Inspection Reports for
Patriot Living of Yadkinville
409 Harrison Avenue Yadkinville, NC 27055, Yadkinville, NC, 27055
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
104% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
44 residents
Based on a September 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
This was a Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is needed.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 27, 2024
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation from 03/26/24 through 03/27/24 regarding medication administration issues at the facility.
Complaint Details
The investigation was initiated due to complaints regarding medication administration errors involving three residents. The complaint was substantiated based on observations, record reviews, and interviews confirming medication administration failures and order discrepancies.
Findings
The facility failed to administer medications as ordered for 3 of 6 sampled residents, including incorrect dosing of losartan potassium for Resident #1, failure to administer pantoprazole for Resident #3 despite an active order, and discontinuation errors with hydroxyzine for Resident #6. Multiple interviews and record reviews revealed discrepancies between medication orders, administration records, and medication availability.
Deficiencies (3)
Failed to administer losartan potassium as ordered for Resident #1, including cutting 100mg tablets in half when 50mg tablets were ordered.
Failed to administer pantoprazole 40mg daily for Resident #3 despite an active order; medication was discontinued in the eMAR erroneously without physician order.
Erroneous discontinuation of hydroxyzine HCL 50mg twice daily for Resident #6 without physician order, resulting in missed doses.
Report Facts
Residents sampled: 6
Residents with medication administration failures: 3
Tablets remaining: 86
Tablets remaining: 90
Medication doses missed: 0
Hydroxyzine doses administered: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operations Manager | Operations Manager (OM) | Responsible for medication order audits and acknowledged erroneous discontinuation of medications |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for medication cart and eMAR audits; aware of medication discrepancies |
| Medication Aide | Medication Aide (MA) | Administered medications; involved in cutting tablets and unaware of correct dosages/orders |
| Administrator | Administrator | Unaware of medication discrepancies and expected staff to follow eMAR orders |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Feb 14, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 02/14/24 to 02/15/24 to verify correction of previous deficiencies.
Findings
The facility failed to provide clean bed linens for Resident #3 as required, failed to complete a timely assessment for Resident #2 after a significant decline and multiple falls, failed to provide adequate supervision for Resident #4 who had multiple falls resulting in injury, and failed to serve therapeutic diets as ordered for Residents #1, #2, and #3.
Deficiencies (4)
Facility failed to provide a clean top and bottom sheet for Resident #3 with bed changed at least once a week.
Facility failed to ensure an assessment was completed within 10 days for Resident #2 following a significant decline and frequent falls.
Facility failed to provide supervision for Resident #4 who was a high fall risk and had four falls in two months resulting in pain and a closed head injury.
Facility failed to serve therapeutic diets as ordered by the physician for Residents #1, #2, and #3 including no concentrated sweets diet, no added salt, mechanical altered diet, and 2% milk or less at every meal.
Report Facts
linen change opportunities: 12
linen change opportunities: 9
linen change opportunities: 14
linen change opportunities: 6
falls: 5
falls: 4
deficiencies cited: 4
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
Report of Construction Section Complaint Follow Up and a Biennial Survey conducted on January 31, 2024.
Findings
Corrections have been made. No further action is needed. Biennial Survey deficiencies will be documented on a separate additional survey.
Inspection Report
Capacity: 50
Deficiencies: 6
Date: Jan 31, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety regulations applicable to the facility.
Findings
Multiple deficiencies were cited including failure to comply with code requirements for emergency release switch keys, lack of current sanitation and fire safety inspection reports, absence of wrist type lever handles on medication preparation sinks, improper storage of oxygen bottles presenting hazards, missing documentation for fire extinguisher inspections, and non-operable exhaust fans in several restrooms and shower areas.
Deficiencies (6)
Facility is not in compliance with code requirements at time of construction; emergency release switch keys not carried by responsible staff.
Facility failed to maintain current sanitation and fire safety inspection reports; no records of fire alarm system inspection.
Handwashing sinks at drug storage area not equipped with wrist type lever handles.
Oxygen bottles improperly stored without restraint, presenting hazard.
Portable fire extinguishers lacked required routine inspection documentation.
Facility not maintaining exhaust fans in operable condition in multiple restrooms and shower areas.
Report Facts
Licensed bed capacity: 50
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a complaint investigation from 11/01/23 through 11/03/23. The complaint was initiated by Yadkin County Department of Social Services on 10/20/23.
