Inspection Reports for Mallard Ridge

Follow up construction survey conducted by documentation review to verify correction of previously cited deficiencies.

Based on documentation received, all previously cited deficiencies have been corrected or will be corrected by January 15, 2025, and no further action is required at this time.

The Adult Care Licensure Section conducted a follow-up survey on 12/04/24-12/06/24 and 12/09/24-12/10/24 to verify correction of previous deficiencies.

The facility failed to provide clean linens on seven resident beds, failed to provide personal care assistance to residents requiring help with bathing and grooming, failed to ensure healthcare referral and follow-up for missed appointments and medication refusals, failed to maintain menu substitution records, failed to clarify medication orders, failed to label medication containers correctly, failed to administer medications as ordered, failed to ensure accurate medication administration records, failed to ensure residents had physician orders for self-administration of medications, failed to store medications securely in resident rooms, and failed to maintain accurate controlled substance records.

This is a biennial follow-up construction survey conducted to verify correction of previously cited deficiencies related to building maintenance and safety.

Deficiencies remain in the facility including uninstalled wall base in a bedroom, failure to maintain fire safety systems due to improper sealing of pipe penetrations, and plumbing issues such as missing toilet tank lid, unsecured commode, and a separated sink in resident restrooms.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from 07/09/24 through 07/12/24.

The facility was found deficient in multiple areas including failure to complete criminal background checks, drug screenings, infection control training for staff, failure to provide personal care and supervision according to care plans, failure to ensure health care referral and follow-up for residents, medication administration errors, and inaccurate controlled substance records.

The visit included a complaint investigation related to personal care, medication administration, and staff qualifications.

The inspection visit was conducted as a complaint investigation to address allegations related to medication administration, health care follow-up, and resident care concerns at the facility.

The facility failed to ensure medications were administered as prescribed for 2 of 6 sampled residents, failed to provide appropriate referral and follow-up for routine and acute health care needs, including suprapubic catheter care and wound care, resulting in serious harm including multiple hospitalizations and wounds. There were failures in medication reordering, documentation, and provider notification.

The complaint investigation substantiated failures in medication administration and health care follow-up for residents #1 and #2, including failure to reorder medications, failure to notify providers of missed doses or elevated blood glucose, and failure to provide catheter and wound care resulting in serious harm to Resident #1.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual survey and complaint investigation on 05/07/24 - 05/09/24. The complaint investigation was initiated by the Buncombe County Department of Social Services on 04/30/24.

The facility failed to ensure medication aides completed required training and testing, failed to have an Activity Director, failed to complete required background and registry checks, failed to provide diabetic care training, failed to ensure an Administrator or Administrator-In-Charge was present at all times, failed to notify primary care providers of medication errors and refusals, failed to administer medications as prescribed, failed to ensure therapeutic diet menus, failed to provide adequate activities for residents, and failed to prevent staff from sleeping during shifts.

Complaint investigation initiated by Buncombe County Department of Social Services on 04/30/24 related to medication aide qualifications and medication administration.

This document is a Construction Section Biennial Survey conducted to assess the physical plant conditions of the facility, including housekeeping, furnishings, building equipment, fire safety, plumbing, electrical systems, and exhaust ventilation.

The survey found multiple deficiencies including unclean and damaged walls and floors, missing or damaged furnishings such as towel bars, unsafe fire safety penetrations, plumbing issues including non-functional toilets and rusted water heaters, electrical hazards due to missing cover plates, and inadequate exhaust ventilation in certain areas.

Biennial Construction Section Survey conducted to assess conformance with the North Carolina State Building Code, Homes for the Aged and Infirm Minimum Desired Standards, and Rules for Adult Care Homes of Seven or More Beds.

Multiple deficiencies were cited including lack of ground fault protection at electrical outlets near water sources, failure to maintain fire safety systems with gaps in fire rated walls, plumbing system issues such as rusted water heaters and missing floor drain cover, and non-operable exhaust fans in visitor restrooms.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual survey, follow-up, and complaint investigation from 03/09/23 to 03/10/23 at Chase Samaritan Assisted Living.

