Inspection Reports for Foundation Senior Living
1437 State Rd 2710, Garner, NC 27529, United States, NC, 27529
Back to Facility Profile
Inspection Report
Follow-Up
Deficiencies: 0
Apr 26, 2024
Visit Reason
Follow up construction survey conducted based on documentation received to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected or will be corrected by May 10, 2024, and no further action is required at this time.
Report Facts
Correction completion date: May 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Reported the follow up construction survey by documentation |
Inspection Report
Capacity: 126
Deficiencies: 8
Mar 21, 2024
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 2005 Rules for Adult Care Homes of Seven or More Beds and the 2018 North Carolina State Building Code, Institutional (I-2) Occupancy.
Findings
Multiple deficiencies were identified including unfinished patching around sprinkler heads, flaking paint, trip hazards from unraveling carpet, failure to conduct quarterly fire safety rehearsals on each shift, and failure to maintain fire safety equipment in a safe operating condition such as fire doors not closing or latching properly, gaps in fire resistant ceilings, blocked or wedged open doors, mechanical equipment issues, and unsecured plumbing fixtures.
Deficiencies (8)
| Description |
|---|
| Walls, ceilings, and floors not kept in good repair including unfinished patching around sprinkler heads, flaking paint, and unraveling carpet creating trip hazards. |
| Facility failed to conduct quarterly fire rehearsals on each shift and did not include short descriptions of rehearsals in records. |
| Fire safety equipment not maintained in safe operating condition; roll-down fire door and other doors did not automatically close or latch properly. |
| Holes or gaps at penetrations through fire resistant ceilings or walls allowing potential spread of fire and smoke. |
| Resident room doors had gaps between door and frame stops, compromising smoke resistance. |
| Fire safety doors were blocked or held open by unapproved devices, limiting ability to contain smoke and fire. |
| Mechanical equipment not maintained in safe and operating condition; vent cover fallen out. |
| Plumbing equipment not maintained safely; toilet not securely mounted to floor. |
Report Facts
Total licensed capacity: 126
Inspection Report
Follow-Up
Deficiencies: 3
Oct 19, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on October 17-19, 2017 to verify correction of previous deficiencies.
Findings
The facility failed to maintain walls, ceilings, floors, and furnishings in good repair and clean condition, with multiple areas showing dirt buildup, stains, missing paint, and damaged furniture. The facility also had ongoing pest infestations including bed bugs, roaches, and flies in residents' rooms and common areas. Additionally, the facility failed to ensure proper assessments, physician orders, and care plans for the use of geri-chairs as restraints for three residents.
Severity Breakdown
Type B Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure walls, ceilings, floors, and furnishings were kept clean and in good repair in multiple resident rooms and common areas. | — |
| Facility failed to assure residents' rooms and common areas were free of hazards as evidenced by presence of bed bugs, roaches, and flies. | Type B Violation |
| Facility failed to ensure geri-chairs were used for safety with appropriate restraint assessments, physician orders, and care plans for 3 residents. | Type B Violation |
Report Facts
Number of residents sampled with geri-chair restraint issues: 3
Dates of pest control treatments: 8/15/17, 9/19/17, 10/13/17 (no room numbers provided)
Number of cigarette butts observed: 190
Number of residents observed smoking: 6
Number of resident rooms with observed damage or dirt: 15
Inspection Report
Follow-Up
Deficiencies: 6
Jul 12, 2017
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted a follow-up survey on July 12-14, 2017 to verify correction of previous deficiencies.
Findings
The facility failed to maintain walls, ceilings, and floors in good repair and clean condition in multiple resident rooms and common areas. There was a significant pest infestation including roaches, flies, ants, fruit flies, and bed bugs, with failure to follow bed bug treatment protocols. Personal care was inadequate for one resident who did not receive nail care as needed. The facility failed to ensure proper health care follow-up for a resident with a urinary catheter and failed to administer medications as ordered for several residents, including failure to administer a new medication, sliding scale insulin at bedtime, and errors in medication administration. One resident was treated without dignity related to disposal of soiled incontinent briefs.
