Inspection Reports for Dunmore Senior Living of Siler City
260 Village Lake Road Siler City, NC 27344, Siler City, NC, 27344
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 19
Capacity: 86
Deficiencies: 14
Date: Nov 21, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and a complaint investigation on September 19-21, 2024.
Complaint Details
The survey included a complaint investigation related to residents from an independent living facility moving into the assisted living facility without proper licensing and concerns about resident privacy and wandering.
Findings
The facility was found to have multiple deficiencies including allowing independent living residents to reside in licensed assisted living beds, failure to ensure referral and follow-up for health care needs, food safety violations, inadequate mealtime service, lack of activities program, failure to maintain resident privacy, medication administration errors, medication storage issues, and failure to notify the county department of social services of reportable incidents.
Deficiencies (14)
Facility allowed independent living residents to reside in licensed assisted living beds, which was detrimental to resident health and safety.
Failed to ensure referral and follow-up to meet health care needs of a resident related to notifying the PCP of elevated blood sugar readings.
Failed to ensure food items stored and prepared were served under sanitary conditions including uncovered foods and unclean kitchen surfaces.
Failed to ensure mealtime table service included a napkin, non-disposable knife, fork, spoon, and cup.
Failed to ensure a matching therapeutic diet menu for a resident with a physician ordered pureed diet.
Failed to ensure snacks were offered to all residents between meals as required.
Failed to ensure water was served at each meal in addition to other beverages.
Failed to ensure an activities program that promoted active involvement of residents.
Failed to maintain privacy for two residents related to other residents wandering into rooms and taking belongings causing mental anguish.
Failed to administer medications as ordered for residents including missed doses and incomplete administration.
Failed to ensure medication room door, treatment cart, and medication refrigerator were locked when not under direct supervision.
Failed to notify the County Department of Social Services of an incident involving a resident fall requiring emergency medical evaluation.
Failed to ensure medication aides observed residents take their medications and did not leave medications unattended on dining room tables.
Failed to ensure the electronic medication administration record was accurate including documentation of discontinued and administered medications.
Report Facts
Licensed capacity: 86
Current census: 19
Residents moved from independent living: 7
Medication error rate: 10
Number of sutures: 11
Medication doses: 8
Medication doses missed: 1
Medication doses missed: 1
Medication doses missed: 0.5
Medication doses remaining: 1
Medication doses remaining: 0.75
Residents in dining room: 16
Souffle cups with pills: 5
Residents served water at breakfast: 2
Residents not served water at breakfast: 16
Inspection Report
Capacity: 86
Deficiencies: 14
Date: Mar 25, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with building, fire safety, and physical plant regulations for Coventry House of Siler City.
Findings
Multiple deficiencies were cited including failure to maintain current building safety inspection reports, corridor obstructions, lack of wanderer alarms on exit doors, unsafe outside premises, housekeeping hazards, improperly posted fire evacuation plans, lack of regular fire safety rehearsals, malfunctioning emergency lighting and fire safety equipment, electrical system issues, sprinkler system deficiencies, and use of prohibited portable electric heaters.
Deficiencies (14)
Facility failed to maintain current building safety inspection reports.
Corridors were obstructed by furniture reducing required width from six feet to four feet.
Exit doors accessible by residents lacked sounding devices to prevent wanderers from exiting unnoticed.
Outside grounds were not maintained in a clean and safe condition; a six-foot section of PVC fence had fallen.
Hazard present due to lack of vacuum breakers on hose bibs risking backflow contamination.
Fire evacuation diagrams were improperly oriented and not maintained correctly.
Fire safety rehearsals were not performed regularly with at least one per shift per quarter.
Emergency lighting and exit signs did not illuminate on backup power or were incorrectly marked.
Commercial kitchen hood fire suppression system lacked required semi-annual inspections and monthly documentation.
Fire safety was compromised by holes and unsealed penetrations in fire-resistance-rated ceilings.
Smoke tight corridor doors had gaps exceeding allowable limits and were equipped with manual flush bolts circumventing safety requirements.
Electrical system deficiencies including non-functioning GFCI receptacles and receptacles without ground fault protection near sinks.
Building sprinkler system was not maintained properly; escutcheon plates missing or dropped exposing openings.
Use of prohibited portable electric heater found in Nurse Station-Med Room.
Report Facts
Licensed capacity: 86
Beds in middle portion: 55
Beds in right addition: 14
Beds in left back addition: 20
Corridor width reduction: 2
Fire suppression maintenance interval exceeded: 5
Gap in corridor door: 0.75
Gap in corridor doors: 0.25
Gap in corridor doors: 0.375
Hole in corridor door: 0.25
Fire sprinkler opening size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding lack of current building safety inspection reports and fire safety rehearsals |
Inspection Report
Annual Inspection
Capacity: 13
Deficiencies: 6
Date: Nov 29, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on November 28 and 29, 2023.
