Inspection Reports for Eno Pointe Assisted Living

5600 N Roxboro St, Durham, NC 27712, NC, 27712

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Inspection Report Annual Inspection Deficiencies: 2 Mar 6, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 03/06/2025 to assess compliance with regulations for the assisted living facility.
Findings
The facility was found deficient in maintaining cleaning agents in a locked area inaccessible to residents, posing a hazard. Additionally, the facility failed to ensure implementation of physician orders for one resident regarding the application and removal of TED hose daily.
Deficiencies (2)
Description
Facility failed to ensure that cleaning agents and other hazardous substances were kept in a separate locked area and not accessible to residents.
Facility failed to ensure physician orders were implemented for one resident, including daily application and removal of TED hose.
Report Facts
Sampled residents: 5 Opportunities for TED hose application: 29 Opportunities for TED hose removal: 28 Opportunities for TED hose application: 24 Opportunities for TED hose removal: 24 Opportunities for TED hose application: 6 Opportunities for TED hose removal: 5
Inspection Report Follow-Up Deficiencies: 0 Jan 24, 2025
Visit Reason
Follow up construction survey conducted by documentation review to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected based on documentation received, and no further action is required at this time.
Inspection Report Capacity: 147 Deficiencies: 3 Jan 9, 2025
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with building and physical plant regulations applicable to adult care homes.
Findings
Deficiencies were found related to housekeeping and furnishings, including ceilings not kept in good repair with flaking and peeling in the kitchen ceiling. Electrical equipment was not maintained safely, with GFCI outlets lacking power in two locations, and fire safety equipment deficiencies were noted with a cross corridor door not latching properly, which was corrected during the survey.
Deficiencies (3)
Description
Ceilings were not kept in good repair; kitchen ceiling over freezer and cooler units was flaking and peeling.
Electrical equipment not maintained safely; GFCI outlets at Back New Hall Shower Room and Room 228 Bathroom sinks did not have power.
Fire safety equipment failure; cross corridor door by Room 108 did not latch when released by fire alarm, corrected during survey.
Report Facts
Licensed capacity: 147
Inspection Report Follow-Up Deficiencies: 2 Feb 7, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from February 7 to February 8, 2024, to verify correction of previous deficiencies related to physician treatment orders and wound care implementation for Resident #2.
Findings
The facility failed to ensure physician treatment orders were implemented for Resident #2 regarding the application of thrombo-embolic deterrent (TED) hose and wound care. Staff did not document or apply TED hose as ordered despite swelling in the resident's legs, and wound care orders for a stage 3 ulcer on the resident's right second toe were not documented or followed as required.
Deficiencies (2)
Description
Failure to implement physician orders for TED hose application and removal as needed for edema in Resident #2.
Failure to implement and document wound care orders for a stage 3 ulcer on Resident #2's right second toe.
Report Facts
Dates of TED hose orders: Feb 7, 2024 Wound care order start date: Dec 7, 2023 Wound size: 4
Employees Mentioned
NameTitleContext
Medication AideReported not applying TED hose due to lack of availability and documentation.
Resident Care CoordinatorResponsible for ordering TED hose and reviewing provider notes; applied TED hose on 02/08/24.
Primary Care Provider (PCP)Ordered TED hose and wound care; expected staff to follow and document orders.
AdministratorExpected staff to communicate refusals and document wound care; aware of Resident #2's condition.
PodiatristOrdered wound care for Resident #2's stage 3 ulcer on right second toe.
Inspection Report Annual Inspection Deficiencies: 5 Nov 2, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey of Eno Pointe Assisted Living to assess compliance with health care, medication administration, nutrition, infection control, and other regulatory requirements.
Findings
The facility failed to implement physician orders for blood sugar monitoring and insulin administration for one resident, failed to serve therapeutic diets as ordered for multiple residents, failed to maintain accurate medication administration records, allowed a resident to self-administer medication without an order, and failed to implement infection control policies consistent with CDC guidelines resulting in sharing of glucometers among residents.
Severity Breakdown
Type B: 3
Deficiencies (5)
DescriptionSeverity
Failed to implement physician orders for blood sugar rechecks and insulin administration for Resident #3.Type B
Failed to serve therapeutic diets as ordered for 5 of 6 sampled residents.
