Inspection Reports for Legacy Heights

This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously noted deficiencies and to identify any new deficiencies.

The facility was found to have multiple deficiencies including lack of ground fault interrupters on electrical outlets in wet locations, unsafe and non-operating smoke-tight corridor doors, gaps in fire rated ceiling assemblies, fire alarm control panel trouble indications, and numerous exhaust fans not working throughout the facility.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey of Legacy Heights Senior Living Community on October 13-14, 2024.

The facility failed to ensure food stored and served to residents was protected from contamination, with multiple instances of unlabeled and undated food items and ceiling vents covered with black and gray particles. The kitchen vents and storage vents required cleaning and repair.

The report documents a biennial construction section survey conducted to assess compliance with building codes and adult care home regulations.

Multiple deficiencies were identified including lack of ground fault interrupters in electrical outlets near water sources, smoke-tight corridor doors not fitting properly, fire safety systems and emergency equipment not maintained in safe operating condition, and numerous exhaust fans in bathrooms, laundries, and housekeeping areas not working.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual and follow-up survey from March 7, 2023 through March 9, 2023.

The facility failed to provide adequate supervision for a high-risk resident with multiple falls resulting in head injuries, failed to administer medications as ordered for two residents, including omission of a medication for indigestion and inaccurate medication administration records for blood pressure and vitamin D treatments.

The Adult Care Licensure Section conducted an annual, follow-up, and complaint investigation survey on May 18-19, 2021.

The facility was found deficient in multiple areas including failure to update resident assessments and care plans after significant changes, failure to ensure physician referral and follow-up for medications, failure to provide timely reports to the Health Care Personnel Registry for alleged abuse, failure to provide required disclosure information for admission to the Special Care Unit, and failure to ensure medication aides completed required training.

The complaint investigation included allegations of abuse to Resident #1, specifically that a staff member struck the resident. The investigation found the resident was not struck but was aggressively struck with a teddy bear. The incident was not timely reported by staff witnesses. The facility terminated the involved staff. The facility failed to provide the required five-day report to the Health Care Personnel Registry investigator.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a complaint investigation with onsite visits on 03/03/21 and 03/05/21, and a telephone exit on 03/09/21 regarding COVID-19 infection prevention and control practices.

The facility failed to implement and maintain CDC, NC DHHS, and local health department COVID-19 guidance during an outbreak, including weekly testing of residents and staff and cohorting of COVID-19 positive residents with dedicated staff. Residents who tested positive were not cohorted in designated areas, and staff provided care to both positive and negative residents without proper separation, increasing risk of transmission.

Complaint investigation triggered by concerns about COVID-19 infection prevention and control practices during an outbreak at the facility, including testing and cohorting failures.

The Adult Care Licensure Section conducted an annual and follow-up survey on January 14-15, 2019 to assess compliance with health care and medication administration regulations.

The facility failed to implement physician orders to obtain a pulse prior to administering medication for one resident, and failed to administer the correct dose of a medication for gastroesophageal reflux disease for the same resident. Documentation and communication errors with the pharmacy and medication aides contributed to these deficiencies.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 06/26/18-06/28/18 to assess compliance with health care referral, medication administration, and follow-up requirements.

The facility failed to assure health care referral and follow-up for 3 of 9 sampled residents related to medication crushing orders and fingerstick blood sugar (FSBS) results outside parameters without physician notification. Medication administration errors were observed in 7 of 9 residents, including insulin administration errors, failure to administer ordered medications, and failure to follow medication administration policies. Documentation errors on the Medication Administration Record (MAR) were also noted.

Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.

The corridor was found not to be maintained free of obstructions, with two medication carts stored in the second floor corridor reducing the clear width to 3 feet 4 inches, which is below the required 6 feet clearance.

The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.

Multiple deficiencies were identified related to physical plant, safety, housekeeping, fire safety, and equipment maintenance in both the Assisted Living and Special Care Buildings. Issues included improperly marked and locked exits, corridor obstructions, fire safety system malfunctions, housekeeping hazards, improper storage, and failure to maintain required exhaust ventilation and heating system standards.

The Adult Care Licensure Section and the Mecklenburg County DSS conducted a follow-up survey on March 7-8, 2018 to verify correction of previous deficiencies related to medication administration and notification of primary care providers.

The facility failed to assure the primary care provider was notified regarding medications not administered as ordered for 4 of 7 residents, and failed to assure medications were administered as ordered for 5 of 7 residents. Documentation on the Medication Administration Record (MAR) was also inaccurate for 2 residents. These failures were detrimental to resident health and safety and constitute a Type B Violation.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on November 14-15, 2017 with a telephone exit on November 16, 2017.

The facility failed to administer medications as ordered for 1 of 4 residents observed during medication passes and 3 of 7 sampled residents, including errors with blood pressure medication, sliding scale insulin, thyroid supplement, anxiety medication, and medication for fluid retention. This failure put residents at risk for adverse health effects including increased blood pressure, hypoglycemia, falls, agitation, and hypothyroid symptoms.

Follow-up survey conducted to verify correction of previously identified deficiencies.

The fire safety was not maintained in a safe and operating condition due to unsealed PVC vents penetrating fire-resistance-rated ceiling assemblies in two furnace rooms, allowing potential spread of fire and smoke.

Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code.

Multiple deficiencies were identified including lack of hand grips in bathrooms, poor housekeeping and maintenance issues, fire safety hazards such as improperly maintained fire extinguishers, sprinkler system deficiencies, fire-resistance-rated construction penetrations, malfunctioning emergency exit signs, unsafe interior doors, electrical hazards, prohibited portable electric heaters, and inadequate exhaust ventilation in certain areas.