Inspection Report
Annual Inspection
Census: 14
Capacity: 60
Deficiencies: 2
Dec 11, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Jurney's Assisted Living from December 10, 2024 through December 11, 2024.
Findings
The facility failed to ensure that written disclosure information was provided to family members upon admission to the Special Care Unit for 2 of 2 sampled residents. Additionally, the facility failed to update Special Care Unit resident profiles on a quarterly basis for these residents.
Deficiencies (2)
| Description |
|---|
| Failed to ensure disclosures were completed upon admission for 2 of 2 sampled residents admitted to the Special Care Unit. |
| Failed to ensure 2 of 2 sampled residents had Special Care Unit resident profiles updated on a quarterly basis. |
Report Facts
Special Care Unit census: 14
Total licensed capacity: 60
Special Care Unit capacity: 16
Residents sampled with deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Named as responsible for ensuring SCU disclosures and quarterly profiles |
| Administrator | Administrator | Named as responsible for ensuring SCU disclosures and quarterly profiles but unaware of requirements |
| Special Care Coordinator | Special Care Coordinator | Named as responsible for completing resident care plans and ensuring SCU disclosures |
Inspection Report
Follow-Up
Deficiencies: 3
Jan 22, 2020
Visit Reason
Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies.
Findings
Some deficiencies were not corrected, including corridor doors that do not latch properly and compromised one-hour fire rated walls and ceilings with unsealed holes and penetrations. Additionally, a fire collar was not properly mounted to the ceiling of the water heater room.
Deficiencies (3)
| Description |
|---|
| Corridor doors are prevented from closing quickly and latching, specifically the door to room 41 will not latch when closed. |
| Required one-hour fire rated walls and/or ceilings were compromised with holes and penetrations not sealed with approved materials. |
| A fire collar was not properly mounted to the ceiling of the water heater room. |
Inspection Report
Capacity: 60
Deficiencies: 12
Nov 6, 2019
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 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
Multiple deficiencies were identified related to physical plant requirements including lack of staff awareness of emergency release switches, missing annual fire alarm inspection report, obstructions in exit pathways, housekeeping hazards, inadequate fire safety rehearsals, fire door malfunctions, compromised fire rated walls and ceilings, improper storage near sprinkler heads, unsafe electrical system use, and use of prohibited portable electric heaters.
Deficiencies (12)
| Description |
|---|
| Staff were not aware of the location or use of the required central emergency release switch for the Special (magnetic) Locking on all exit doors. |
| Required annual fire alarm system inspection report could not be located. |
| Pathway to one of the exits from the Activity room was blocked with chairs and an easel. |
| Dust pan on sidewalk outside exit was a trip and fall hazard; two electrical outlet expanders were in use in the laundry, which are not approved. |
| Fire drill rehearsals were not conducted regularly with at least one per shift each quarter; records lacked description of rehearsals. |
| Many corridor doors did not close quickly and latch properly to resist fire and smoke passage; several doors were blocked or propped open. |
| Required one-hour fire rated walls and ceilings were compromised with unsealed holes and penetrations. |
| Fire Department Connection (FDC) sign had fallen off and was not legible. |
| No documentation of required monthly inspections for range hood fire suppression system since June. |
| Improper storage too close to fire sprinkler heads in multiple rooms, potentially negating sprinkler effectiveness. |
| Electrical system unsafe: washing machine plugged into power tap not designed for high power loads. |
| Facility failed to adhere to prohibition of portable electric heaters; one found in use in Business office. |
Report Facts
Total licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 5, 2019
Visit Reason
The Adult Care Licensure Section and the Iredell County Department of Social Services conducted an annual, follow-up and complaint investigation survey on September 4-5, 2019.
Findings
The facility failed to assure therapeutic diets were served as ordered for 3 sampled residents, failed to ensure medications were administered with proper infection control measures by medication aides, improperly disposed of sharps, and failed to complete a required drug screening for one staff member prior to hire.
Complaint Details
The survey included a complaint investigation component as indicated by the report stating the survey was an annual, follow-up and complaint investigation survey.
