Inspection Report
Annual Inspection
Deficiencies: 2
Nov 13, 2024
Visit Reason
The Adult Care Licensure Section and the Durham County Department of Social Services conducted an annual survey of the facility on 11/13/2024 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure that one of three sampled residents was tested for tuberculosis upon admission and failed to administer medications as ordered for the same resident, including fluid reduction medication, blood thinner, pain medication, and inhaler. Multiple interviews and record reviews revealed medication administration errors and documentation issues.
Deficiencies (2)
| Description |
|---|
| Failed to ensure that 1 of 3 sampled residents was tested for tuberculosis upon admission. |
| Failed to administer medications as ordered for 1 of 3 sampled residents related to a fluid reduction medication, a blood thinner, a pain medication, and an inhaler. |
Report Facts
Sampled residents: 3
Medication cards dispensed: 60
Medication cards dispensed: 60
Medication cards dispensed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Responsible for residents' records and ensuring TB skin tests were completed; conducted monthly record audits; involved in medication cart audits and ordering | |
| Administrator | Responsible for ensuring TB skin tests were completed; conducted monthly medication cart audits; monitored medication administration documentation | |
| Medication Aide | Administered medications to Resident #3; responsible for medication cart audits and checking medication availability; involved in medication administration and documentation | |
| Pharmacist | Provided information about medication orders, dispensing, and cycle fills for Resident #3 | |
| Primary Care Provider (PCP) | Provided medical orders and information regarding Resident #3's medications and conditions |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Apr 18, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility to assess compliance with licensing and safety regulations.
Findings
The facility failed to notify the Division of Health Service Regulation that the residents' evacuation capabilities differed from those listed on the license. Six residents required verbal prompting to evacuate during fire drills and did not respond independently. The facility was licensed for 6 ambulatory residents but all sampled residents had cognitive impairments affecting their evacuation ability. Staff always assisted residents during fire drills and did not use the fire alarm, instead yelling 'fire' to prompt evacuation.
Severity Breakdown
Type A2 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify DHSR that residents' evacuation capabilities differed from those listed on the license; residents required verbal prompting to evacuate during fire drills. | Type A2 Violation |
| Facility failed to ensure residents' evacuation capabilities were in accordance with the evacuation capability listed on the license for 6 of 6 sampled residents who did not respond to fire drills independently. | Type A2 Violation |
Report Facts
Residents present: 6
Licensed capacity: 6
Fire drill evacuation times: 5
Fire drill evacuation times: 6
Correction date: 2023
Inspection Report
Annual Inspection
Deficiencies: 2
Apr 14, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 14, 2021.
Findings
The facility failed to ensure that one of three sampled staff and one of three sampled residents had complete tuberculosis (TB) testing documentation in compliance with the control measures adopted by the Commission for Health Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 1 of 3 sampled staff (Staff A) had documentation of being tested for tuberculosis disease in compliance with control measures. |
| Facility failed to ensure 1 of 3 sampled residents (#2) was tested for tuberculosis disease in compliance with control measures. |
Report Facts
Sampled staff: 3
Sampled residents: 3
Staff A TB skin test date: Jan 29, 2020
Staff A TB skin test read date: Feb 1, 2020
Resident #2 admission date: Feb 27, 2020
Resident #2 TB skin test date: Feb 28, 2020
Resident #2 TB skin test read date: Mar 2, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in deficiency related to incomplete TB testing documentation |
| Administrator | Responsible for ensuring TB testing completion and documentation for staff and residents |
Inspection Report
Annual Inspection
Deficiencies: 1
Sep 21, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Autumn's Way Care Home on September 21, 2017.
Findings
The facility failed to ensure that one of two medication aides (Staff B) who began performing medication aide duties after October 1, 2013, had completed the required 5/10 or 15 hour medication aide training program or had verification of previous employment as a medication aide. Staff B had documentation of passing the medication aide test and clinical skills checklists but lacked documentation of required training and employment verification.
Deficiencies (1)
| Description |
|---|
| Failure to assure that medication aide (Staff B) completed the required 5/10 or 15 hour medication aide training program or had verification of previous employment as a medication aide. |
Report Facts
Dates of medication administration documented by Staff B: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Named in deficiency for not completing required medication aide training and employment verification. |
| Administrator | Interviewed regarding medication aide training and verification responsibilities. |
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