Inspection Reports for Open Arms Retirement Center

The visit included a complaint investigation as well as a follow-up survey.

The facility failed to maintain floors in good repair in the assisted living hallways and failed to administer medications as ordered for multiple residents, including controlled substances and topical patches. Medications were also administered late beyond the allowed time frame for all observed residents in the assisted living side.

Complaint investigation initiated by the Hoke County Department of Social Services on 05/30/25.

The facility failed to maintain an approved sanitation classification, had unclean and cluttered common bathrooms, a non-operational call bell system, water temperatures out of range, failure to implement physician orders for weekly blood pressure and pulse checks, medication administration errors, inaccurate medication administration records, and missing resident records.

Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, maintenance, and safety equipment. Issues included non-compliance with fire safety door locking and release mechanisms, lack of current fire and building safety inspection reports, unlocked janitor closets, missing wanderer alarms, unsafe outside premises and lighting, damaged walls and furnishings, hazards in housekeeping and kitchen areas, failure to conduct quarterly fire drills, malfunctioning fire safety and electrical equipment, and inadequate exhaust ventilation in specified areas.

The complaint investigation was initiated by Hoke County Department of Social Services on 02/21/25.

The facility failed to ensure oxygen cylinders were stored safely, the front entrance door was in disrepair and insecure, hot water temperatures exceeded safe limits, staff competency validations were incomplete, orders for weights and vital signs were not consistently implemented, licensed health professional support evaluations were not completed quarterly, medications were not administered as ordered to some residents, medication administration lacked proper observation and infection control measures.

The complaint investigation substantiated that the facility failed to ensure Resident #5 was seen by home health wound care nurse and at the pain clinic as ordered, resulting in open wounds, exposed orthopedic hardware, pain, and infection. The exposed screws increased from none to five over eight weeks. The facility also failed to maintain a working call bell system for assisted living and special care unit residents.

The facility failed to ensure timely health care referrals and follow-ups for Resident #5, leading to exposed orthopedic screws and hardware, pain, infection, and deterioration of the resident's condition. Additional findings included failure to ensure call bell systems were working properly for assisted living and special care unit residents.

The facility failed to maintain a hazard-free environment on the special care unit, failed to notify a resident's primary care physician regarding a worsening wound, and failed to ensure medications were administered as ordered, including errors with medication administration and pain patch application.

Complaint investigation was part of the visit due to the incident involving Resident #3 who sustained burns from unsupervised smoking.

The facility failed to provide adequate supervision for a resident in the Special Care Unit who was allowed to smoke unsupervised, resulting in severe burns and hospitalization. Additionally, medication administration errors were identified for two residents, and documentation for the use of bedrails as restraints was incomplete.

The facility failed to meet the NC State Building Code requirements for emergency release switches on locked unit exit doors, as not all staff responsible for evacuation carried keys. During the survey, staff were given the emergency release switch keys and the administrator planned training on their use and safety procedures.

Complaint investigations were initiated by the Hoke County Department of Social Services on 04/02/19, 05/02/19, and 05/28/19.

The facility failed to provide personal care assistance related to incontinence care for 3 of 5 sampled residents. The facility failed to provide supervision for 2 of 6 sampled residents who had multiple falls resulting in injuries and emergency visits. The facility failed to assure infection control measures during medication administration by 3 medication aides. The facility failed to assure residents who self-administer medications had physician orders. The facility failed to report suspected physical abuse to the Health Care Personnel Registry within required timeframes. The facility failed to use physical restraints according to physician orders and failed to notify the physician within 24 hours of emergency restraint use. The facility failed to ensure special care unit staff received required orientation training.

The facility was found not in compliance with licensure and building code requirements regarding electromagnetic lock emergency release switches. The existing momentary switches rely on electronic circuits and do not meet the requirement for an emergency release switch that does not depend on relays or other devices. A resolution was discussed with the security contractor and plans for corrective action were initiated.

The survey identified multiple deficiencies related to physical plant requirements including noncompliance with building code requirements for electromagnetic locks, corridor obstructions, housekeeping and furnishings not kept in good repair, presence of unpleasant odors, hazards related to unsecured oxygen bottles, missing parts on exit doors, failure to maintain emergency lighting and exit signs, fire safety equipment issues including fire doors not latching properly, unapproved devices impeding fire doors, holes and gaps in fire resistant ceilings and walls, failure to maintain clear space below sprinklers, and unsafe electrical equipment conditions.

The facility failed to ensure hazardous chemicals were stored in locked areas accessible to residents, failed to coordinate referral appointments for 3 of 5 sampled residents, and failed to assure 2 of 3 residents who self-administered medications had physicians' orders and proper medication labeling.

The complaint investigation was initiated by the Hoke County Department of Social Services on 10/13/17 and included follow-up survey from 01/23/18 to 01/26/18.

The facility failed to assure bleaches, cleaners, and disinfectants were stored in a locked area and not accessible to residents in the assisted living side of the facility. The facility failed to provide supervision for 3 of 9 sampled residents resulting in two residents eloping without staff knowledge and one wandering into other residents' rooms. The facility failed to assure physician notification and follow-up care for 2 of 7 sampled residents related to compression stockings and eye drops for glaucoma. The facility failed to administer medications as ordered for 2 of 6 residents observed during medication passes, including insulin and topical antifungal powder errors. The facility failed to assure 3 of 3 residents who self-administered medications had physicians' orders to do so. The facility failed to assure physical restraints were used only after an assessment and care planning process and with a physician's order. The facility failed to communicate with 2 residents who only spoke Spanish, resulting in feelings of loneliness and agitation.

The inspection identified multiple deficiencies including walls not kept in good repair, facility hazards such as improper use of extension cords and blocked exit gates, failure to maintain fire alarm and emergency lighting equipment in safe operating condition, doors that do not latch properly, and failure to provide required exhaust ventilation in specified areas.

The facility failed to ensure that staff and residents were properly tested for tuberculosis according to state regulations, including failure to complete two-step TB testing for a staff member and failure to have a TB test upon admission for a resident. Additionally, the facility did not provide mandatory annual infection prevention training for medication aides as required by state law.