Complaint Details
Complaint investigation initiated by Yadkin County Department of Social Services on 10/20/23 was part of the annual survey visit from 11/01/23 to 11/03/23.
Findings
The facility failed to provide adequate supervision for Resident #3 who had multiple falls resulting in injury, failed to ensure referral and follow-up for acute health care needs for Residents #1 and #3, failed to follow up on Licensed Health Professional Support recommendations for Resident #3, and failed to serve therapeutic diets as ordered for Resident #4.
Deficiencies (4)
Failed to provide supervision for Resident #3 who had a history of falls resulting in an ankle fracture.
Failed to ensure referral and follow-up to meet acute health care needs for Residents #1 and #3 related to medication refusals and lack of notification to PCP about weight increases.
Failed to ensure follow-up on recommendations by Licensed Health Professional Support nurse for Resident #3 related to oxygen monitoring and order changes.
Failed to serve therapeutic diets as ordered for Resident #4 including no concentrated sweets diet, no added table salt, second servings of green vegetables, and 2% milk with each meal.
Report Facts
Falls: 5
Weight gain: 4.4
Weight gain: 6.6
Weight gain: 5
Weight gain: 3.2
Weight gain: 6.6
Weight gain: 6
Medication refusals: 13
Medication doses remaining: 2
Medication supply: 30
Medication supply: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Named in multiple interviews related to fall supervision, medication refusals, and follow-up on LHPS recommendations. |
| Operations Manager | Operations Manager (OM) | Responsible for ensuring incident reports, follow-up on LHPS recommendations, and medication refusals notifications. |
| Medication Aide | Medication Aide (MA) | Named in interviews related to fall supervision, medication administration, and oxygen monitoring. |
| Personal Care Aide | Personal Care Aide (PCA) | Named in interviews related to fall supervision and resident assistance. |
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 2
Date: Aug 14, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that the facility had a fire. The complaint was substantiated.
Complaint Details
The complaint alleged that the facility had a fire. The complaint was substantiated.
Findings
The facility was found to have deficiencies related to fire safety and ventilation. Specifically, the fire alarm system was not maintained in a safe and operating condition, and mechanical ventilation was missing in required spaces such as the ladies bathroom near Bedroom 13.
Deficiencies (2)
Fire alarm system is not maintained in a safe and operating condition, affecting early detection and activation.
Facility failed to provide mechanical ventilation for required spaces; exhaust fan removed from ladies bathroom near Bedroom 13.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 23, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 03/22/23 to 03/23/23 to verify correction of previous deficiencies and assess compliance with regulations.
Findings
The facility failed to ensure staff qualifications were properly verified, failed to ensure adequate health care follow-up for residents with choking and behavioral issues, failed to implement physician's orders for continuous oxygen therapy for a resident, failed to maintain residents' rights regarding mail and package handling, failed to administer medications as ordered for two residents, and failed to provide medications for a resident during a temporary leave of absence.
Deficiencies (6)
Facility failed to ensure 1 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire.
Facility failed to ensure health care follow-up to meet the needs of 2 of 5 sampled residents who had choking episodes and increased behaviors.
Facility failed to implement physician's orders for continuous oxygen therapy for 1 of 5 sampled residents who had an order for continuous oxygen but was not wearing it as ordered.
Facility failed to ensure 1 of 5 sampled residents was treated with respect and dignity by receiving mail and packages unopened.
Facility failed to administer medications ordered for 2 of 5 sampled residents who had orders for as needed diuretic and to discontinue an acid reflux medication but were not administered or discontinued accordingly.
Facility failed to ensure provision of medication for 1 of 5 sampled residents who went on temporary leave for three weeks without his medications, resulting in hospitalization and potential withdrawal symptoms.