Findings
The facility was found deficient in multiple areas including food safety due to unsealed bags of frozen food, lack of therapeutic diet menus for residents, absence of a current activities program managed by an activity director, failure to administer medication as ordered for a resident, inaccurate medication administration records, and failure to notify the county Department of Social Services of incidents requiring emergency medical evaluation for three residents.
Deficiencies (6)
Facility failed to ensure foods were free from contamination related to unsealed bags of food in the freezer.
Facility failed to have matching therapeutic diet menus for guidance for staff for residents with orders for therapeutic diets.
Facility failed to develop a current activities program managed by an activity director to promote residents' active involvement.
Facility failed to administer medication as ordered for 1 of 3 residents related to a medication used for allergies.
Facility failed to ensure the accuracy of medication administration records for 1 of 3 sampled residents related to a medication used for constipation.
Facility failed to notify the County Department of Social Services of incidents/accidents that required emergency medical evaluation for 3 of 3 residents.
Report Facts
Licensed capacity: 13
Medication administration records reviewed: 3
Residents with unreported incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager (DM) | Mentioned in relation to food safety and therapeutic diet menu deficiencies |
| Executive Director | Executive Director (ED) | Mentioned in relation to oversight of kitchen and activities program, and incident reporting |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for medication cart audits and sending accident/injury reports |
| Medication Aide | Medication Aide (MA) | Mentioned in relation to medication administration and audits |
| Personal Care Assistant | Personal Care Assistant (PCA) | Mentioned as acting activity director and assisting with exercise classes |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 27, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 01/25/22 to 01/27/22 to assess compliance with health care, medication administration, nutrition and food service, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure referral and follow-up for residents' health care needs, failure to implement physician orders, failure to protect food from contamination, failure to have matching therapeutic diet menus, failure to serve therapeutic diets as ordered, failure to clarify medication orders, failure to administer medications as ordered, and failure to accurately document medication administration.
Deficiencies (9)
Failed to ensure referral and follow-up for 2 of 5 sampled residents related to referrals for a spine center, orthotics, and an eye examination.
Failed to ensure physician orders were implemented for 1 of 5 sampled residents related to an order for a urinalysis and culture.
Failed to ensure foods were free from contamination related to uncovered food being transported on open carts and soiled food delivery carts.
Failed to have matching therapeutic diet menus for guidance for staff for residents with orders for therapeutic diets.
Failed to serve the correct therapeutic diet order for 1 of 2 residents who had an order for a pureed diet and nectar thickened liquids.
Failed to clarify medication orders for 1 of 5 sampled residents related to medications used to treat diabetes and gastroesophageal reflux disease.
Failed to administer medications as ordered for 1 of 4 residents related to a medication used to treat dementia and a vitamin supplement, and for 3 of 5 residents related to medications for constipation, acid indigestion, diabetes, and COPD.
Failed to ensure medication aides were not pre-charting the administration of medication for 1 of 5 sampled residents related to the application of topical creams.
Failed to ensure the accuracy of medication administration records for 1 of 5 sampled residents related to a medication used to treat diabetes.
Report Facts
Medication error rate: 5.2
Unadministered Spiriva doses: 22
Insulin pen units: 300
Medication doses administered: 8
Medication doses administered: 10
Medication doses administered: 500
Medication doses administered: 17
Medication doses administered: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for verifying medication orders, reviewing eMARs, ensuring residents attended appointments, and managing medication cart audits. |
| Administrator | Facility Administrator | Responsible for overall facility compliance and oversight of medication administration and care. |
| Medication Aide | Medication Aide (MA) | Administered medications and involved in medication cart audits; involved in medication errors and documentation issues. |
| Nurse Practitioner | Nurse Practitioner (NP) | Provided medical orders and participated in interviews regarding resident care. |
| Primary Care Provider | Primary Care Provider (PCP) | Provided medical orders and participated in interviews regarding resident care and medication orders. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 15, 2019
Visit Reason
The report documents a Biennial Follow Up Construction Survey conducted to assess the correction of previously cited deficiencies in the facility.
Findings
The survey found ongoing deficiencies including ceilings not kept in good repair with patched seams in the dining area, missing escutcheon plate on a sprinkler head creating a gap, and life safety equipment not maintained safely, including dust accumulation on radiation dampers in mechanical exhaust vents.
Deficiencies (3)
Ceilings were not kept in good repair; dining area ceiling finishes were separating at the joints and are in the process of being finished for paint.
