Inspection Reports for Phoenix Assisted Care

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on April 15-16, 2025.

The facility was found to have a significant cockroach infestation throughout the Special Care Unit (SCU), including live and dead cockroaches and excrement in residents' rooms and common areas. Additionally, unsecured personal care products were found in residents' rooms. The facility failed to update a care plan within 10 days following a significant change in condition for a resident with a pressure ulcer. The facility also failed to administer insulin as ordered for a diabetic resident, missing 26 doses of Lispro insulin due to the order not being entered in the electronic medication administration record (eMAR). Lastly, a resident was found with medication in their dresser drawer, which was not observed being taken and posed a safety risk.

The visit included a complaint investigation related to pest infestation and medication administration issues.

The Adult Care Licensure Section conducted a follow-up and complaint investigation at Phoenix Assisted Care from February 11 through 13, 2025.

The facility was found to have multiple deficiencies including a cockroach infestation, failure to ensure clean bed linens and timely linen changes, lack of a qualified activity director and insufficient activities, failure to update care plans after significant changes, inadequate personal care and documentation for residents, failure to ensure timely referral and follow-up for acute health care needs, failure to implement physician orders for TED hose, and abuse of a resident by staff.

Complaint investigation included allegations of abuse of Resident #1 involving physical restraint, unauthorized search, and exposure. Police investigation led to assault charges pending against a staff member.

The Adult Care Licensure Section conducted a follow-up and state involved complaint investigation on November 19 and 20, 2024.

The facility was found to have multiple deficiencies including a severe cockroach infestation throughout the facility, failure to employ a qualified activity director, inadequate personal care related to bathing assistance for residents, failure to implement physician orders for thrombo-embolic deterrent hose (TED), failure to provide 14 hours of planned group activities per week, inaccurate medication administration records, and failure to follow infection control measures during medication administration.

The visit was a follow-up and state involved complaint investigation conducted on November 19 and 20, 2024.

The Adult Care Licensure Section and Wake County Department of Social Services conducted an annual, follow-up, and complaint investigation on September 5 and 6, 2024.

The facility was found to have multiple deficiencies including a severe cockroach infestation throughout the facility, failure to provide personal care assistance to residents including bathing and dressing, failure to ensure health care coordination and follow-up for residents with medical needs, failure to provide 14 hours of planned group activities per week, and medication administration errors including missed doses and administration of expired medications.

The visit included a complaint investigation triggered by resident and staff reports of cockroach infestation and personal care failures.

The visit was conducted as a complaint investigation regarding the supervision and safety of residents, specifically focusing on an incident involving a resident with dementia eloping from the facility.

The facility failed to provide adequate supervision for one of five sampled residents with dementia, resulting in the resident eloping from the facility without staff knowledge. This failure posed a substantial risk of serious injury and was classified as a Type A2 violation.

The complaint investigation focused on Resident #4, who had a diagnosis of dementia and eloped from the facility. The investigation included review of policies, resident records, interviews with staff and family, and observations. The resident was found nearly a mile away from the facility near a busy highway. The facility was unaware of the elopement until EMS notified them. The failure to supervise was substantiated and resulted in a Type A2 violation.

The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure.

Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, electrical and plumbing systems. Issues included non-compliance with emergency release switches, delayed egress door signage, corridor obstructions, floor hazards, lack of residential laundry equipment, unsecured outside premises, furniture and structural disrepair, fire safety rehearsal record deficiencies, non-functioning electrical outlets, fire safety equipment not maintained or inspected, and unsafe electrical and plumbing conditions.

The Adult Care Licensure Section conducted a follow-up survey on July 13-15, 2021 to assess compliance with previously cited deficiencies and overall regulatory compliance.

The facility failed to respond immediately to a medical emergency involving a resident with a head injury after a fall, failed to ensure physician notification for significant changes in residents' conditions including wounds and blood pressure, failed to schedule timely follow-up appointments after hospital discharge, and failed to promptly administer ordered as-needed pain medication to a resident. These failures were detrimental to resident health and safety and constituted Type B violations.

Annual and follow-up survey conducted onsite from 05/11/21 to 05/13/21 with a desk review and telephone exit on 05/14/21 to assess compliance with state regulations for Phoenix Assisted Care.