Report Facts
Weight gain: 3.1
Weight gain: 2.2
Weight gain: 4.2
Weight gain: 2
Weight gain: 3.7
Weight gain: 2.4
Weight gain: 2.1
Medication count: 18
Medication count: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Resident Care Coordinator | Named in finding for failure to verify Health Care Personnel Registry check prior to hire |
| Administrator | Interviewed regarding staff qualifications, health care follow-up, oxygen therapy, residents' rights, medication administration, and leave of absence medication provision | |
| Business Office Manager | Responsible for maintaining personnel records and ensuring HCPR checks were completed upon hire | |
| Medication Aide | MA | Documented choking incidents, oxygen therapy refusals, medication administration, and resident interactions |
| Health and Wellness Coordinator | HWC | Responsible for reviewing medication orders, oxygen therapy orders, and resident care coordination |
| Resident Care Coordinator | RCC | Responsible for processing medication orders, notifying PCPs, and coordinating resident care |
| Mental Health Provider | MHP | Interviewed regarding resident behavioral health and medication management |
| Activity Director | AD | Delivered mail and packages to residents |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Dec 7, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 12/06/22 through 12/07/22 to verify correction of previous deficiencies.
Findings
The facility failed to ensure health care referral and follow-up for a resident using oxygen without an order, failed to administer medications as ordered for a resident related to an anti-anxiety medication, and failed to implement infection control measures during medication administration. Additionally, one medication aide did not meet training and competency requirements prior to administering medications.
Deficiencies (4)
Failed to ensure health care referral and follow-up to meet the health care needs for 1 of 5 sampled residents (#3) who was receiving oxygen therapy without an order.
Failed to administer medications as ordered for 1 of 5 residents (#5) related to an anti-anxiety medication (lorazepam), resulting in 29 missed doses over a 10-day period.
Failed to ensure infection control measures during medication administration as a medication aide performed fingerstick blood sugar and insulin injection without gloves and did not sanitize hands before and after the procedure.
Failed to ensure 1 of 3 sampled staff (Staff C) met employment verification and training requirements as a medication aide prior to administering medications, including failure to complete the required written medication aide examination within 60 days of hire.
Report Facts
Missed medication doses: 29
Medication administration days: 52
FSBS reading: 223
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to complete required medication aide written test within 60 days of hire and administered medications prior to passing test |
| Resident Care Coordinator | Trained Staff C and created medication administration profile in eMAR system | |
| Health and Wellness Director | Signed evaluations, responsible for medication availability and follow-up with providers | |
| Executive Vice President of Operations | Provided interviews regarding facility expectations and oversight |
Inspection Report
Follow-Up
Census: 44
Deficiencies: 6
Date: Sep 7, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 09/07/22 through 09/08/22 to verify correction of previous deficiencies.
Findings
The facility failed to maintain hot water temperatures within required limits for one resident's sink, failed to ensure health care referral and follow-up for two residents, failed to serve a therapeutic diet as ordered for one resident, failed to provide unrestricted access for residents to go outside and smoke when requested, failed to administer medications as ordered for three residents, and failed to ensure COVID-19 screening of staff was consistently performed.
Deficiencies (6)
Failed to ensure hot water temperatures for 1 fixture (sink) used by a resident was maintained between 100 and 116 degrees Fahrenheit.
Failed to ensure health care referral and follow-up to meet health care needs for 2 residents related to wound care and insulin refusal.
Failed to ensure a therapeutic diet was served for 1 resident with an order for no concentrated sweets, pureed diet with no bread.
Failed to ensure resident rights were maintained related to providing unrestricted access for residents to go outside and smoke when requested.
Failed to administer medications as ordered for 2 residents observed during medication pass including antidepressant omission and crushing medications that should not be crushed; and for 1 resident for failure to administer PRN fast acting insulin as ordered.
Failed to ensure implementation of CDC and NCDHHS COVID-19 guidance related to screening of staff; staff failed to consistently screen for COVID-19 symptoms prior to shift start.
Report Facts
Census: 44
Medication error rate: 9.6
Medication errors: 3
PRN Humalog not administered: 9
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jun 10, 2022
Visit Reason
The Adult Care Licensure Section and the Yadkin County Department of Social Services conducted an annual and follow-up survey from 06/08/22 through 06/10/22 to assess compliance with state regulations.
Findings
The facility failed to maintain hot water temperatures within the required range for 6 resident-used fixtures, failed to ensure diabetic training for medication aides, did not provide adequate health care referrals and follow-up for several residents, failed to maintain clean food storage areas, failed to administer medications as ordered, failed to document oxygen use, failed to implement COVID-19 screening protocols for staff and visitors, and residents experienced long wait times for meals.
Deficiencies (10)
Hot water temperatures for 6 fixtures (sinks) used by residents were not maintained between 100 and 116 degrees Fahrenheit.
