Inspection Reports for Marjorie McCune Memorial Center
101 Lions Way Black Mountain, NC 28711, Black Mountain, NC, 28711
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the Marjorie McCune Memorial Center from 04/25/23 to 04/26/23 to assess compliance with medication administration and other regulatory requirements.
Findings
The facility failed to administer medications as ordered for 2 of 5 sampled residents, including failure to administer insulin correctly for Resident #2 and failure to administer antihypertensive, antacid, and blood thinner medications for Resident #1. These failures placed residents at risk of serious health complications.
Deficiencies (2)
Failure to administer insulin as ordered for Resident #2, including not administering insulin when blood sugar was greater than 80 and administering insulin when blood sugar was less than 80.
Failure to administer antihypertensive medication (amlodipine), blood thinner (clopidogrel), and antacid (famotidine) as ordered for Resident #1 due to medication availability issues.
Report Facts
Instances of insulin not administered: 13
Instances of amlodipine not administered: 15
Instances of lisinopril not administered: 10
Instances of clopidogrel not administered: 13
Instances of famotidine not administered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide Supervisor | Responsible for auditing medication carts and contacting pharmacies regarding medication availability; interviewed regarding medication administration failures. | |
| Clinical Services Director | Responsible for auditing eMARs and medication administration; interviewed regarding medication administration failures. | |
| Administrator | Interviewed regarding knowledge of medication administration failures and facility policies. | |
| Medication Aide | Interviewed about failure to administer insulin as ordered for Resident #2. | |
| Physician's Assistant (contracted) | Interviewed regarding medical risks related to medication administration failures for Residents #1 and #2. |
Inspection Report
Capacity: 64
Deficiencies: 13
Date: Nov 21, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with the North Carolina State Building Code, licensing rules for Adult Care Homes, and applicable regulations for Adult Care Homes of Seven or More Beds.
Findings
Multiple deficiencies were identified including corridor obstructions, hazards related to water backflow and unsecured oxygen cylinders, inadequate fire safety rehearsals, breaches in fire-resistance-rated walls and doors, malfunctioning emergency lighting, unsafe electrical receptacles, improper storage practices, blocked or held-open fire doors, and failure to maintain required exhaust ventilation systems.
Deficiencies (13)
Corridors are obstructed by an unattended medication cart and sofa reducing corridor width to less than three feet.
Cold-water line at exterior can wash lacks a vacuum breaker to prevent backflow contamination.
Portable oxygen cylinders are stored unsecured in plastic crates in the oxygen room.
Fire safety rehearsals are not performed regularly on each shift quarterly and records lack descriptions of rehearsals.
Fire-resistance-rated walls have breaches due to holes in doors where hardware was removed.
Emergency exit sign/emergency light unit does not illuminate on backup power.
Fire wall doors do not close completely or latch properly to restrict fire and smoke.
Smoke tight corridor doors have gaps, hinge binding, or holes compromising smoke containment.
Gaps around conduits penetrating fire-resistance-rated ceiling assemblies are not firestopped.
Electrical power receptacle near sink in medication room is not protected against ground faults.
Materials stored within 24 inches of ceiling in maintenance office, posing fire safety hazard.
Corridor doors are blocked or held open by unapproved devices or objects, compromising fire safety.
Exhaust ventilation system in bedroom 120 bathroom does not work.
Report Facts
Total licensed capacity: 64
Inspection Report
Capacity: 64
Deficiencies: 7
Date: Sep 7, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a Construction Section Biennial Survey conducted on 2017-09-07 at Marjorie McCune Memorial Center, requiring the facility to meet applicable building codes and adult care home regulations.
Findings
The survey identified multiple deficiencies including improper storage of portable medical oxygen cylinders, lack of vacuum breakers on shower hoses, inadequate fire safety rehearsals documentation, malfunctioning smoke barrier doors and emergency lighting, compromised fire-rated walls, and non-functioning exhaust ventilation.
Deficiencies (7)
Improper handling and storage of portable medical oxygen cylinders, including storage in beverage crates and unapproved plastic bins.
Shower wand hoses in multiple locations were long enough to reach sink basins without vacuum breakers, risking siphoning contaminated water into the water system.
Fire safety rehearsal records lacked sufficient description of what the rehearsals involved.
Corridor smoke barrier doors failed to close and latch properly, including a hole by the latchset on a door to room 111.
Battery powered emergency light near room 116 did not work when tested, risking resident and staff safety.
One-hour fire rated walls and ceilings were compromised by unsealed holes in the ceiling of the C Hall furnace room.
Exhaust ventilation was not maintained in working condition; the exhaust fan was removed from the housing in the housekeeping room.
Report Facts
Licensed capacity: 64
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 4, 2016
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Follow-up survey conducted to verify correction of previously identified deficiencies at Marjorie McCune Memorial Center.
Findings
Some deficiencies were not corrected. Specifically, corridor doors, including the double doors to the dining room, were not closing well or latching properly to resist the passage of fire and smoke.
Deficiencies (1)
Corridor doors are not closing well and/or latching to resist the passage of fire and smoke; double doors to the dining room lack hardware to latch when closed.
Inspection Report
Capacity: 64
Deficiencies: 10
Date: Dec 29, 2015
Visit Reason
This is a biennial construction survey conducted to ensure the facility meets the 1978 Edition of the North Carolina State Building Code, the 1977 Rules for Licensing Adult Care Homes, and applicable portions of the 2005 Regulations for Adult Care Homes of Seven or More Beds.
Findings
The survey identified multiple physical plant deficiencies including obstructed exit corridors, trip hazards outside the premises, dirty exhaust fan grills, lack of vacuum breakers on hose bibs, failure to inspect the kitchen fire suppression system monthly, compromised fire rated walls and ceilings, malfunctioning corridor doors, unmaintained smoke and heat detectors, and cracked electrical receptacles.
Deficiencies (10)
Exit corridor near the salon was obstructed to only 3 feet 10 inches of clear space, less than the required 6 feet.
A sewer cleanout cap projected about an inch above the sidewalk at the right rear of the facility, creating a trip hazard.
Ceiling grill for the exhaust fan in the storage room on C Hall was very dirty.
Hose bibs at the can wash wand area were not equipped with vacuum breakers.
Range hood fire suppression system in the kitchen was not inspected monthly; last inspection was in July.
Required one-hour fire rated walls and ceilings were compromised with holes, cracks, and unsealed penetrations in multiple locations.
Corridor doors were not closing well or latching properly, including sagged double doors to the dining room and holes in fire doors.
Duct mounted smoke detector in mechanical room on C Hall lacked an access door for inspection and maintenance.
Heat detector in the attic over the kitchen was not properly mounted.
Electrical receptacle in the corridor near room 102 had a cracked face, posing an electrical hazard.
Report Facts
Total licensed capacity: 64
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