Failure to maintain building's fire safety systems in a safe condition; missing escutcheon plate from front sprinkler head leaving a gap in the ceiling.
Life safety equipment not maintained in a safe and operating condition; radiation dampers in mechanical exhaust vents had heavy dust accumulation.
Report Facts
Completion percentage: 75
Inspection Report
Capacity: 86
Deficiencies: 11
Date: Mar 20, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for the Licensing of Adult Care Homes and the 2002 North Carolina State Building Code Section 407 - Institutional Occupancy, Group I-2.
Findings
Multiple deficiencies were identified including lack of current fire safety inspection reports, unlocked janitor closets storing hazardous chemicals, malfunctioning wanderer alarms, ceilings not in good repair, unsecured oxygen tanks, missing fire rehearsal records, failure to maintain fire safety equipment and emergency lighting, missing plumbing safety devices, and inadequate exhaust ventilation in specified areas.
Deficiencies (11)
Facility does not maintain current fire safety inspection reports; last recorded fire inspection was in 2016.
Cleaning agents were not kept in a locked area; door to 500 Hall Clean Linen closet was unlocked during survey.
Facility did not maintain sounding devices installed at exit doors for manual override switches; alarms did not sound at specified exits.
Ceilings were not kept in good repair; ceiling finishes separating at joints in dining area and large brown water stain over tub in 200 Hall Spa.
Oxygen bottles were unsecured and could fall or be knocked over, presenting a hazard.
Facility did not have records of quarterly fire rehearsals; no fire drills conducted in 2019 as of survey date.
Failure to maintain fire safety equipment in safe operating condition; doors did not latch properly, emergency lights failed to illuminate, gaps in fire resistant ceilings, and unapproved devices used to keep doors open.
Electrical equipment not maintained in safe condition; missing protective covers on exterior electrical outlets.
Failure to install and maintain required plumbing safety devices; hair wash sink lacked vacuum breaker and toilet was not secure to floor.
Life safety equipment not maintained in safe and operating condition; radiation dampers had heavy dust accumulation.
Facility did not provide exhaust ventilation in specified spaces; exhaust ventilation system not working in 300 and 400 Halls.
Report Facts
Licensed capacity: 86
Inspection Report
Capacity: 66
Deficiencies: 9
Date: Mar 7, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey to ensure compliance with the 1996 and applicable portions of the 2005 Rules for the Licensing of Adult Care Homes and the 1996 North Carolina State Building Code for Institutional Occupancy.
Findings
Multiple deficiencies were identified including a non-functioning wanderer alarm on the dining room exit door, improper storage of portable medical oxygen cylinders, failure to conduct required fire safety rehearsals on each shift quarterly, malfunctioning emergency lights, corridor doors not closing and latching properly, compromised fire rated ceiling, presence of prohibited portable electric heaters, and non-functioning exhaust ventilation in the 400 Hall.
Deficiencies (9)
Alarm on the dining room exit door did not work despite residents known to be disoriented or wanderers.
Portable medical oxygen cylinders were stored without containers in multiple locations including room 406, storage off nurse station, and room 403.
Fire drill rehearsals were not conducted regularly on the 3rd shift each quarter and records lacked descriptions and staff attendance.
Special locking magnetic lock on Special Care courtyard gate did not work and secure the gate.
Battery powered emergency lights failed to work in multiple areas including dining room, corridors, public men's bathroom, and near Special Care Unit.
Several corridor doors did not close or latch properly, including doors near rooms 203, 205, employee bathroom, and dining room door had a hole by the latchset.
One-hour fire rated ceiling was compromised by an unsealed penetration in the electronics room.
Portable electric heater found in the outside sprinkler riser room, violating prohibition of portable electric heaters.
Exhaust ventilation system was not working on the 400 Hall, risking unhealthy buildup of moisture and bacteria.
Report Facts
Total licensed capacity: 66
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 3, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 03/01/16 to 03/03/16 at Coventry House of Siler City.
Findings
The facility failed to administer ordered medication (Ativan) to one resident as prescribed and failed to report injuries of unknown cause to the North Carolina Health Care Personnel Registry within required timeframes.
Deficiencies (2)
Failure to assure ordered medication (Ativan) was administered as ordered for Resident #5.
Failure to report injuries of unknown cause (bruise and contusion) for Resident #5 to the Health Care Personnel Registry within 24 hours and conduct investigation within 5 working days.
Report Facts
Dates of survey: Survey conducted from 2016-03-01 to 2016-03-03
Medication order date: Ativan order added to MAR on 2016-02-10
Injury report date: Injury noted on 2016-02-14
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