Severity Breakdown
Type B: 2
Type A2: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Walls, ceilings, and floors were not kept clean and in good repair in multiple resident rooms and common bathrooms. | — |
| Presence of roaches, flies, ants, fruit flies, and bed bugs in residents' rooms, dining room, and common hallways; failure to follow bed bug treatment protocols including not treating linens or clothing and not cleaning rooms with known bed bug activity. | Type B |
| Failure to provide personal care including nail care for a resident requiring total care. | — |
| Failure to assure referral and follow-up to meet routine and acute health care needs for a resident with urinary catheter who did not receive ordered medication and catheter removal as ordered. | Type B |
| Failure to administer medications as ordered for multiple residents including failure to administer Tamsulosin, sliding scale insulin at bedtime, and medication administration errors with inhaler, eye drops, Aspirin, and iron supplement. | Type A2 |
| Failure to treat a resident with respect, dignity, and consideration related to disposal of soiled incontinent briefs requiring the resident to carry briefs to a common bathroom and wait outside with soiled briefs in hand. | — |
Report Facts
Medication error rate: 17
Bed bug count: 20
Ant count: 100
Drain flies count: 20
Live roaches count: 10
Days sliding scale insulin not given: 12
Inspection Report
Annual Inspection
Deficiencies: 11
Mar 13, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual and follow up survey and complaint investigation on 3/7-10/17 and 3/13/17.
Findings
The facility failed to assure full time and consistent responsibility for operation, administration, management and supervision, resulting in significant noncompliance related to staffing, personal care, supervision, health care, medication administration, housekeeping, furnishings and reporting incidents. Medication administration errors, inadequate health care referral and follow up, lack of supervision, and inadequate staffing were noted. Environmental issues included unclean and unrepaired areas, chronic urine odors, and fruit fly infestation.
Complaint Details
The visit included a complaint investigation related to resident supervision, medication administration, and personal care.
Severity Breakdown
Type A1 Violation: 2
Type A2 Violation: 3
Type B Violation: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to assure full time and consistent responsibility for operation, administration, management and supervision of the facility. | Type A1 Violation |
| Failed to administer medications as ordered including missing nebulizer treatments, duplicate antipsychotic therapy, and incorrect muscle relaxer dose. | Type A1 Violation |
| Failed to provide supervision for residents resulting in one resident with dementia leaving the facility twice and another resident discarding cigarette butts near oxygen tank. | Type A2 Violation |
| Failed to assure appropriate health care referral and follow up for residents including unreported vomiting and unresponsive resident, non-working oxygen concentrator, and unreported swelling. | Type A2 Violation |
| Failed to assure adequate staff available to provide supervision and personal care assistance including incontinence care, bathing, and assistance to dining room due to staff assigned housekeeping and laundry duties. | Type B Violation |
| Failed to assure an exit door, walls, ceilings, floors and floor tiles were kept clean and in good repair. | — |
| Failed to assure no chronic urine odors present at entrance and east hall. | — |
| Failed to assure environment free of chronic infestation of fruit flies in resident rooms, hallways, bathrooms and dining room entrance. | — |
| Failed to attend to personal care needs of residents including incontinence care, bathing, showering and assuring clean clothing, towels and linens. | — |
| Failed to report to Department of Social Services the death of a resident occurring in less than 24 hours after fall and new vomiting. | — |
| Failed to administer medications as ordered including late administration of anti-reflux medication and omission of antihistamine eye drops. | — |
Report Facts
Medication error rate: 5
Deficiencies cited: 2
Residents on oxygen: 5
Residents needing two staff assistance: 4
Residents needing increased supervision: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Maintenance Director | Named in findings related to facility repairs and maintenance issues |
| Not provided | Medication Aide | Named in medication administration errors and resident care |
| Not provided | Resident Care Coordinator | Named in oversight of resident care and medication orders |
| Not provided | Regional Director | Named in oversight and follow up of facility operations and care |
| Not provided | Administrator | Named in oversight and management of facility operations |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 2, 2017
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of deficiencies from the previous 11/09/2016 Biennial Follow Up Construction Survey.
