Inspection Reports for Hope Mills Retirement Center
4217 Elk Road Hope Mills, NC 28348, Hope Mills, NC, 28348
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 28, 2018, found multiple deficiencies related to building safety, fire safety practices, and maintenance issues. Earlier inspections from 2016 and 2016 also noted deficiencies, primarily involving fire detection coverage, emergency illumination, and medication administration errors. Inspectors cited recurring themes of fire safety system inadequacies and maintenance of safe building conditions, as well as some issues with medication follow-up and administration. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports, and no complaint investigations were noted. The facility’s inspection history shows ongoing challenges with fire safety and building maintenance, with no clear pattern of improvement or worsening over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Capacity: 64
Deficiencies: 5
Date: Feb 28, 2018
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable standards and regulations for adult care homes and building codes.
Findings
Multiple deficiencies were cited including unsafe outside premises lighting, improper storage of oxygen cylinders, inoperable call systems, inadequate fire safety rehearsals and documentation, unsafe building equipment and fire safety components, and lack of required exhaust ventilation in certain areas.
Deficiencies (5)
Outside premises were not maintained in a safe condition; exterior light at south hall exit was out but corrected on site.
Facility was not maintained free of hazards; six small and seven large oxygen cylinders improperly stored in cardboard carriers in Room 8; inoperable call system in each resident room.
Fire rehearsals were not conducted according to North Carolina Fire Prevention Code; no evacuations or audible alarms on shifts; fire drill logs lacked short descriptions.
Building equipment not maintained safe and operating; windows that do not stay open may cause injury; exit signs did not illuminate on battery backup; GFCI outlet not secure; doors propped open with unapproved devices.
Facility did not provide exhaust ventilation at required rate in specified areas; storage room used for housekeeping items lacked ventilation.
Report Facts
Licensed capacity: 64
Oxygen cylinders improperly stored: 13
Shifts operated: 2
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 6, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey on December 6-7, 2016 at Hope Mills Retirement Center to assess compliance with health care and medication administration regulations.
Findings
The facility failed to assure follow-up on blood pressure results for one resident and failed to administer medications as ordered for two residents, including errors with fast acting insulin and a medication for high cholesterol. Deficiencies included failure to notify physicians of out-of-range blood pressures and improper insulin administration technique and timing.
Deficiencies (2)
Failed to assure follow-up blood pressure results were reported according to parameters provided by the licensed practitioner for 1 of 3 residents.
Failed to administer medications as ordered for 2 of 6 residents observed during medication passes, including errors with fast acting insulin and a medication used to treat high cholesterol.
Report Facts
Medication error rate: 7
Blood pressure readings out of range: 1
Medication administration timing: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Responsible for taking and recording Resident #3's blood pressures and administering medications; did not notify physician of out-of-range blood pressures and did not perform air shot before insulin administration. | |
| Manager | Reviewed blood pressure logs, failed to send November 2016 log to physician, and acknowledged need for better tracking system; conducted training on insulin pen air shot technique. | |
| Nurse at Resident #3's physician's office | Stated expectation that physician should be notified same day of out-of-range blood pressures and that Novolog insulin should be given within 15 minutes before meal. | |
| Pharmacy provider | Provided information on Novolog Flexpen use and noted lack of manufacturer instructions due to packaging. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 12, 2016
Visit Reason
The visit was a follow-up survey to verify correction of a cited deficiency from the prior survey dated 2016-03-09, requiring a new Plan of Correction.
Findings
The facility was found to lack fire detection coverage in all habitable rooms and/or spaces, specifically missing heat detection in the Linen Closets located in the North Wing, which could affect all residents by not activating the fire alarm system for emergency evacuation.
Deficiencies (1)
Facility does not have fire detection/coverage in all habitable rooms and/or spaces, specifically no heat detection in the Linen Closets in the North Wing.
Inspection Report
Capacity: 64
Deficiencies: 4
Date: Mar 9, 2016
Visit Reason
The inspection was a Biennial Construction Survey to assess compliance with the 1987 Minimum and Desired Standards and Regulations for Homes for the Aged and Infirmed, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1978 North Carolina State Building Code.
Findings
Deficiencies were cited related to fire safety and emergency illumination. The facility lacked fire detection coverage in all habitable rooms and emergency illumination was not maintained in several locations, affecting resident safety during emergencies.
Deficiencies (4)
Facility does not have fire detection/coverage in all habitable rooms and/or spaces, affecting smoke or fire detection and fire alarm activation.
Facility emergency illumination has not been maintained in a safe manner, affecting illumination in paths of egress during emergencies.
No heat detection in the Linen Closet located in the North Wing.
Emergency illumination not provided in TV Room North Wing, TV Room South Wing, and Hall outside Room 33.
Report Facts
Licensed capacity: 64
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