Inspection Reports for Durham Ridge Assisted Living

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1991 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1991 Edition of the North Carolina Building Code, Institutional Occupancy. This was a Construction Section Biennial Survey.

Multiple deficiencies were cited related to physical plant, housekeeping, fire safety, electrical, plumbing, and ventilation. Issues included fire alarm system noncompliance, unsafe building conditions such as holes and damage in walls and ceilings, unclean and damaged furnishings, trip hazards, fire safety equipment not maintained or inspected, obstructed sprinkler heads, gaps in fire resistant ceilings, missing electrical cover plates, malfunctioning emergency lighting, plumbing leaks, and non-functioning exhaust fans.

The Adult Care Licensure Section and the Durham County Department of Social Services conducted an annual survey from 04/01/25 to 04/03/25 to assess compliance with adult care home regulations.

The facility was found deficient in multiple areas including failure to provide a comfortable chair for each resident in most rooms, incomplete tuberculosis testing documentation for some residents, inadequate mealtime table service lacking knives, failure to serve therapeutic diets as ordered, medication administration errors including improper mixing and failure to observe medication intake, and inadequate infection control practices during medication administration.

The visit was a Biennial Follow Up Construction Survey to assess compliance with construction and remodeling plan submission requirements.

The facility was found to have new deficiencies related to failure to submit construction documents and specifications for review and approval when remodeling the call system. No plans or specifications had been submitted to the Division of Health Service Regulation Construction Section.

The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building equipment and safety.

Deficiencies remain in the building's call system, which is not maintained in a safe and operating condition, potentially delaying assistance for call requests. Specifically, staff do not receive notification when the call system's pull station is activated in Bedroom 120 on the 100 Hall, and the call button chords were missing at the time of the survey.

The Adult Care Licensure Section conducted an Annual and a Complaint investigation on 01/30/24 - 02/01/24 with an exit date via telephone on 02/02/24. The Durham County Department of Social Services initiated the complaint investigation on 01/19/24.

The facility failed to ensure immediate response and intervention by staff for two residents after falls, failed to notify the PCP and provide wound care for a resident with infected wounds leading to sepsis, failed to provide proper table service with knives, and failed to provide adequate individual feeding assistance. Additionally, the facility failed to report an incident resulting in a resident's death to the local county Department of Social Services.

The complaint investigation was initiated by the Durham County Department of Social Services on 01/19/24 related to concerns about resident care and response to incidents.

This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant and safety code compliance.

The facility was found to have multiple unresolved deficiencies including failure to properly operate doors with special locking, unclean and damaged ceilings with mold growth, unsafe and non-operating fire safety and call systems, unsecured plumbing fixtures, and non-functioning exhaust ventilation in required areas.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation with onsite visits and desk review to verify correction of previous deficiencies and investigate complaints.

The facility failed to implement physician orders for finger stick blood sugar (FSBS) checks for Resident #1, failed to serve ordered nutritional supplements to Resident #1, failed to administer medications as ordered for Residents #1 and #5 including antibiotics, diabetic medications, and injectable anti-psychotic medication, and failed to maintain accurate electronic medication administration records (eMAR) for Residents #8 and #9.

The visit included a complaint investigation related to failure to implement physician orders for FSBS checks and medication administration issues.

Complaint investigation and COVID-19 Focused Infection Control survey conducted due to complaints and outbreak concerns.

The facility failed to ensure coordination of health care for multiple residents, failed to notify primary care providers of significant incidents, failed to cohort residents and staff properly during COVID-19, failed to provide adequate over the bed tables for in-room dining, failed to administer medications as ordered including controlled substances, failed to maintain accurate controlled substance records, failed to notify responsible parties timely of incidents and hospitalizations, failed to maintain adequate staffing levels in the Special Care Unit, and failed to implement infection prevention and control guidelines including proper PPE use and social distancing during communal dining.

Complaint investigation initiated by Durham County Department of Social Services on October 9, 2020, related to COVID-19 outbreak and care concerns.

The Adult Care Licensure Section and the Durham County Department of Social Services conducted a follow-up survey and a COVID-19 infection control focused survey on site September 3, 2020 and September 11, 2020 with a desk review from September 4 through September 10, 2020 and an exit conference on September 14, 2020.

The facility failed to implement a physician order for the application of compression stockings for one sampled resident (#4). Observations, interviews, and record reviews revealed that Resident #4 was not wearing the ordered compression stockings on the day of observation despite the order and documentation indicating the stockings should be applied daily. Staff interviews indicated lack of communication and responsibility for applying the stockings. The order was discontinued on 09/11/20 after the physician's assessment.

The Adult Care Licensure Section and the Durham County Department of Social Services conducted a complaint investigation initiated by the Durham County Department of Social Services on April 28, 2020, focusing on concerns related to Resident #1 and Resident #3.

The facility failed to notify the contracted Nurse Practitioner of changes in condition for Resident #1 and Resident #3, resulting in the death of Resident #1 and hospitalization of Resident #3 to the intensive care unit. Resident #1 experienced a fall and subsequent decline with pain and distress, while Resident #3 developed worsening pressure ulcers and declined in condition without appropriate notification or intervention.