Findings
The facility failed to keep walls, ceilings, floors or floor coverings and furniture clean and in good repair, specifically noting damaged edges on doors of renovated public bath/showers/restrooms.
Deficiencies (1)
| Description |
|---|
| Facility failed to keep walls, ceilings, floors or floor coverings and furniture clean and in good repair, with damaged edges on doors of renovated public bath/showers/restrooms. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Nov 17, 2016
Visit Reason
The Adult Care Licensure Section and Wake County Human Services conducted a follow-up survey and complaint investigation initiated by Wake County Human Services on 2016-11-09.
Findings
The facility failed to maintain clean and well-repaired walls and floors, had chronic unpleasant odors of urine and feces, pest infestations including roaches and bedbugs, and failed to provide adequate personal care and medication administration. Multiple residents had unmet health care needs including missed appointments, untreated wounds, and lack of safety equipment. The facility also failed to ensure proper coordination of health care and medication administration.
Complaint Details
Complaint investigation was initiated by Wake County Human Services on 2016-11-09 and included follow-up survey visits on 2016-11-15, 2016-11-16, and 2016-11-17.
Deficiencies (6)
| Description | Severity |
|---|---|
| Walls and floors were not kept clean and in good repair in multiple resident rooms and common areas, with stained carpets, torn duct tape, and holes in walls. | — |
| Chronic unpleasant odors of urine and feces were present in residents' rooms, common bathrooms, and hallways. | — |
| Facility was not clean and uncluttered, with presence of roaches, bedbugs, and ants in multiple resident rooms, bathrooms, common areas, and dining room. | — |
| Personal care tasks were not consistently carried out for residents requiring assistance with incontinence, bathing, and use of medical devices such as leg braces. | — |
| Facility failed to meet health care needs for residents by missing neurology and oncology appointments, failing to notify providers of hospital visits, missing mental health appointments, failing to notify physician of infected toe wound, failing to follow up on cardiology referral, and failing to obtain wheelchair safety harness. | Type A1 Violation |
| Medication administration errors occurred including missed insulin doses, incorrect timing of insulin, missed antibiotic dose, administration of wrong calcium supplement and eye drops, and missed topical pain medication. | — |
Report Facts
Medication error rate: 13
Number of resident rooms with bedbugs found: 4
Number of housekeepers: 1
Number of housekeepers scheduled: 2
Number of residents with unmet health care needs: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Named in medication administration errors and health care coordination failures. |
| Interim Administrator | Interim Administrator | Named in interviews regarding facility staffing, cleaning, and health care coordination. |
| Maintenance Director | Maintenance Director | Named in interviews regarding facility maintenance and cleaning issues. |
| Medication Aide | Medication Aide | Named in medication administration errors. |
| Administrator from sister facility | Administrator | Named in interviews providing support and assistance to Interim Administrator. |
Inspection Report
Follow-Up
Deficiencies: 4
Nov 9, 2016
Visit Reason
Follow Up Survey conducted to verify correction of deficiencies identified in the 07/27/2016 Biennial Survey.
Findings
The facility failed to correct previous deficiencies related to housekeeping and furnishings, chronic unpleasant odors, building equipment maintenance, and exhaust ventilation. Specific issues included damaged doors, worn furniture finishes, ongoing bathroom renovations, malfunctioning fire safety doors, and exhaust fans that were not properly ventilating, allowing odors to remain.
Deficiencies (4)
| Description |
|---|
| Facility failed to keep walls, ceilings, floors or floor coverings and furniture clean and in good repair, including marred doors and worn dining tables. |
| Facility failed to prevent chronic unpleasant odors, including strong urine odor in Bedroom 320 and incomplete bathroom renovations. |
| Interior doors were not maintained in a safe and operating condition, including fire doors that did not latch and missing gaskets on cross-corridor doors. |
| Exhaust ventilation equipment/components were not maintained in good working order, causing odors to remain in multiple bathrooms, laundry, and storage areas. |
Inspection Report
Follow-Up
Deficiencies: 4
Aug 5, 2016
Visit Reason
The Adult Care Licensure Section conducted a follow up survey from 8/2/16 through 8/5/16 to verify correction of previously identified deficiencies.