Deficiencies (4)
| Description |
|---|
| Facility failed to assure therapeutic diets were served as ordered for 3 residents with diet orders for puree and mechanical soft ground meat diets. |
| Medication aides did not use appropriate hand hygiene techniques and did not wear gloves when breaking tablets. |
| Medication aide disposed of insulin flex pen needles improperly in the garbage instead of sharps container. |
| Facility failed to ensure examination and screening for controlled substances was completed for one staff member prior to hire. |
Report Facts
Residents with diet order issues: 3
Medication Aides observed with infection control issues: 2
Insulin flex pen needles improperly disposed: 3
Staff without documented drug screen: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Observed not using proper hand hygiene and improperly disposing of insulin flex pen needles. |
| Staff D | Medication Aide | Observed not using proper hand hygiene and not wearing gloves when breaking tablets. |
| Staff C | Dietary Manager | Contracted employee with no documented drug screening prior to hire. |
Inspection Report
Annual Inspection
Deficiencies: 3
May 23, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 05/22/18-05/23/18 to assess compliance with regulations for Journey's Assisted Living.
Findings
The facility was found deficient in tuberculosis testing upon admission for one resident, failure to have matching therapeutic diet menus for physician-ordered diets for four residents, and inaccurate medication administration documentation for one resident regarding Lasix medication.
Deficiencies (3)
| Description |
|---|
| Facility failed to assure 1 of 5 sampled residents was tested upon admission for tuberculosis disease in compliance with control measures. |
| Facility failed to have a matching therapeutic diet menu for 4 of 5 sampled residents as evidenced by no No Concentrated Sweets (NCS) menu for Residents #1, #3 and #4 and no Puree menu for Resident #2. |
| Facility failed to assure accurate documentation on the electronic Medication Administration Record (eMAR) for 1 of 5 sampled residents regarding Lasix medication; medication was documented as administered when no medication was available. |
Report Facts
Sampled residents with TB testing deficiency: 1
Sampled residents with therapeutic diet menu deficiency: 4
Medication administration documentation errors: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Interviewed regarding tuberculosis testing and medication administration oversight |
| Administrator | Facility Administrator | Interviewed regarding tuberculosis testing, therapeutic diet menus, and medication administration |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding therapeutic diet menus and meal observations |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration and documentation errors |
| Assistant Resident Care Director | Assistant Resident Care Director (A-RCD) | Interviewed regarding medication administration and eMAR auditing |
| Director of Clinical Services | Director of Clinical Services, contracted pharmacy | Interviewed regarding eMAR system and medication orders |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 8, 2017
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
Some deficiencies were not corrected, specifically a 10"x10" hole in the wall above the mop sink in the housekeeping closet was observed, indicating the building's wall was not maintained in good repair.
Deficiencies (1)
| Description |
|---|
| Building's wall not maintained in good repair; approximately 10"x10" hole in the wall above the mop sink in housekeeping closet. |
Inspection Report
Capacity: 60
Deficiencies: 13
Sep 21, 2017
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 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
The survey identified multiple deficiencies related to physical plant maintenance including lack of current fire sprinkler inspection report, damaged ceilings and walls, improperly stored oxygen bottles, hazardous door locks, fire safety doors not latching properly, gaps in resident room doors, non-functioning emergency lighting and exit signs, exposed electrical wiring, obstructed fire sprinkler heads, and presence of prohibited portable electric heaters.
Deficiencies (13)
| Description |
|---|
| Facility failed to have current (within the calendar year) required fire sprinkler system inspection report available for review. |
| Ceiling damaged from a sprinkler leak in BreakRoom. |
| Approximately 10"x10" hole in the wall above mop sink in Housekeeping Closet. |
| Oxygen bottles stored without restraint in Room #44 and Resident Care Coordinator's office, presenting hazard. |
| A hasp type lock installed on pantry door that cannot be unlocked from inside, posing hazard. |
| Smoke resisting cross corridor doors failed to close completely and latch in multiple locations including Kitchen, Laundry, Housekeeping, Sunroom, and corridor adjacent to employees breakroom. |
| Resident room doors (#2, #3, #8, #12) have gaps approximately 1/4" or larger between door and frame stops. |
| Emergency lights in corridor adjacent to Room #41 and Dining Room did not illuminate on battery power. |
| Exit sign above cross corridor doors adjacent to Break Room did not operate on battery power. |
| Electrical outlet detached from wall exposing wiring at Kitchen dishwasher. |
| Wall mounted GFCI at sink in Resident Bath "A" did not function when tested. |
| Items stored on shelf within 18" of fire sprinkler head in Resident Care Coordinator area, impeding water flow. |
| Portable electric heater found in Business Office, prohibited by rule. |
Report Facts
Total licensed capacity: 60
Deficiency count: 13
Inspection Report
Follow-Up
Deficiencies: 1
Feb 14, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on February 14 and 15, 2017 to verify correction of previous deficiencies related to medication administration.
