Inspection Reports for Divine Family Care Homes
45 Cannady Way, Franklinton, NC 27525, United States, NC, 27525
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Inspection Report
Annual Inspection
Deficiencies: 1
Nov 5, 2024
Visit Reason
The Adult Care Licensure section conducted an annual survey of Divine Family Care Home III on November 5, 2024.
Findings
The facility failed to ensure that physicians' orders were implemented for one resident related to an order for compression stockings. Specifically, Resident #2 had an order for compression stockings that was not applied, documented, or ordered properly through the pharmacy, leading to non-compliance with the physician's directive.
Deficiencies (1)
| Description |
|---|
| Failed to ensure physicians' orders were implemented for Resident #2 related to an order for compression stockings. |
Report Facts
Number of residents sampled with deficiency: 1
Date of physician's order: Jul 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #2's PCP | Primary Care Provider | Ordered compression stockings and provided information about the order and expected care |
| Medication Aide | Interviewed regarding awareness and documentation of compression stocking orders | |
| Facility's contracted nurse | Contracted Nurse | Interviewed about oversight of the compression stocking order and review of physician's orders |
| Administrator | Administrator | Interviewed about facility procedures for faxing orders to pharmacy and ensuring compliance |
Inspection Report
Biennial Survey
Census: 6
Capacity: 6
Deficiencies: 1
Mar 19, 2024
Visit Reason
DHSR Construction Section conducted a Biennial Survey to ensure compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the 2009 North Carolina State Building Code for Residential Care Homes.
Findings
The survey found that the heat detector in the attic was disconnected and not functioning properly, which is not compliant with the applicable rules. The detector needs repair or replacement and must be wired on a dedicated circuit.
Deficiencies (1)
| Description |
|---|
| Heat detector in the attic was disconnected and not functioning properly; needs repair or replacement and wiring on a dedicated circuit. |
Report Facts
Licensed capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Hickman | Reported the survey findings |
Inspection Report
Annual Inspection
Deficiencies: 1
Jul 16, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on July 16, 2021.
Findings
The facility failed to administer medications as ordered by a licensed prescribing practitioner for one of three sampled residents (#3), specifically related to a medication used to treat mental and mood disorders. Resident #3 was administered paliperidone after a discontinuation order was issued, due to communication and pharmacy coordination issues.
Deficiencies (1)
| Description |
|---|
| Failed to administer medications as ordered by a licensed prescribing practitioner for Resident #3 related to paliperidone ER medication. |
Report Facts
Tablets remaining in bubble package: 15
Tablets dispensed: 17
Tablets dispensed: 31
Tablets dispensed: 30
Tablets dispensed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Supervisor-in-Charge | Supervisor-in-Charge | Administered medications to Resident #3, was unaware of the March 11, 2021 discontinue order, continued administration through June 2021. |
| Owner/Administrator designee | Owner/Administrator designee | Responsible for ensuring medications were administered as ordered, was unaware Resident #3 was administered paliperidone after discontinuation. |
Inspection Report
Annual Inspection
Deficiencies: 6
Jun 17, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on June 14, 2019 and June 17, 2019.
Findings
The facility was found deficient in multiple areas including failure to ensure staff had current CPR training, lack of matching therapeutic menus for physician-ordered diets, failure to serve water to residents at meals, failure to ensure medication aides completed required infection control and medication aide training, and failure to perform required drug screening for new hires.
Complaint Details
The inspection included a complaint investigation conducted on June 14, 2019 and June 17, 2019.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure 3 of 3 sampled staff had current CPR and choking management training within the past 24 months. |
| Facility failed to have matching therapeutic menus for guidance of staff for 1 of 3 sampled residents with physician orders for a no concentrated sweets diet. |
| Facility failed to serve water to 5 of 5 residents at meals despite menus indicating water should be served. |
| Facility failed to assure 2 of 3 medication aides completed the state-mandated annual infection control training. |
| Facility failed to assure 2 of 3 medication aides completed required 5, 10, or 15-hour medication aide training and/or had verification of employment as a medication aide in the previous 24 months. |
| Facility failed to assure examination and screening for controlled substances was performed for 1 of 3 sampled staff hired after 10/01/13. |
Report Facts
Number of sampled staff without current CPR training: 3
Number of sampled residents without matching therapeutic menus: 1
Number of residents not served water at meals: 5
Number of medication aides without annual infection control training: 2
Number of medication aides without required medication aide training: 2
Number of staff without drug screening documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide / Supervisor in Charge | Named in findings for expired CPR, missing infection control training, missing medication aide training, and missing drug screening. |
| Staff C | Medication Aide | Named in findings for missing CPR training and missing medication aide training. |
| Owner | Named in findings for expired CPR, missing infection control training, responsible for personnel records and training scheduling. | |
| Administrator | Interviewed regarding staff training and compliance; responsible for ensuring training and drug screening. |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 3, 2017
Visit Reason
The Adult Care Licensure Section and the Franklin County Department of Social Services conducted an annual and follow-up survey on 10/31/17 and 11/2/17 with an exit conference on 11/3/17.