Medication administration records were inaccurate for Resident #3 including blood sugar readings documentation errors.Type B
Resident #6 self-administered Tylenol Arthritis without a physician's order or assessment.
Failed to implement infection control policies consistent with CDC guidelines resulting in sharing of glucometers among 3 sampled diabetic residents.Type B
Report Facts
Deficiencies cited: 5 Tresiba insulin units: 15 Novolog insulin units: 4 Novolog insulin units: 5 Blood sugar readings: 60
Employees Mentioned
NameTitleContext
Medication AideMultiple medication aides interviewed regarding medication administration and blood sugar monitoring.
Primary Care ProviderInterviewed regarding medication orders and concerns about medication administration and blood sugar monitoring.
Resident Care CoordinatorInterviewed regarding medication administration policies and infection control procedures.
AdministratorInterviewed regarding expectations for medication administration, diet compliance, and infection control.
Dietary ManagerInterviewed regarding therapeutic diet preparation and meal service.
Personal Care AideInterviewed regarding meal service and medication observations.
CookInterviewed regarding food preparation and diet compliance.
PharmacistInterviewed regarding medication orders and dispensing.
Inspection Report Follow-Up Deficiencies: 1 Dec 13, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on December 13-14, 2022 to verify correction of previously identified deficiencies.
Findings
The facility failed to ensure that Resident #4, who had a physician's order for nectar thickened liquids, was served nectar thickened liquids with medication administration. Instead, the resident was given regular thin water with medications, contrary to the physician's order.
Deficiencies (1)
Description
Facility failed to serve Resident #4 nectar thickened liquids with medication administration as ordered by the physician.
Report Facts
Residents with thickened liquid orders: 1 Sampled residents: 5
Inspection Report Annual Inspection Deficiencies: 7 Aug 25, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey, a follow-up survey and a complaint investigation from August 23, 2022 to August 25, 2022.
Findings
The facility failed to ensure proper discharge notice procedures, therapeutic diets were served as ordered, feeding assistance was provided respectfully, medications were administered as ordered, infection prevention and control measures were followed, and residents were free from abuse and neglect related to medication administration.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (7)
DescriptionSeverity
Failed to ensure requirements for written discharge notice were met for one resident discharged by the facility.
Failed to ensure therapeutic diets were served as ordered for 2 of 5 sampled residents with mechanical soft and carbohydrate-controlled diet orders.
Failed to ensure 5 of 5 residents were treated with respect and dignity during feeding assistance as staff rushed meals and stood while feeding residents.
Failed to ensure medications were administered as ordered for 3 of 5 residents related to multiple medications including antibiotics, mood stabilizers, and hypertension treatments.Type A1 Violation
Failed to ensure medication aides observed residents take their medications prior to documenting administration for 2 of 3 sampled residents.
Failed to implement CDC and NC DHHS guidance for infection prevention and control related to staff not properly wearing PPE and lack of daily screening of staff and residents for COVID-19 symptoms and fever.
Failed to ensure residents were free from mental and physical abuse, neglect, and exploitation related to medication administration.
Report Facts
cefpodoxime tablets remaining: 9 nitrofurantoin capsules remaining: 25 memantine tablets remaining: 21 citalopram tablets remaining: 14 divalproex capsules remaining: 43 cyclosporine single-use vials remaining: 25 Quetiapine tablets dispensed: 750 Trazadone tablets remaining: 10 Aspirin tablets remaining: 32 Atorvastatin tablets remaining: 49 Amlodipine tablets remaining: 24 Isosorbide mononitrate tablets remaining: 2
Inspection Report Follow-Up Deficiencies: 1 Oct 1, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on October 1 - 4, 2019.
Findings
The facility failed to administer medications as ordered to 1 of 7 sampled residents (#5), specifically a diabetic medication (Novolog insulin) at bedtime. Documentation review and interviews revealed multiple missed administrations of insulin doses at scheduled times, due to errors in medication order entry and verification processes.
Complaint Details
The visit included a complaint investigation. The complaint was substantiated as the facility failed to administer prescribed insulin doses correctly to Resident #5.
Deficiencies (1)
Description
Failed to administer medications to 1 of 7 sampled residents as ordered by the physician, including a diabetic medication administered at bedtime.