Findings
The facility failed to administer medication as ordered by a physician for 1 of 5 residents (Resident #2), specifically missing three consecutive doses of Lopressor due to misplaced medication and lack of notification to the physician or supervisor.
Deficiencies (1)
| Description |
|---|
| Failed to administer medication as ordered by a physician for Resident #2, missing three consecutive doses of Lopressor due to misplaced medication and failure to notify appropriate staff. |
Report Facts
Missed medication doses: 3
Residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in medication error finding for missing Resident #2's medication |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for medication order problems and notification; interviewed regarding failure to be notified of missed medication |
| Administrator | Administrator | Interviewed regarding unawareness of missed medication doses and failure to follow procedure |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 16, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Jurney's Assisted Living on November 15-16, 2016 to assess compliance with state regulations including hot water temperature requirements and resident care.
Findings
The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit in multiple resident bathroom sinks, showers, and common sinks, posing a safety risk. Additionally, the facility failed to assure follow-up with a physician to obtain a hard prescription for a narcotic sleep medication for one resident, resulting in lack of medication availability.
Severity Breakdown
Type B Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Hot water temperatures throughout the facility were not maintained between 100 and 116 degrees Fahrenheit in 5 of 10 resident bathroom sinks, 2 of 10 resident showers, and 2 of 2 common resident sinks. | Type B Violation |
| Failure to assure follow-up with a physician for 1 of 5 sampled residents to obtain a hard prescription for an ordered as-needed narcotic sleep medication, preventing pharmacy dispensing. | Type B Violation |
| Failure to assure residents received care and services adequate and appropriate in compliance with laws related to safe hot water temperatures. | Type B Violation |
Report Facts
Resident bathroom sinks with improper hot water temperature: 5
Resident showers with improper hot water temperature: 2
Common resident sinks with improper hot water temperature: 2
Resident rooms with temperature logs: 9
Resident rooms with temperature logs: 10
Resident rooms with temperature logs: 12
Resident rooms with temperature logs: 13
Water heater capacity: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Housekeeper | Performed monthly water temperature monitoring and completed logs |
| Maintenance Director | Responsible for water temperature checks, adjusting water heater temperature, and monitoring compliance | |
| Resident Care Director | Informed staff and residents about hot water temperature issues and coordinated corrective actions | |
| Medication Aide | Reported lack of Ambien medication due to insurance and pharmacy issues | |
| Administrator | Facility Administrator | Oversaw facility operations and corrective actions related to medication and water temperature issues |
Inspection Report
Capacity: 60
Deficiencies: 10
Nov 20, 2015
Visit Reason
Biennial Construction Survey conducted to ensure the facility meets the 1996 Edition of the North Carolina State Building Code, the 1996 Rules for the Licensing of Adult Care Homes, and applicable portions of the current Rules for Adult Care Homes of Seven or More Beds.
Findings
Multiple deficiencies were identified including lack of current fire alarm system inspection, unapproved installation of special locking on exits, incomplete fire plan rehearsal records, corridor doors not latching properly, dirty smoke detector sampling tube, non-functional emergency light, compromised fire rated walls and ceilings, failure to inspect fire suppression and extinguisher systems monthly, and improper ice machine drain line installation.
Deficiencies (10)
| Description |
|---|
| Current copy of a fire alarm system inspection was not available in the home for review. |
| Special (magnetic) Locking is being installed on the exits throughout the facility without approved construction documents. |
| Records of fire plan rehearsals did not include any description of what the rehearsal involved. |
| Many corridor doors are not closing well and/or latching to resist the passage of fire and smoke, including doors to Chapel, Activity room, rooms 17, 20, 21, 23, and a hole through the 20 minute rated door from kitchen to Activity room. |
| Sampling tube for the duct mounted smoke detector in the attic above the dining room was very dirty. |
| Battery powered emergency light in the Florida room would not work when tested. |
| Required one-hour fire rated walls and/or ceilings were compromised in several locations with holes and penetrations not sealed properly. |
| Range hood fire suppression system in the kitchen is not being inspected monthly as required; had not been inspected this year. |
| Fire extinguishers were not being properly inspected monthly as required; they were in locked cabinets and had not been physically inspected this year. |
| Ice machine drain line was in direct contact with the floor drain, not maintained at least 2 inches above as required by Code. |
Report Facts
Licensed capacity: 60
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