Findings
The facility failed to maintain clean and safe housekeeping conditions, including soiled carpets, peeling duct tape creating tripping hazards, water-damaged ceilings, and bathrooms in disrepair. Additionally, medication administration errors were found, including failure to administer medications as ordered, administration of medications without orders, and late administration of medications.
Severity Breakdown
Type B VIOLATION: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to keep ceilings, floors, and floor coverings clean and in good repair, including soiled carpets and peeling duct tape creating tripping hazards. | — |
| Facility failed to keep 2 of 3 common bathrooms clean and free from obstructions and hazards, with damaged vanities held together by duct tape. | — |
| Medication administration errors including failure to administer Methadone, Novolin 70/30, Seroquel, Norvasc, Losartan as ordered; administration of Aspirin and Sodium Bicarbonate without orders; and late administration of Carafate Suspension and Xanax. | Type B VIOLATION |
| Residents' rights to receive adequate and appropriate care and services in compliance with laws and regulations were not met due to medication administration issues. | — |
Report Facts
Medication error rate: 14
Medication errors: 4
Medication errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator in Training | Interviewed regarding medication administration errors, order processing, and facility policies. | |
| Maintenance Director | Interviewed about facility maintenance issues including ceiling water damage and duct tape on floors. | |
| Resident Care Coordinator | Interviewed regarding medication administration, order processing, and resident care. | |
| Medication aide | Interviewed regarding medication administration and missing medications. |
Inspection Report
Plan of Correction
Capacity: 126
Deficiencies: 13
Jul 27, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes and adult care home regulations.
Findings
Multiple deficiencies were identified including inadequate fire detection, obstructions in corridors, poor housekeeping with damaged and stained surfaces, presence of mold, plumbing issues, fire safety code violations such as unsealed penetrations and damaged fire-resistance-rated assemblies, malfunctioning emergency lighting and exit signage, lack of proper maintenance and testing of fire suppression systems, overcrowding increasing fire load, malfunctioning interior doors, and ventilation systems failing to properly exhaust odors.
Deficiencies (13)
| Description |
|---|
| No fire alarm detection connected to the fire alarm system in the attic above the Med Room. |
| Corridors were not free of all equipment and obstructions; exit door blocked with a chair on the exterior. |
| Facility failed to keep walls, ceilings, floors or floor coverings and furniture clean and in good repair with multiple instances of stains, peeling paint, mold growth, loose fixtures, and water damage. |
| Facility failed to prevent chronic unpleasant odors due to dried-up plumbing traps allowing sewer gases and strong urine odor. |
| Hazard present due to possibility of backflow of contaminated water into domestic water supply from shower wands without vacuum breakers. |
| Facility failed to maintain building in an uncluttered, clean, and orderly manner free of obstructions and hazards; examples include falling HVAC supply grille and plywood ceiling about to fall due to leak. |
| Building fire safety not maintained in safe and operating condition with crushed fire-resistance-rated ceiling construction, unsealed cable penetrations, incomplete duct wrap, holes not firestopped, and unapproved firestop materials. |
| Building emergency equipment not maintained in safe and operating condition; emergency lights spaced too far apart and missing exit signs. |
| Required inspections and testing of commercial kitchen hood's fire extinguishing system not completed since March 2016. |
| Building not maintained in a safe manner due to overpacked combustible items increasing fire load. |
| Interior doors not maintained in safe and operating condition; doors not latching properly or hitting floor preventing closure. |
| Facility failed to provide proper exhaust ventilation; exhaust fans exhausting some air on one side while blowing air back into rooms allowing odors to remain. |
| Local exhaust ventilation systems running but not removing required amount of air to dissipate odors in multiple bathrooms. |
Report Facts
Total licensed capacity: 126
Inspection Report
Annual Inspection
Deficiencies: 8
May 10, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey, follow up survey and complaint investigation on 5/4/16, 5/5/16, 5/6/16, 5/9/16 and 5/10/16.