Two of three sampled medication aides had not completed training on care of diabetic residents prior to administering insulin and obtaining fingerstick blood sugars.
Failed to ensure health care referral and follow-up for residents related to GI specialist appointments, podiatry care, urology referrals, oxygen tank availability, weight gain notifications, and medication refusals.
Food storage areas including walk-in refrigerator and freezer were not maintained clean and orderly, with grime, dirt buildup, and ice accumulation observed.
Failed to administer glucose gel for low blood sugar and diuretic medication for weight gain as ordered for a resident.
Electronic medication administration record (eMAR) was inaccurate and incomplete for two residents with continuous oxygen orders, lacking documentation of oxygen use.
Failed to implement COVID-19 screening for staff and visitors consistently, with missing screening logs and incomplete screening during all shifts.
Residents were not treated with respect, dignity, and privacy as evidenced by long wait times exceeding 30 minutes for meals to be served in the dining hall.
Residents did not receive adequate and appropriate care related to elevated hot water temperatures and health care referral and follow-up failures.
Residents were not ensured to be free from neglect related to health care referral and follow-up failures.
Report Facts
Hot water fixtures out of range: 6
Weight gain notifications missed: 7
FSBS low without glucose gel administration: 6
Residents initially seated in dining hall: 29
Residents not served by 12:26pm: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in finding for failure to complete diabetic training prior to insulin administration. |
| Staff C | Medication Aide | Named in finding for failure to complete diabetic training prior to insulin administration. |
| Administrator | Interviewed regarding water temperature issues, health care referrals, COVID-19 screening, and meal service delays. | |
| Resident Care Coordinator | Interviewed regarding diabetic training, health care referrals, medication administration, and COVID-19 screening. | |
| Dietary Manager | Interviewed regarding food storage cleanliness and meal service delays. | |
| Business Office Manager | Interviewed regarding scheduling of appointments and visitor screening. |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 7
Date: Jan 10, 2019
Visit Reason
The Adult Care Licensure Section and the Yadkin County Department of Social Services conducted an annual survey on January 09 and 10, 2019 with an exit via telephone on January 11, 2019.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing upon hire for staff, failure to provide training on diabetic care prior to insulin administration, failure to provide all residents with non-disposable utensils at meals, failure to serve water at breakfast, failure to serve therapeutic diets as ordered, failure to guarantee residents' rights related to reasonable response to requests for milk, and failure to administer medications as ordered by licensed practitioners.
Deficiencies (7)
Facility failed to ensure 1 of 3 sampled staff was tested for tuberculosis upon hire.
Facility failed to assure 1 of 3 sampled medication aides had completed training on care of diabetic residents prior to insulin administration.
Facility failed to assure all residents received a non-disposable place setting consisting of a knife, spoon, and a fork at each meal.
Facility failed to assure water was served to 33 of 33 residents observed during the breakfast meal.
Facility failed to ensure therapeutic diets were served as ordered for 1 of 7 sampled residents with physician's orders for a low concentrated sweets diet with double portions.
Facility failed to assure residents' rights were guaranteed and maintained without hindrance related to reasonable response to requests related to serving milk.
Facility failed to assure medications were administered as ordered by a licensed prescribing practitioner for 2 of 5 sampled residents related to a topical pain relieving gel and eye drops for dry eyes and cough medicine.
Report Facts
Residents without utensils: 6
Residents without utensils: 4
Residents without utensils: 2
Residents present: 33
Refusals documented: 15
Benzonatate administrations without order: 205
Milk containers: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Personal Care Aide/Medication Aide | Named in tuberculosis testing deficiency. |
| Staff B | Medication Aide | Named in diabetic care training deficiency. |
| Resident Care Coordinator | Interviewed regarding personnel records and medication administration. | |
| Administrator | Interviewed regarding personnel records, training, and meal service. | |
| Dietary Manager | Interviewed regarding meal service and utensil availability. | |
| First shift Medication Aide | Interviewed regarding medication administration. | |
| Second shift Medication Aide | Interviewed regarding medication administration. |
Inspection Report
Capacity: 50
Deficiencies: 9
Date: Apr 11, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with the 1977 Minimum and Desired Standards and Regulations for Homes for the Aged and Infirm, the 1978 NC State Building Code, and current Rules for Adult Care Homes of Seven or More Beds.
