Inspection Reports for Piedmont Christian Home
1510 Deep River Road High Point, NC 27265, High Point, NC, 27265
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
61 residents
Based on a May 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 28, 2025
Visit Reason
The Adult Care Licensure Section and the Guilford County Department of Social Services conducted an annual and follow-up survey from 08/26/25 to 08/28/25.
Findings
The facility failed to ensure window openings in the Special Care Unit were restricted to 6 inches to prevent elopement or suicide, failed to ensure medication aides completed required training and testing before administering medications, failed to ensure referral and follow-up to meet health care needs related to compression sock application, and failed to ensure medications were administered as ordered for multiple residents. Additionally, infection control measures during medication administration were not followed, and a resident was allowed to self-administer medications without proper physician orders and assessments.
Deficiencies (6)
Failed to ensure window openings in the Special Care Unit residents' rooms were restricted to 6 inches to prevent elopement or suicide.
Failed to ensure 1 of 6 sampled medication aides had a Clinical Skills Competency Validation Checklist and passed the written examination prior to administering medications.
Failed to ensure referral and follow-up to meet the health care needs for 1 of 5 sampled residents related to failure to notify the primary care provider of a resident not wearing compression socks as ordered.
Failed to ensure medications were administered as ordered for multiple residents including crushing a delayed release medication, not administering diabetic medication, iron, vitamin D, sleep aide, and laxative, and administering cardiac medication when pulse was below ordered parameters.
Failed to ensure medications were administered in accordance with infection control measures to prevent disease transmission for 3 residents observed during medication administration.
Failed to ensure 1 resident had a physician's order and assessment completed to self-administer medications related to hair growth treatment and dandruff shampoo.
Report Facts
Medication pass error rate: 19
Resident rooms with windows: 9
Windows opened more than 6 inches: 3
Medication reorder attempts: 17
Medication doses missed: 12
Medication doses missed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to complete Clinical Skills Competency Validation Checklist and pass written exam before administering medications |
| Director of Clinical Services | Interviewed regarding window safety, medication administration, and infection control expectations | |
| Resident Care Coordinator | Interviewed regarding medication administration and compression sock application | |
| Maintenance Director | Interviewed regarding window pins and maintenance notifications | |
| Special Care Unit Coordinator | Interviewed regarding window safety and medication cart audits | |
| Administrator | Interviewed regarding expectations for medication administration, window safety, and resident self-administration | |
| Medication Aide | Observed and interviewed regarding medication administration errors and infection control practices | |
| Pharmacist | Interviewed regarding medication orders, crushing medications, and pharmacy procedures | |
| Resident #1 Primary Care Provider | Interviewed regarding medication orders and self-administration | |
| Resident #4 Primary Care Provider | Interviewed regarding digoxin and compression sock orders | |
| Resident #7 Primary Care Provider | Interviewed regarding medication orders |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Aug 14, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 08/13/24 to 08/14/24 to assess compliance with previously identified deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure window openings in the Special Care Unit (SCU) were restricted or alarmed properly to prevent elopement, failure to secure hazardous cleaning agents and substances from residents, failure to notify primary care providers (PCPs) of elevated or refused finger stick blood sugar (FSBS) values for residents, failure to have physician orders and assessments for self-administration of medications, and failure to maintain accurate controlled substance records.
Deficiencies (5)
Failed to ensure window openings in the SCU residents' bedrooms were restricted to 6 inches or had a workable sounding device to notify staff when opened to prevent elopement.
Failed to ensure cleaning agents and hazardous substances were kept in a separate locked area and not accessible to residents in the SCU.
Failed to ensure referral and follow-up for 2 sampled residents related to PCP not being notified of elevated FSBS values and refusal of FSBS and sliding-scale insulin.
Failed to assure 1 sampled resident in the SCU had physician orders and assessment for self-administration of medications found in the resident's room.
Failed to ensure a readily retrievable record that accurately reconciled the receipt and administration of controlled substances for 1 sampled resident related to Lorazepam for anxiety.
Report Facts
Resident rooms with windows: 14
FSBS readings: 527
FSBS readings: 427
FSBS readings: 411
FSBS readings: 433
FSBS readings: 300
FSBS readings: 327
FSBS readings: 307
FSBS readings: 277
FSBS readings: 326
FSBS readings: 269
FSBS readings: 253
FSBS readings: 255
Lorazepam tablets dispensed: 30
Lorazepam tablets remaining: 9
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 15
Date: May 10, 2024
Visit Reason
The Adult Care Licensure Section and the Guilford County Department of Social Services conducted an annual survey and complaint investigation from May 08, 2024 through May 10, 2024.