The facility failed to have a qualified activity director, resulting in lack of resident activities and engagement. Additionally, the facility failed to ensure that one resident had physician orders for self-administration of multiple medications, with medications found in the resident's room without proper authorization.

The visit included a complaint investigation component as stated in the initial comments, but no substantiation status is provided in the report.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual survey and complaint investigation on 03/01/22 - 03/02/22. The complaint investigation was initiated by the Buncombe County Department of Social Services on 02/25/22.

The facility failed to maintain clean and well-repaired floors and ceilings, with leaking toilets and moldy ceilings in shared bathrooms. Water temperatures in resident bathroom sinks exceeded the maximum allowed temperature of 116°F. The facility also failed to provide an adequate activities program, with no activities offered and no activity director employed.

The complaint investigation was initiated by the Buncombe County Department of Social Services on 02/25/22 and conducted concurrently with the annual survey on 03/01/22 - 03/02/22.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual and follow-up survey and complaint investigation on 01/22/20 - 01/23/20.

The facility was found deficient in multiple areas including failure to maintain the women's shower room heater, failure to ensure tuberculosis testing for contracted staff, failure to verify staff qualifications via the Health Care Personnel Registry, inadequate resident activity programming, and failure to administer prescribed medications to a resident resulting in a Type B violation.

The visit included a complaint investigation as indicated by the report stating it was an annual and follow-up survey and complaint investigation conducted on 01/22/20 - 01/23/20.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted a follow-up survey to verify correction of a previous Type B medication administration violation.

The facility failed to administer medications as ordered for 1 of 13 residents observed during the medication pass, resulting in a 5% medication administration error rate. The medication aide administered only one capsule of clindamycin instead of two as ordered for Resident #6.

Biennial Construction Section Survey to assess conformance with the North Carolina State Building Code, Homes for the Aged and Infirm Minimum Desired Standards, and Rules for Adult Care Homes of Seven or More Beds.

Multiple deficiencies were found related to unsafe and non-operational plumbing and mechanical equipment, including unsecured toilets, lack of vacuum breaker on salon sink, non-operational exhaust system, and a recessed plumbing floor clean-out creating a trip hazard.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted an annual survey on August 15 - 16, 2017.

The facility failed to ensure food and beverages were protected from contamination, substitutions on the menu were appropriate and documented, and residents with physician orders for puree diets were not served as ordered.

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

One deficiency related to compromised one-hour fire rated walls and ceilings was not corrected, specifically the attic access door in the linen closet was not positioned correctly to maintain the ceiling rating.

Biennial Construction Survey conducted to assess conformance with the 1967 edition of the North Carolina State Building Code, the 1971 Homes for the Aged and Infirm Minimum Desired Standards and Regulations, and applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds.

Multiple deficiencies were identified including lack of current fire alarm inspection, missing hand grips in bathrooms, hazardous door hardware, inadequate documentation of fire suppression system inspections, plumbing issues, fire safety rehearsal record deficiencies, fire alarm system maintenance trouble, corridor doors not closing or latching properly, and compromised fire-rated walls and ceilings with unsealed penetrations.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted a follow-up survey and complaint investigation on December 4, 7-8, 10-11 and 16, 2015.

The facility failed to assure total operation related to resident rights, medication aide training, medication administration, controlled substances, pharmaceutical care, transferring medications to another container, and controlled substance medication storage. Significant discrepancies were found in medication administration and controlled substance accountability, including 1,203 tablets of Oxycodone unaccounted for. Privacy issues were noted in the female common bathroom. The facility failed to ensure proper training for a re-hired medication aide and failed to maintain controlled substances under locked security.

The visit was a follow-up survey and complaint investigation conducted by the Adult Care Licensure Section and the Buncombe County Department of Social Services on December 4, 7-8, 10-11 and 16, 2015.

The Adult Care Licensure Section and the Buncombe County Department of Social Services conducted a follow-up survey to verify correction of previous deficiencies related to resident rights and medication administration.

The facility failed to provide a reasonable response to requests for a smoke-free area for non-smoking residents and failed to assure medications (Augmentin, Neurontin, and Oxycodone) were administered as ordered to 3 of 7 sampled residents. Smoking was observed in non-smoking areas by residents and staff, and medication administration records showed missed or undocumented doses.