The facility was found to have multiple deficiencies including unsecured hazardous substances accessible to residents, failure to provide adequate personal care and supervision, medication administration errors, unlocked medication carts and rooms, inadequate resident personal fund transaction documentation, insufficient staffing in the special care unit, lack of resident dining tables in rooms, and an incident of physical abuse of a resident.

Complaint investigation triggered by allegations of bedbug infestation, inadequate staffing, medication errors, and infection control issues.

The facility was found to have multiple deficiencies including unsafe outdoor smoking courtyard, active bedbug infestation in resident rooms, inadequate staffing levels in assisted living and memory care units, failure to complete required medication aide training, failure to report injuries to the Health Care Personnel Registry, failure to maintain residents' personal funds records and provide refunds, failure to implement COVID-19 infection control guidelines, and failure to obtain consent for COVID-19 vaccinations.

Complaint investigation triggered by allegations of bedbug infestation, inadequate staffing, medication errors, infection control issues, and resident neglect.

The Adult Care Licensure Section conducted an annual and follow-up survey from 10/22/19 to 10/24/19 at Phoenix Assisted Care.

The facility was found to have multiple deficiencies including unsafe storage of oxygen cylinders, failure to assure physician notification and implementation of orders, failure to maintain clean kitchen and food storage areas, failure to provide proper table settings including knives, failure to serve milk twice daily as ordered, failure to maintain accurate diet lists, failure to serve therapeutic diets as ordered, delayed assistance with feeding, and medication administration errors including improper timing of sliding scale insulin and incomplete medication administration records.

The inspection was conducted due to a complaint alleging a hole in the dining room ceiling.

The complaint was substantiated. The facility failed to maintain fire safety components in a safe and operating condition, with ceiling damage and failure due to leaks of sprinkler piping in the attic observed in the dining room and kitchen pantry.

The complaint alleging a hole in the dining room ceiling was substantiated.

This facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code(s) and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure.

Multiple deficiencies were cited including loose corridor handrails, damaged interior doors, malfunctioning sprinkler system components, doors that do not latch properly, improper storage of oxygen cylinders, wedged fire-rated doors obstructing closure, failure of emergency lighting, unsecured magnetic holding devices on cross-corridor doors, and broken ground-fault circuit interrupter receptacles.

The Adult Care Licensure Section and the Wake County Department of Social Services conducted an annual and follow-up survey from August 16 to August 18, 2016.

The facility failed to document food substitutions for residents, maintain an accurate and current listing of residents with physician-ordered therapeutic diets, and ensure medication (Lantus insulin) was administered as ordered for one resident. The dietary staff prepared meals from memory without following menus or substitution logs, and medication administration did not comply with physician orders.

Biennial follow-up survey conducted to verify correction of previously cited deficiencies and to assess ongoing compliance.

Some cited deficiencies were verified as corrected; however, deficiencies remain that require corrective action, specifically related to maintaining fire safety systems and equipment in a safe and operating condition.

This is a biennial follow-up survey conducted to verify correction of previously cited deficiencies and to assess remaining issues requiring further action.

The facility has corrected most previously cited deficiencies; however, some deficiencies remain, including unsafe outside premises with deteriorated parking lot, unsecured oxygen bottles, missing door hardware components, and fire safety system maintenance issues such as unsealed penetrations in fire resistant ceilings, lack of access panel for duct smoke detector, and staff lacking keys for manual override of magnetic locks.

The facility underwent a biennial survey to assess conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and related building codes and regulations.

The inspection identified multiple deficiencies including unsafe outside premises with deteriorated parking lot paving, housekeeping hazards such as doors that do not latch and improperly stored oxygen bottles, failure to maintain fire safety systems including unsealed penetrations in fire resistant ceilings and non-functioning emergency lights, and electrical equipment issues such as improperly wired fans and non-working light fixtures.

The Adult Care Licensure Section conducted an Annual Survey of Phoenix Assisted Care from March 25 to March 27, 2015.

The facility was found deficient in maintaining walls, ceilings, and baseboards in good repair; failure to provide tuberculosis (TB) testing documentation for staff and residents; lack of required special care unit staff training; failure to provide mandatory annual infection control training for a medication aide; and failure to ensure drug screening consent for a staff member upon hire.