Complaint investigation was initiated by the Durham County Department of Social Services on April 28, 2020, and conducted May 11-15 and 18-20, 2020, focusing on allegations related to Resident #1's fall and death and Resident #3's decline and hospitalization.

The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies related to building equipment and physical plant safety.

The survey found deficiencies in fire safety door operation where doors protecting firewalls did not close completely or latch, and exhaust ventilation systems in multiple bathrooms were not creating sufficient airflow to hold a thin plastic sheet, indicating improper ventilation.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1991 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1991 Edition of the North Carolina Building Code, Institutional Occupancy.

Multiple deficiencies were cited related to physical plant, safety, housekeeping, electrical systems, fire safety, and ventilation. These included issues with emergency release keys, hand grips in bathrooms, floor hazards, housekeeping and maintenance problems, electrical outlet safety, fire safety equipment and doors, sprinkler system maintenance, use of prohibited portable electric heaters, and non-functioning exhaust ventilation systems.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on November 6 - 9, 2018, initiated by the Durham County Department of Social Services on October 31, 2018.

The facility was found to have multiple deficiencies including poor housekeeping and maintenance issues such as stained and damaged walls, ceilings, floors, and bathroom fixtures in multiple resident rooms and common areas. Additionally, the facility failed to schedule a dental appointment for a resident with a tooth abscess and improperly administered Tylenol medication to another resident, exceeding prescribed dosages.

Complaint investigation was initiated by the Durham County Department of Social Services on October 31, 2018.

The Adult Care Licensure Section and the Durham County Department of Social Services conducted an annual survey and complaint investigation on June 20, 21, 22 and 25, 26, 2018. The complaint investigation was initiated by the Durham County Department of Social Services on May 17, 2018.

The facility failed to maintain resident rooms and bathrooms in clean and good repair condition, including issues with caulking, stains, and cleanliness. The facility also failed to assure residents' sink vanity tops were free of hazards, provide adequate supervision for residents at high risk for falls, and administer medications as ordered by licensed prescribers. Additional deficiencies were found in housekeeping, maintenance, nutrition and food service, and resident rights.

The complaint investigation was initiated by the Durham County Department of Social Services on May 17, 2018, and included allegations related to cleanliness, supervision, medication administration, and resident safety.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1991 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1991 Edition of the North Carolina Building Code, Institutional Occupancy.

The survey identified multiple deficiencies related to physical plant and safety including failure to meet code requirements for special locking arrangements, lack of current sanitation inspection reports, corridors obstructed by equipment, ceilings and floors not maintained in good repair, hazards such as storage in front of electrical panels, fire safety equipment not maintained properly, plumbing and mechanical equipment issues, exterior facade damage, hot water temperature exceeding safe limits, and inadequate exhaust ventilation in several areas.

The Adult Care Licensure Section and the Durham County Department of Social Services conducted an annual survey and complaint investigation on 8/23-26/16 and 8/29/16. The complaint investigation was initiated by the Durham County Department of Social Services on 8/18/16.

The facility failed to provide adequate supervision for residents with exit-seeking behaviors and elopement risk, failed to administer medications as ordered for multiple residents including insulin and other medications, failed to follow sanitation guidelines during feeding assistance, and failed to report two incidents to the Health Care Personnel Registry within required timeframes.

Complaint investigation was initiated by the Durham County Department of Social Services on 8/18/16 related to supervision and resident safety concerns.

This report is of a follow-up survey conducted to determine if previously identified deficiencies at Durham Ridge Assisted Living have been corrected.

The follow-up survey revealed that several deficiencies remain uncorrected, including missing latch plates, stained carpet, hazardous door hardware that could trap occupants, holes in fire-resistant ceilings, and doors that do not fully close and latch, compromising fire safety.

Biennial Construction Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1991 Edition of the North Carolina Building Code and licensing rules.

The facility was found to have multiple physical plant deficiencies including loose and detaching handrails in bathrooms, lack of nonskid strips in showers, damaged and inadequately repaired doors compromising fire resistance, deteriorating ceilings, damaged furnishings, housekeeping issues, hazards from sharp edges and improper door hardware, improper storage of oxygen bottles, fire safety equipment not maintained properly, compromised fire resistant construction with holes and gaps, doors not fully closing and latching, electrical safety hazards, and inadequate exhaust ventilation in the nurses' station restroom.

The inspection was conducted to assess compliance with regulations regarding the use of physical restraints and alternatives in the facility, specifically focusing on the use of a Geri Chair with a tray as a restraint for one resident.

The facility failed to assure an assessment or care planning had been completed prior to the use of a Geri Chair with tray as a restraint for one resident. Multiple observations, interviews, and record reviews revealed that Resident #6 was restrained with a Geri Chair tray without proper assessment or documentation, and staff were unaware if the resident could remove the tray. The facility was cited for a Type B violation related to this issue.