Findings
Multiple deficiencies were cited including failure to meet building code requirements for special locking system doors, lack of current sanitation and fire safety inspection reports, unsafe storage of portable medical oxygen cylinders, incomplete fire safety rehearsal records, malfunctioning warning devices on emergency exits, corridor doors not closing properly to resist fire and smoke, and compromised fire-rated ceilings.
Deficiencies (9)
Facility failed to meet NC State Building Code by not having all required components for doors with Special Locking System.
No wiring diagram or systems components location map posted under glass at the fire alarm panel.
Most recent Fire Marshal building safety inspection report could not be located.
Required annual sprinkler system inspection report could not be located.
Building was not maintained safely by improper handling of portable medical oxygen cylinders; four cylinders stored without containers in oxygen room.
Fire safety rehearsals records incomplete; only two months of records available, no records for all shifts, no descriptions, times, or staff lists included.
Warning devices ('screamers') protecting emergency release switches were not working at some exits (near room 29, Activity room, kitchen).
Corridor doors prevented from closing and latching properly, including doors to bedrooms 2, 3, 4, 23, Activity room, and RCC office, compromising fire and smoke resistance.
Required one-hour fire rated ceiling compromised by holes and penetrations not sealed with approved materials; smoke detector hanging by wires in women's bathroom across from room 24.
Report Facts
Total licensed beds: 50
Portable medical oxygen cylinders improperly stored: 4
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 2
Date: Oct 4, 2017
Visit Reason
The inspection was conducted due to a complaint alleging the presence of bed bugs in the facility.
Complaint Details
The complaint alleging bed bugs was substantiated based on observations and interviews. Bed bugs have been present since at least 05/27/2016 and continue to be present as of the inspection date.
Findings
The complaint was substantiated with live bed bugs observed in Rooms 20 and 23. The facility had a bed bug policy and a contract with a pest management company, but the measures were ineffective. The facility also failed to maintain a sanitation score in compliance with state rules, scoring 80.5 on 09/01/2017, below the required 85.
Deficiencies (2)
Facility did not have an effective policy describing measures to prevent bed bugs or mitigate infestation; live bed bugs observed in Rooms 20 and 23.
Facility failed to maintain a sanitation score in compliance with state rules; current sanitation score was 80.5.
Report Facts
Total licensed capacity: 50
Sanitation score: 80.5
Date of last bed bug treatment: Sep 13, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Strickland | Conducted the Construction Section Complaint Survey. |
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 6
Date: Dec 7, 2016
Visit Reason
The inspection was conducted as a biennial complaint survey triggered by allegations that the facility had bed bugs and was not adequately treating them.
Complaint Details
The complaint alleged the facility had bed bugs and was not adequately treating them. The complaint was substantiated.
Findings
The complaint was substantiated with findings that the facility lacked an effective policy to prevent or mitigate bed bug infestations, had been self-treating without proper documentation or licensed pest control, and live bed bugs and evidence of infestation were observed in multiple rooms and throughout the facility.
Deficiencies (6)
The facility did not have an effective policy in place describing measures to prevent bed bugs or mitigate infestation.
Self-treatment for bed bugs was performed by maintenance staff using foggers and diatomaceous earth without licensed pest control involvement or documentation.
Live bed bugs were observed in multiple rooms and evidence of infestation was found throughout the facility.
No measures ensured mist from foggers did not migrate into occupied areas.
No clear separation of clean and dirty laundry to prevent cross-contamination with bed bugs.
Self-treatment caused bed bugs to flee into walls creating a structural infestation.
Report Facts
Total licensed capacity: 50
Date of last licensed pest control treatment: 201606
Date bed bugs first present: May 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Hoppin | Surveyor conducting the biennial complaint survey |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 8
Date: Aug 12, 2016
Visit Reason
The Adult Care Licensure Section and Yadkin County Department of Social Services conducted an annual and complaint investigation on August 2-4, and August 8, 2016. The complaint investigation was initiated by the Yadkin County Department of Social Services on July 21, 2016.
Complaint Details
The complaint investigation was initiated by the Yadkin County Department of Social Services on July 21, 2016.
Findings
The facility failed to assure minimum staffing requirements for aides for 10 out of 47 shifts, personal care staff performed housekeeping and food service duties beyond allowed limits, two residents were not tested for tuberculosis upon admission, medications for five residents were not available or administered as ordered, the facility failed to notify physicians about medication issues for some residents, and medication reviews were inadequate for four residents. The Administrator failed to assure overall compliance with staffing, tuberculosis testing, health care, medication administration, and pharmaceutical care requirements.
