Inspection Reports for Cranberry House

The facility had several deficiencies including furniture in disrepair, improper storage of oxygen bottles posing hazards, failure to maintain fire safety systems due to holes in corridor doors, and inadequate exhaust ventilation in specified areas causing humidity and odor issues.

The facility failed to ensure medications were administered as ordered for Resident #4 related to two eye infection medications, and failed to observe and accurately document medication administration for Resident #2. These failures posed a risk to resident health and violated medication administration policies.

The inspection included a complaint investigation triggered by allegations of abuse and neglect involving multiple residents and staff. Specific substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to update resident assessments after significant changes, failure to ensure timely referral and follow-up for health care needs, failure to protect residents from abuse and neglect, failure to administer medications as ordered, failure to accurately document medication administration, failure to immediately notify law enforcement of abuse allegations, and failure to properly use physical restraints with required assessments and consents.

The visit was complaint-related, triggered by concerns about infection control practices during the COVID-19 pandemic. The facility had multiple residents and staff testing positive for COVID-19, and observations and interviews revealed staff not consistently wearing PPE correctly, residents not masked, and gowns not used appropriately.

The facility failed to ensure implementation of CDC, NCDHHS, and local health department guidelines related to infection prevention and control during the COVID-19 pandemic, including improper use of PPE by staff, residents not wearing masks while moving around, and staff not wearing gowns when providing care to COVID-19 positive residents, increasing risk of virus spread.

Multiple deficiencies were cited including lack of required exit signs, incomplete fire sprinkler protection, unresolved deficiencies in annual fire sprinkler inspection, unsafe storage of oxygen cylinders, malfunctioning emergency exit lights, gaps in fire-resistance-rated assemblies, obstructed fire sprinkler heads, unsafe electrical system components, corridor doors not resisting smoke passage, and presence of prohibited portable electric heaters.

The facility had not corrected the deficiencies related to maintaining the wood finishes of interior doors, which were damaged due to wheelchair interaction. Replacement doors had been ordered but not yet installed as of the inspection date.

Complaint investigation initiated by Avery County Department of Social Services on August 29, 2017 regarding allegations of abuse and neglect by Staff D. Multiple signed and dated witness statements were obtained. The facility initially did not report allegations to the Health Care Personnel Registry due to lack of substantiation but later filed reports after Department of Social Services intervention. Staff D was terminated on September 7, 2017.

The facility failed to ensure competency validation for Licensed Health Professional Support tasks for 3 of 5 sampled staff prior to performing tasks. Additionally, the facility failed to report allegations of physical and mental abuse and neglect by Staff D to the Health Care Personnel Registry within required timeframes. Multiple residents were found to have been subjected to verbal and physical abuse and neglect by Staff D, including pinning, twisting arms, verbal insults, neglecting hygiene, and inappropriate physical handling. Staff D was terminated following substantiation of verbal abuse allegations.

The facility had not maintained the wood finishes of the interior doors in good repair, specifically the entry doors for Rooms 101 and 103 were damaged due to wheelchair interaction. Replacement doors were scheduled to be ordered with delivery and installation expected to take 7 to 13 weeks.

Deficiencies were cited related to maintenance issues including damaged wood finishes on interior doors, holes in doors due to hardware replacement, and improper storage of oxygen cylinders posing safety hazards.

Deficiencies were cited related to housekeeping and furnishings, including damaged interior doors and hardware, and improper storage of oxygen cylinders. Plans of correction were required.

The facility failed to assure competency validation for Licensed Health Professional Support tasks for 3 of 6 sampled staff. Additionally, the facility failed to supervise a resident with a history of agitated behaviors, resulting in injury to another resident and disturbance to others. The facility also failed to obtain quarterly pharmaceutical care reviews for 5 sampled residents in the memory care unit.

The facility was found not to be maintained in a safe manner due to multiple deficiencies including smoke barrier doors not latching properly, emergency lights and exit signs not functioning correctly, dirty smoke detector sampling tubes, non-alarming magnetic locking emergency release switches, improper storage near sprinkler heads, improper juice dispenser drain line installation, and a non-functioning exhaust system on the 200 Hall.

The survey found multiple deficiencies including lack of current sanitation and fire safety inspection reports, smoke barrier doors not latching properly, non-functioning emergency lights and exit signs, compromised fire rated walls and ceilings, dirty smoke detector sampling tubes, non-working alarm devices on emergency release switches, storage too close to sprinkler heads, improper drain line installations, and a non-functioning exhaust system on the 200 Hall.

The complaint was substantiated. The fire sprinkler system was out of service and the facility had stopped performing a Fire Watch. The Fire Watch was promptly reinstated on 02/06/2015 and continued through the survey date.

The complaint was substantiated with deficiencies cited including a non-functional fire sprinkler system since 10/14/2014, inconsistent transmission of fire alarm signals to the monitoring company, and the facility not maintaining a safe condition due to the disabled sprinkler system and lack of Fire Watch at the time of investigation.