Inspection Report
Follow-Up
Deficiencies: 0
May 12, 2025
Visit Reason
Follow up construction survey by documentation 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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Reported the follow up construction survey. |
Inspection Report
Follow-Up
Deficiencies: 2
Apr 10, 2025
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of deficiencies identified in a prior Biennial Construction Survey.
Findings
The facility failed to maintain the emergency fire alarm system in a safe operating condition, with a circuit trouble signal present on the fire alarm control panel. Additionally, exhaust ventilation was not maintained in specified spaces, with a pattern of exhaust fans not working in the SCU unit back halls.
Deficiencies (2)
| Description |
|---|
| Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; circuit trouble signal on the fire alarm control panel. |
| Facility did not maintain exhaust ventilation in specified spaces, causing humidity buildup and odor dissipation issues; exhaust fans not working in SCU back halls. |
Inspection Report
Annual Inspection
Deficiencies: 2
Apr 5, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey of the facility from April 5 to April 7, 2022.
Findings
The facility failed to provide adequate supervision for Resident #3, resulting in six unwitnessed falls in one month, and failed to ensure that Resident #4's self-administered medications were stored safely and securely as required by policy.
Deficiencies (2)
| Description |
|---|
| Failure to provide supervision for Resident #3, resulting in six unwitnessed falls in a month and lack of proper post-fall assessments and care plan updates. |
| Failure to ensure Resident #4's self-administered medications were stored in a locked and secure manner as required by facility policy. |
Report Facts
Number of falls: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Healthcare Director (HCD) | Notified of Resident #3's falls and responsible for initiating alert charting and monitoring. |
| Administrator | Administrator | Aware of Resident #3's multiple falls and responsible for staffing decisions. |
| Licensed Health Professional Support nurse | Licensed Health Professional Support nurse | Responsible for ensuring Resident #4's medications were kept in locked storage. |
Inspection Report
Complaint Investigation
Deficiencies: 12
Jun 12, 2019
Visit Reason
The Adult Care Licensure Section conducted an initial survey and a complaint investigation initiated by the Cumberland County Department of Social Services regarding Harmony at Hope Mills.
Findings
The facility was found deficient in multiple areas including failure to provide diabetic training to medication aides, failure to have physician-signed care plans within required timeframes for sampled residents, failure to provide adequate personal care and supervision leading to incontinent care issues and multiple falls with injuries, medication administration errors including insulin and Protonix, failure to maintain ice machines free from contamination, failure to serve water to residents at meals, failure to follow infection control measures during medication administration, and failure to respect residents' rights related to privacy and dignity.
Complaint Details
The complaint investigation was initiated by the Cumberland County Department of Social Services on March 28, 2019 and May 24, 2019.
Severity Breakdown
Type B: 5
Type A1: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Medication aide Staff C did not receive training on care of diabetic residents prior to administering insulin and had no medication clinical skills competency validation. | — |
| Physicians failed to certify residents' care plans by signing and dating within 15 days of assessment for 5 sampled residents. | — |
| Facility failed to provide personal care assistance related to incontinent care for Resident #2, resulting in saturated briefs and bedding. | Type B |
| Facility failed to provide supervision for Resident #2, resulting in multiple falls and serious injuries including a fractured eye socket and head laceration. | Type A1 |
| Facility failed to assure health care referral and follow-up for Resident #2, including failure to obtain a hospital bed as ordered and failure to notify the PCP. | — |
| Facility failed to assure licensed health professional support evaluations were completed quarterly for Residents #3 and #5 who required finger stick blood glucose testing and medication injections. | — |
| Facility failed to assure all food and beverage were protected from contamination related to wet pink, brown and black build-up substance in two ice machines. | Type B |
| Facility failed to assure water was served to residents at each meal in two dining rooms; residents had to ask for water to receive it. | — |
| Facility failed to administer medications as ordered for Residents #2, #3, #5, and #13 including insulin administration errors, missed Protonix doses, and missed Digoxin doses. | Type B |
| Medication aide Staff C administered medications without required training, competency validation, or verification of previous employment. | — |
| Medication aide failed to follow infection control measures by not washing or sanitizing hands between residents during medication administration. | — |
| Facility failed to treat residents with respect, dignity, and privacy by denying Resident #2 the right to sleep in her room and moving her bed without consent, and posting a document listing Resident #12's name with 'nasty habits' visible to the public. | Type B |
Report Facts
Medication error rate: 12
Falls: 17
Bruise size: 4
Bruise size: 7
Bruise size: 8.5
Bruise size: 8
Bruise size: 3
Bruise count: 6
Bruise count: 6
Bruise size: 2.5
Bruise size: 1.5
Medication doses: 5
Medication doses: 8
Medication doses: 5
Medication doses: 30
Medication doses: 5
Medication doses: 125
Medication doses missed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to complete required medication training and competency validation prior to administering medications |
| MA | Medication Aide | Observed administering insulin without performing required air shot and failing to review eMAR before administration |
| LPN Supervisor | Licensed Practical Nurse Supervisor | Responsible for medication administration oversight and communication with pharmacy |
| HCC | Health Care Coordinator | Responsible for ensuring LHPS reviews and medication administration compliance |
| Executive Director/Administrator | Administrator | Facility leadership responsible for overall compliance and resident care |
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