beverage Service Bar does not have a 2" air gap. |
| Emergency lights above the A Hall Egress Door and on the right wall of the Living Room did not illuminate when tested. |
| Exhaust fans in multiple locations including C Hall Room 23, Room 31, Staff Bathroom, Women's Guest Bathroom, Men's Guest Bathroom, Communication Room, and D Hall Housekeeping are not working. |
Report Facts
Total licensed capacity: 66
Inspection Report
Follow-Up
Deficiencies: 7
Jan 17, 2019
Visit Reason
Biennial Follow Up Construction Survey conducted to assess compliance with physical plant and fire safety code requirements.
Findings
The facility failed to meet code requirements for special locking arrangements on doors, including issues with fire alarm activation unlocking mechanisms and emergency override switches. Additionally, the fire alarm system and smoke tight corridor doors were not maintained in a safe and operating condition.
Deficiencies (7)
| Description |
|---|
| Facility failed to have all required working components or procedures to properly operate doors equipped with Special Locking Arrangements. |
| Four of five special locking exits unlock on fire alarm activation but reenergize when fire detection system is silenced; one exit does not unlock on fire alarm activation. |
| Central emergency override switch did not unlock the doors. |
| Twenty percent of staff did not carry keys for metal-keyed emergency release switches, violating NC State Building Code requirements. |
| Fire alarm system was not maintained in a safe and operating condition, failing to provide all control functions. |
| Smoke tight corridor doors were not maintained in a safe and operating condition. |
| Storefront doors in Business Office, Beauty Shop, and Chapel had paddle locks without positive latching. |
Report Facts
Percentage of staff without keys: 20
Number of special locking exits: 5
Number of special locking exits unlocking on fire alarm: 4
Inspection Report
Capacity: 66
Deficiencies: 17
Nov 16, 2018
Visit Reason
This document is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for the Licensing of Adult Care Homes and applicable building codes for a facility licensed for 66 beds.
Findings
Multiple deficiencies were cited related to physical plant safety and maintenance, including corridor obstructions, unsecured oxygen cylinders, lack of vacuum breakers on water fixtures, non-operational fire safety and electrical systems, missing fire sprinkler protection, and the presence of prohibited portable electric heaters.
Deficiencies (17)
| Description |
|---|
| Corridors are obstructed by an unattended medication cart reducing corridor width from six feet to three feet. |
| Oxygen cylinders in Bedroom 15 are not physically secured, posing a hazard if they fall. |
| Beauty Shop shampoo sinks lack vacuum breakers, risking backflow contamination. |
| Five of ten building exits have special locking systems that are out of service and cannot be tested. |
| Fire alarm system hold open devices reenergize when silenced, failing to maintain smoke compartment protection. |
| Emergency lighting near Bedroom 5 did not illuminate on backup power; corrected before surveyors departed. |
| Fire sprinkler head in Kitchen Freezer was discharged and not replaced. |
| Corridor door to Hopper Room did not latch into frame on its own power. |
| Inside door handle missing on Laundry door to soiled linen. |
| Fire sprinkler heads obstructed by stored items in Library/Therapy Closet and Bistro Closet. |
| Escutcheon plates missing or dropped on fire sprinklers in Bedroom 9, exposing openings that allow smoke and heat spread. |
| Gaps around cable bundles in Communication Room not firestopped. |
| Smoke tight corridor doors in Bedrooms 13 and 14 did not latch into frames when closed. |
| Storefront doors in Business Office, Beauty Shop, and Chapel lack positive latching hardware. |
| Bistro room lacks a door separating it from corridor and has inadequate smoke detection. |
| Electrical panel K in Kitchen has an open slot exposing energized components. |
| Use of prohibited portable electric heater found in D Hall Bathroom. |
Report Facts
Total licensed beds: 66
Number of building exits: 10
Number of exits with non-operational special locking: 5
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 2, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey on November 1-2, 2017 to assess compliance with medication administration regulations.
Findings
The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for one resident (Resident #2), specifically regarding the administration of levothyroxine. The issue was linked to errors during the conversion from paper MARs to electronic MARs and lack of proper auditing, resulting in Resident #2 missing doses for 15 days.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications were administered as ordered by a licensed prescribing practitioner for Resident #2, involving levothyroxine medication errors. |
Report Facts
Days medication not administered: 15
TSH level: 115
TSH level: 109
Tablets remaining: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Campus facility RN who performed an override in the eMAR system discontinuing Resident #2's levothyroxine by mistake. | |
| Resident Care Coordinator (RCC) | Responsible for reviewing audit logs and ensuring medication audits were completed; unsure if audit was done for Resident #2. | |
| Director of Operations | Director of Operations for the facility's contracted pharmacy who explained the medication order entry and audit process. | |
| Lead Medication Aide (MA) | Unaware of auditing process for eMARs and did not administer levothyroxine to Resident #2 due to scheduling and lack of documentation. | |
| Primary Care Provider (PCP) | Resident #2's PCP who had not ordered discontinuation of levothyroxine and re-ordered the medication after notification of missed doses. |
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