Report Facts
Missed insulin administrations: 7 Sampled residents: 7
Employees Mentioned
NameTitleContext
Resident Care CoordinatorRCCResponsible for entering and verifying medication orders in the eMAR system.
First shift Medication AideMAInterviewed regarding medication administration and order verification.
Second shift Supervisor/Medication AideSupervisor/MAInterviewed about medication order processing and verification.
First shift Supervisor/Medication AideSupervisor/MAInterviewed about medication order changes and verification process.
AdministratorAdministratorInterviewed regarding medication order processing and pharmacy discrepancies.
Inspection Report Capacity: 147 Deficiencies: 11 Sep 25, 2019
Visit Reason
This report documents a Construction Section Biennial Survey conducted to assess compliance with the 1984 Regulations for Adult Care Homes, applicable portions of the 2005 Regulations for Adult Care Homes of Seven or More Beds, and the 1978 North Carolina State Building Code-Section 409-Institutional.
Findings
Multiple deficiencies were cited related to physical plant conditions including unsafe outside premises, housekeeping and furnishings not maintained, hazards from improperly stored oxygen bottles, failure to maintain fire safety systems and equipment in safe operating condition, electrical emergency lighting issues, plumbing not maintained safely, and alarms not functioning properly.
Deficiencies (11)
Description
Outside premises were not maintained in a clean and safe condition, including a dragging gate, a sagging planter box, and broken concrete creating a trip hazard.
Furnishings were not kept in good repair, including missing end cap on fire door push bar and loose corridor handrail.
Ceilings were not kept clean, with heavy dust accumulation on kitchen toilet exhaust fan.
Facility was not maintained free from hazards due to improperly stored oxygen bottles without restraint.
Failure to maintain building's fire safety systems in safe condition due to holes or gaps at penetrations through fire resistant ceilings or walls.
Fire safety equipment not maintained in safe operating condition; doors did not automatically close and latch upon fire alarm activation.
Improperly labeled fire safety equipment, including master manual override switches not properly labeled or understood by staff.
Electrical emergency/safety lighting equipment not maintained; exit sign by Room 228 did not illuminate on battery test.
Failure to install and maintain plumbing piping with minimum 2" air gap; icemaker drain line resting directly on floor grate.
Fire safety equipment alarms did not function; alarm did not sound on override switch box when opened.
Plumbing equipment not maintained in safe and operating condition; toilet fixture in kitchen bath not secure to floor.
Report Facts
Total licensed capacity: 147
Inspection Report Annual Inspection Census: 108 Deficiencies: 8 Jun 6, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation on June 4-6, 2019.
Findings
The facility was found deficient in multiple areas including tuberculosis testing, licensed health professional support evaluations, kitchen cleanliness, food service practices, meal quality, milk service, therapeutic diet adherence, and infection control related to glucometer use.
Complaint Details
The survey included a complaint investigation as part of the annual and follow-up survey conducted June 4-6, 2019.
Severity Breakdown
Type B Violation: 1
Deficiencies (8)
DescriptionSeverity
Facility failed to assure 1 of 7 sampled residents was tested for tuberculosis disease upon admission.
Facility failed to ensure Licensed Health Professional Support evaluation was completed quarterly for 1 of 7 sampled residents.
Facility failed to assure kitchen and food storage areas were clean and free of contamination including buildup in ice machine, dirty floors, and unlabeled food items.
Facility failed to assure all residents received a non-disposable place setting including beverage container and utensils at each meal.
Facility failed to assure residents were served nutritious and palatable meals; residents reported burned food, undercooked vegetables, and poor taste.
Facility failed to assure 8 ounces of milk was served to residents twice a day; milk was often only served at breakfast and upon request.
Facility failed to assure therapeutic diets were served as ordered; residents with mechanical soft and pureed diets received inappropriate food consistencies.