Findings
The facility failed to report three low monthly blood pressure readings for Resident #1 on antihypertensive medication as ordered by the Primary Care Provider, which was detrimental to the resident's health. Additionally, the facility failed to administer triamterene/hydrochlorothiazide as ordered for Resident #3 for 27 days due to communication and documentation issues with the PCP and pharmacy.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report three low monthly blood pressure readings for Resident #1 on antihypertensive medication (Lisinopril) with PCP orders to report blood pressure outside ordered parameters. | Type B Violation |
| Failure to administer triamterene/hydrochlorothiazide as ordered by the PCP for Resident #3 for 27 days. | — |
Report Facts
Deficiency duration: 27
Dates of low blood pressure readings not reported: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Supervisor in Charge (SIC) | Responsible for contacting PCP and documenting communication; involved in notification failures for Resident #1 | |
| Administrator | Involved in contacting PCP, arranging appointments, and planning corrective actions |
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 3
Jul 21, 2016
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including tuberculosis testing, therapeutic diet menus, and staff qualifications at Divine Family Care Home III.
Findings
The facility failed to provide tuberculosis testing documentation for one resident, lacked matching therapeutic diet menus for residents with physician-ordered diets, and did not maintain staff qualification records on site for two staff members.
Deficiencies (3)
| Description |
|---|
| Failed to assure 1 of 3 residents sampled had Tuberculosis (TB) Disease testing in compliance with control measures upon admission. |
| Failed to assure matching therapeutic diet menus for 3 of 3 residents with physician-ordered therapeutic diets. |
| Failed to maintain staff qualifications in Employee Records for Staff A and Staff B in the facility. |
Report Facts
Residents sampled for TB testing: 3
Residents with therapeutic diet orders sampled: 3
Residents living in facility during survey: 6
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 17
Aug 20, 2015
Visit Reason
The Division of Health Service Regulation conducted a Biennial Survey to ensure compliance with the 2005 Rules for Family Care Homes and the 2009 North Carolina State Building Code for Residential Care Homes.
Findings
Multiple deficiencies were cited related to building maintenance and safety, including dismantled ventilation fan, broken windows, damaged flooring, non-functional smoke detector, unsecured electrical mast, water leaks, dry rot on porch columns, insufficient bedroom square footage, and missing handrails.
Deficiencies (17)
| Description |
|---|
| Master bathroom ventilation fan had been dismantled and was not operable. |
| A number of windows had been smashed out and were in the process of being replaced. |
| Kitchen and laundry room had holes in the flooring and buckled seam in the living room. |
| Rear storm door had a ripped screen needing replacement. |
| Smoke detector in the staff bedroom did not trip when tested. |
| Electrical mast on the right (South) side pulled away from building and needed securing. |
| Tree on the right (South) side needed trimming to remove branches contacting the roof. |
| Water leaks in the basement crawl space; condensation pipe needed reattachment and leak source repair. |
| Pressure tank in basement crawl space shifted from its support and needed securing. |
| Heat detector in the attic had been removed and needed reinstalling. |
| Dry rot at the base of two front porch columns requiring correction or replacement. |
| Front handrail did not extend entire length of ramp and needed continuous handrail installation. |
| Dryer vent not secure to duct work and needed permanent attachment. |
| Electrical plug behind dryer was loose and needed repair or replacement. |
| Metal duct work from dryer to outside was 'flex' type not approved and needed replacement with hard metallic type. |
| Bedroom #2 had insufficient square footage (146 sq ft) for two residents; occupancy needed adjustment or room conversion. |
| Front steps required handrails on both sides; an additional handrail needed installation on left (North) side. |
Report Facts
Licensed capacity: 6
Current census: 6
Bedroom #2 square footage: 146
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