Inspection Report
Follow-Up
Deficiencies: 0
May 6, 2025
Visit Reason
Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is needed.
Inspection Report
Annual Inspection
Deficiencies: 4
Apr 14, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Falls River Village Assisted Living Community on April 13-14, 2022 to assess compliance with state regulations.
Findings
The facility failed to ensure a criminal background check was completed for one staff member upon hire and failed to provide adequate supervision for a resident with a history of falls, resulting in multiple falls including one with a head injury. Additionally, the facility failed to implement physician orders for increased supervision for another resident.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 sampled staff had a criminal background check completed upon hire. | — |
| Failed to provide supervision for 1 of 5 residents with a recent history of falls resulting in a fractured hip and subsequent falls including a head injury with scalp laceration. | Type A2 Violation |
| Failed to ensure implementation of physician's orders for 1 of 5 residents regarding an order to check on the resident every thirty minutes for a 24-hour period. | — |
| Failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to personal care and supervision. | — |
Report Facts
Staff sampled: 3
Residents sampled: 5
Falls: 4
30-minute checks order duration: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide / Medication Aide | Named in deficiency for missing criminal background check upon hire |
| Business Office Manager | Responsible for requesting criminal background checks; recently hired | |
| Administrator | Facility Administrator | Interviewed regarding supervision failures and background check processes |
| Medication Aide/Personal Care Aide | Medication Aide/Personal Care Aide | Provided care and supervision details for Resident #3 |
| Health and Wellness Director | Health and Wellness Director | Responsible for initiating temporary service plans and 72-hour reports after falls |
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 3, 2019
Visit Reason
The Adult Care Licensure Section and Wake County Department of Social Services conducted an annual survey and follow-up survey on April 2, 2019 through April 3, 2019.
Findings
The facility failed to ensure at least one staff on third shift had current CPR training for 8 of 11 sampled shifts, failed to maintain clean kitchen and food storage areas, and failed to administer medications as ordered for several residents, including errors with a topical antifungal cream, a medication for constipation, a blood thinner, and a diuretic dosage change.
Severity Breakdown
Type B Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assure at least one staff on third shift had completed CPR and choking management training within the last 24 months for 8 of 11 shifts sampled. | Type B Violation |
| Failed to assure kitchen and food storage areas were clean and free of contamination including floors, refrigerator and freezer doors, and food storage containers. | — |
| Failed to ensure medications were administered as ordered including omission of topical antifungal cream, failure to administer medication for constipation as ordered, and incorrect dosage administration of blood thinner and diuretic. | Type B Violation |
Report Facts
Shifts without CPR trained staff: 8
Medication error rate: 7
Medication administration opportunities: 27
Dates with undocumented Coumadin administration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Worked third shift without current CPR training on 04/01/19 |
| Staff D | Medication Aide | CPR expired 07/2018, worked third shift without CPR coverage on multiple dates |
| Staff E | Personal Care Aide | No documentation of current CPR training, worked third shift on 03/26/19 |
| Staff F | Personal Care Aide | CPR expired 09/2011, CPR certified for pediatrics only, scheduled to take adult CPR on 04/16/19 |
| Staff G | Medication Aide | CPR expired June 2018, worked third shift without CPR coverage on multiple dates |
| Staff H | Personal Care Aide | No documentation of CPR training, worked third shift on multiple dates |
| Administrator | Unaware of CPR training lapses and medication administration errors | |
| Health and Wellness Director | Responsible for CPR training oversight and medication administration audits | |
| Medication Aide | Failed to administer topical antifungal cream and administered incorrect diuretic dosage |
Inspection Report
Plan of Correction
Capacity: 60
Deficiencies: 6
Sep 27, 2018
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1998 Rev) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Deficiencies were cited related to housekeeping, maintenance, and fire safety. Observations included excessive grease and debris on floors, obstructions such as a basket holding a door open, fire safety components turned off or not properly maintained, unprotected HVAC penetrations, holes in ceilings, and excessive particulate build-up on return-air grilles.
Deficiencies (6)
| Description |
|---|
| Facility failed to maintain floors in a clean and good condition with excessive grease build-up and debris behind refrigerators, freezers, and prep tables. |
| Facility failed to be free of all obstructions and hazards; a basket was holding the door open at the Salon in 100 Hall. |
| Facility failed to maintain fire safety components in a safe and operating condition; accelerators were turned off at the sprinkler riser. |
| HVAC lines penetrating the one-hour roof/ceiling assembly were not fire protected in Mechanical Room/400 Hall and Mechanical Room/800 Hall. |
| There were holes in the ceiling at Room 711 penetrating the one-hour roof/ceiling assembly that were not fire protected. |
| Return-air grilles at Mechanical Room/400 Hall and all corridors had excessive particulate build-up. |
Report Facts
Licensed capacity: 60
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Aug 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding the kitchen not being in operation due to renovation work, with complaints that meals were often cold when served.
Findings
The complaint was substantiated. The kitchen stove/oven was not operational due to delayed renovations, the refrigerator and freezer were unplugged and not in use, and a stop work order was issued by the City of Raleigh Inspections Department until plans are submitted to the Health Department for review.
Complaint Details
Complaint stated that since the kitchen in the building was not in operation due to renovation work, meals were being prepared from a kitchen in a memory care building adjacent to the facility and operated by the same provider. Complaint stated that meals were often cold when served. The complaint was substantiated.
Deficiencies (1)
| Description |
|---|
| The kitchen equipment is not in an operating condition; stove/oven not operational due to delayed renovations; refrigerator and freezer unplugged and not used; stop work order issued for kitchen renovation. |
Report Facts
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Billy S. Bryant | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 15, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Falls River Village Assisted Living Community on October 14-15, 2015.
Findings
The facility failed to assure that one of three staff sampled (Staff B) had a 2-step tuberculosis skin test within the required 12 month period as mandated by state regulations.
Deficiencies (1)
| Description |
|---|
| Failure to assure 1 of 3 staff sampled were tested upon employment for tuberculosis disease in compliance with control measures, specifically no documentation of a 2-step TB skin test within 12 month period for Staff B. |
Report Facts
Staff sampled: 3
Staff not compliant: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personal Care Aide | Named in tuberculosis testing deficiency |
| Executive Director | Interviewed regarding tuberculosis testing compliance and responsibility | |
| Assisted Living Director | Responsible for ensuring staff had 2-step TB skin test; no longer employed at facility |
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