Facility failed to implement infection control procedures consistent with CDC guidelines for glucometer use, resulting in sharing glucometers between residents without proper cleaning.Type B Violation
Report Facts
Resident census: 108 Environmental Health sanitation score: 96.5 Milk delivery volume: 20 Milk daily requirement: 13.5 Glucometer readings count: 100
Employees Mentioned
NameTitleContext
Resident Care CoordinatorResponsible for assuring residents had TB skin testing and LHPS completed
AdministratorInterviewed regarding TB testing, kitchen cleaning, meal service, milk service, and glucometer use
Kitchen ManagerInterviewed regarding kitchen cleanliness, meal preparation, and milk service
Medication AideInterviewed regarding blood glucose checks and glucometer use
MA SupervisorInterviewed regarding training and glucometer cleaning procedures
Licensed Health Professional Support nurseInterviewed regarding quarterly assessments
Inspection Report Capacity: 147 Deficiencies: 5 Aug 10, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with applicable adult care home regulations and building codes for the facility licensed for 147 residents.
Findings
Multiple deficiencies were cited including failure to provide mechanical ventilation in certain bathrooms and closets, lack of towel bars in some resident rooms, unsafe and non-operational building equipment such as doors that do not latch and non-functional locking hardware on kitchen freezers, and incomplete fire protection for plumbing penetrations.
Deficiencies (5)
Description
Failure to provide mechanical ventilation in bathrooms and housekeeping closet, resulting in odors affecting residents and staff.
Lack of towel bars in bedrooms and shared bathrooms (Rooms 217, 219, 221).
Interior doors do not latch due to damaged hardware, preventing containment of fire and/or smoke (Rooms 202, 226, cross corridor doors near Room 211).
Failure to provide fire protection for copper plumbing ceiling penetrations in South Hall Mechanical Room.
Non-operational locking hardware safety features on walk-in kitchen freezers, preventing safe exit if locked inside.
Report Facts
Licensed capacity: 147
Inspection Report Annual Inspection Deficiencies: 1 Sep 21, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual and a follow-up survey on September 20-21, 2016.
Findings
The facility failed to ensure two of the seven washers were in operating condition, resulting in delays with the cleaning of residents' dirty clothes. Despite repair attempts, the washers remained non-functional due to needed parts and lack of documentation for repairs.
Deficiencies (1)
Description
Two of the seven washers were not in operating condition, causing delays in cleaning residents' dirty clothes.
Report Facts
Number of washers: 7
Employees Mentioned
NameTitleContext
Maintenance DirectorResponsible for ensuring equipment was in good working condition; notified Administrator about washer issues.
AdministratorWas aware of washer issues in the South Hall Laundry Room.
Business Office ManagerResponsible for notifying repair agencies and making appointments; had no documentation of repair visits.
Laundry AideReported washer issues and interviewed regarding washer functionality.
Inspection Report Capacity: 147 Deficiencies: 12 Sep 10, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1984 Regulations for Adult Care Homes, applicable portions of the 2005 Regulations for Adult Care Homes of Seven or More Beds, and the 1978 North Carolina State Building Code Section 409 - Institutional.
Findings
Multiple deficiencies were identified including missing door knobs and furniture in need of repair, lack of proper documentation for fire safety rehearsals, compromised fire-rated walls and ceilings with unsealed holes and penetrations, malfunctioning cross-corridor doors, disconnected exhaust ducts, missing electrical junction box covers, lack of vacuum breakers on water fixtures, a loosely mounted toilet, and a dry waste trap allowing odors and bacteria to enter the facility.
Deficiencies (12)
Description
Missing door knob on a closet door in room 213 and chair and chest of drawers in need of repair in room 213.
Records of fire plan rehearsals not maintained including missing list of staff present and no description of rehearsals.
Compromised one-hour fire rated walls and ceilings with multiple holes and penetrations not sealed with approved materials.
Cross-corridor doors near room 212 failed to latch closed upon fire alarm activation.
Holes through many corridor doors compromising fire and smoke resistance.
On-duty staff could not locate key to open fire alarm panel without administrator assistance.
Disconnected exhaust ducts in attic causing fans to exhaust into attic rather than outside.
Missing cover(s) on electrical junction box(es) over the kitchen.
Make-up air duct disconnected in attic over kitchen causing make-up fan to pull air from attic.
No vacuum breakers provided on hair wash wand in Beauty Salon and spray wand in tub room near room 224.
Toilet loosely mounted to floor in shared bathroom by room 215.
Waste trap for hopper on South Hall allowed to become dry, allowing odors and bacteria to enter facility.
Report Facts
Total licensed capacity: 147

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