Findings
The facility failed to ensure each exit door accessible by residents had a functioning alarm or alert system device activated when the door was opened for 2 residents with dementia and disorientation. The facility also failed to maintain walls, ceilings, and floors in good repair in several areas, and failed to eliminate chronic unpleasant odors in common men's restroom and shower room. Additionally, the facility failed to assure tuberculosis testing upon admission for one resident, failed to provide supervision resulting in elopement for two residents, failed to implement physician orders for lab testing for three residents, and failed to administer medications as ordered for multiple residents.
Severity Breakdown
Type A2 Violation: 3
Type B Violation: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to assure each exit door accessible by residents had a functioning alarm or alert system device activated when the door was opened for 2 residents with dementia and disorientation. | Type A2 Violation |
| Failed to assure walls, ceilings, and floors were kept in good repair in common men's restrooms, shower rooms, dining area, and resident bathroom. | — |
| Failed to ensure no chronic unpleasant odors in common men's restroom and shower room. | — |
| Failed to assure tuberculosis testing upon admission for one resident. | — |
| Failed to provide supervision of residents in accordance with assessed needs, resulting in elopement for 2 residents. | Type A2 Violation |
| Failed to assure physician orders for lab testing were implemented for 3 residents. | Type B Violation |
| Failed to assure medications were administered as ordered for multiple residents, including insulin administration errors and missed medication orders. | Type A2 Violation |
| Failed to assure examination and screening for controlled substances was performed for one employee hired after 10/1/13. | — |
Report Facts
Medication error rate: 9
Dates of inspection: 5
Residents sampled: 7
Staff sampled: 3
Inspection Report
Follow-Up
Deficiencies: 2
Mar 4, 2015
Visit Reason
This report is a follow-up survey conducted to verify the completion of previously cited deficiencies at North Pointe Assisted Living of Garner.
Findings
Most of the previously cited deficiencies have been completed; however, some deficiencies remain uncorrected, including the lack of an emergency release switch on the locked yard gate and kitchen/dining room doors that will not latch.
Deficiencies (2)
| Description |
|---|
| Locked yard gate equipped with keypad and magnetic lock but no emergency release switch installed. |
| Both kitchen/dining room doors will not latch; the door on the right will not close and latch. |
Inspection Report
Follow-Up
Deficiencies: 4
Jan 16, 2015
Visit Reason
Adult Care Licensure conducted a follow up survey on 1/13/15, 1/15/15, and 1/16/15 to assess compliance with housekeeping, furnishings, and health care regulations.
Findings
The facility failed to maintain walls, ceilings, floors, and furnishings in good repair and free of hazards in multiple bathrooms and common areas. Additionally, the facility failed to assure proper medication administration and notification to the physician regarding finger stick blood sugar results and insulin administration for a diabetic resident, resulting in a Type B violation.
Severity Breakdown
Type B Violation: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to assure walls, ceilings, and floors were kept in good repair in 4 of 9 common bathrooms and the front lobby carpet had a gap. | — |
| Facility failed to assure that 2 of 9 common bathrooms were maintained free of all obstructions and hazards. | — |
| Facility failed to notify the physician of 1 of 3 sampled residents (#1) with Diabetes Mellitus regarding finger stick blood sugar results and insulin administration. | Type B Violation |
| Facility failed to assure the sliding scale insulin was administered as ordered by a licensed prescribing practitioner for 1 of 3 sampled residents (#1). | Type B Violation |
Report Facts
Dates of follow-up survey: 1/13/15, 1/15/15, and 1/16/15
Number of common bathrooms with issues: 4
Number of common bathrooms with obstructions and hazards: 2
Number of sampled residents with medication issues: 1
Dates of blood sugar monitoring forms reviewed: From 11/1/14 to 1/13/15
Number of insulin administration errors documented: 6
Number of times insulin administered without order in December 2014: 4
Loading inspection reports...