Deficiencies (8)
Failed to assure minimum staffing requirements for aides for 10 out of 47 shifts from 6/25/16 through 7/10/16.
Failed to assure that all housekeeping performed by personal care staff between 7:00am and 9:00pm was limited to occasional, non-routine tasks.
Failed to assure that all food service duties performed by personal care staff between 7:00am and 9:00pm was limited only to help with eating and carrying plates, trays or beverages to residents.
Failed to assure 2 of 5 residents were tested upon admission for tuberculosis disease in compliance with control measures.
Failed to assure medications for 5 of 8 sampled residents were available and administered as ordered.
Failed to notify the physician for 3 of 8 sampled residents regarding medication issues and one resident who failed to receive a monthly Invega injection.
Failed to assure adequate medication reviews were completed for 4 of 6 sampled residents in the areas of medication refusals and medications unavailable to administer.
Failed to assure the total operation of the facility to meet and maintain rules related to Adult Care Home Personal Care and Other Staffing requirements, Tuberculosis Testing of Residents, Health Care, Medication Administration, and Pharmaceutical Care.
Report Facts
Shifts with inadequate staffing: 10
Resident census: 41
Resident census range: 33
Resident census: 42
Medication refusal occurrences: 3
Medication refusal occurrences: 4
Medication refusal occurrences: 4
Medication refusal occurrences: 2
Medication refusal occurrences: 1
Medication refusal occurrences: 1
Medication refusal occurrences: 1
Medication refusal occurrences: 1
Medication refusal occurrences: 1
Medication refusal occurrences: 1
Medication refusal occurrences: 3
Medication refusal occurrences: 3
Medication refusal occurrences: 1
Medication refusal occurrences: 3
Medication refusal occurrences: 8
Medication refusal occurrences: 8
Medication refusal occurrences: 49
Medication refusal occurrences: 13
Medication refusal occurrences: 49
Medication refusal occurrences: 13
Medication refusal occurrences: 99
Medication refusal occurrences: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Responsible for scheduling, staffing, and medication tracking; interviewed multiple times regarding staffing and medication issues |
| Administrator | Administrator | Facility Administrator interviewed multiple times regarding staffing, medication, and compliance issues |
| Staff A | Medication Aide | Named in relation to medication administration and incident involving Resident #3 |
| Staff C | Medication Aide | Named in relation to medication administration and documentation |
| Staff D | Personal Care Aide | Witnessed Resident #3 fight and reported to police |
| Staff E | Personal Care Aide | Interviewed regarding Resident #4 behaviors and medication |
Inspection Report
Capacity: 50
Deficiencies: 8
Date: May 10, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1977 Minimum and Desired Standards and Regulations for Homes for the Aged and Infirm, the 1978 NC State Building Code, and applicable portions of the current Rules for Adult Care Homes of Seven or More Beds.
Findings
The facility was found deficient in maintaining current sanitation and fire safety inspection reports, proper housekeeping and hazard-free environment, fire safety rehearsals on each shift, and maintaining building equipment in safe and operating condition. Specific issues included outdated fire safety inspections, unsafe storage of oxygen cylinders, loose toilet mounting, lack of fire plan rehearsals on certain shifts, compromised fire-rated walls and ceilings, corridor doors not closing and latching properly, roof sagging, and non-functional GFCI receptacle.
Deficiencies (8)
Several required inspections had not been done within the last 12 months, including fire alarm, sprinkler system, and Fire Marshal's inspections.
Portable medical oxygen cylinders were stored in an unapproved beverage crate, posing a safety hazard.
A toilet in the Men's bath was loosely mounted to the floor, creating potential leaking and fall hazards.
No rehearsals of the fire plan were conducted during the 3rd shift in the 2nd and 4th quarters of the year, and records lacked descriptions of rehearsals.
One-hour fire rated walls and ceilings were compromised in several locations with holes and penetrations not sealed properly.
Corridor doors were prevented from closing quickly and latching, including a door propped open and another equipped only with a deadbolt.
A portion of the roof was severely sagged and probably rotted under the shingles.
No power at the GFCI receptacle in the Ladies' bath, preventing proper operation check.
Report Facts
Total licensed capacity: 50
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