Complaint Details
Complaints were initiated by the Guilford County Department of Social Services from 03/20/24 to 04/25/24.
Findings
The facility had multiple deficiencies including failure to restrict window openings in the Special Care Unit to prevent elopement or suicide, lack of handwashing facilities adjacent to medication storage, malfunctioning air conditioning/heating units, failure to test a resident for tuberculosis upon admission, failure to notify primary care providers of refused insulin doses, failure to implement physician orders for treatments and medications, inadequate table service and therapeutic diet menus, insufficient time between meals, failure to serve required milk and water at meals, lack of resident privacy in shared bathrooms, medication administration errors, and failure to maintain accurate controlled substance records.
Deficiencies (15)
Failed to ensure window openings in the Special Care Unit residents' bedrooms were restricted to 6 inches to prevent elopement or suicide.
Failed to ensure medication storage area for 3 medication carts in the assisted living unit were immediately adjacent to a handwashing sink.
Failed to ensure air conditioning/heating units in the Special Care Unit were maintained in an operating condition.
Failed to ensure 1 of 5 residents sampled was tested upon admission for tuberculosis disease in compliance with control measures.
Failed to ensure referral and follow-up to meet health care needs for 1 of 6 sampled residents related to notifying the primary care provider for refused doses of sliding scale insulin.
Failed to ensure implementation of physician's orders for 2 of 6 sampled residents related to treatments and fingerstick blood sugars.
Failed to ensure table service included a napkin and non-disposable place setting consisting of at least a knife, fork, spoon, plate, and beverage containers for all residents and non-disposable utensils for residents in the Special Care Unit.
Failed to have matching therapeutic diet menus for 6 sampled residents with physician-ordered therapeutic diets.
Failed to ensure there were at least 10 hours between the breakfast and dinner meals.
Failed to ensure that 8 ounces of milk or other equivalent dairy products were served three times daily to residents in the Assisted Living and Special Care Unit.
Failed to ensure water was served in addition to other beverages to each resident in the Assisted Living and Special Care Unit.
Failed to ensure residents were treated with consideration, respect, dignity, and full recognition of individuality and right to privacy related to female and male residents residing in bedrooms sharing adjoining bathrooms.
Failed to ensure a readily retrievable record that accurately reconciled the receipt and administration of a controlled substance for 2 of 4 sampled residents who received a controlled substance for pain.
Failed to ensure medications were administered as prescribed for 3 of 6 sampled residents related to sliding scale insulin, and multiple other medications including allergy, cholesterol, anti-seizure, anti-depressant, anti-anxiety, and mood stabilizer medications.
Failed to notify a resident's Guardian within 24 hours related to a confrontation between the resident and his roommate resulting in evaluation by Hospice nurse.
Report Facts
Resident rooms with windows: 14
Closed windows: 10
Unlocked windows: 4
Residents present: 61
Missed FSBS checks: 15
Missed loratadine doses: 11
Missed divalproex doses: 5
Missed hydroxyzine doses: 8
Missed sertraline doses: 8
Missed levetiracetam doses: 7
Missed oxycodone doses: 17
Missed morphine doses: 7
Missed Humalog SSI doses: 12
Hemoglobin A1C value: 10.6
Hemoglobin A1C value: 10.4
Residents served in SCU dining room: 16
Residents served in AL dining room: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Nurse | Responsible for auditing eMARs, medication administration, and controlled substance counts; left employment abruptly in April 2024. |
| Special Care Unit Coordinator | Administered medications, reviewed medication administration, and noticed medication issues; employed since April 2024. | |
| Business Office Manager | Assumed some duties of Resident Care Coordinator; maintained controlled substance count logs. | |
| Administrator | Provided multiple interviews regarding deficiencies, expectations, and corrective actions. | |
| Medication Aide | Interviewed multiple times regarding medication administration, documentation, and resident care. | |
| Cook | Interviewed regarding meal preparation, therapeutic diet menus, and table service. | |
| Personal Care Aide | Interviewed regarding meal service and resident care. | |
| Resident Care Coordinator | Responsible for medication audits and controlled substance documentation; left employment in April 2024. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 93
Deficiencies: 6
Date: Feb 3, 2023
Visit Reason
The Adult Care Licensure Section and the Guilford County Department of Social Services conducted an annual and follow-up survey from February 1, 2023 to February 3, 2023.
Findings
The facility failed to ensure medication staff qualifications, therapeutic diets were served as ordered, resident rights were respected regarding blood sugar monitoring, medications were administered as ordered, medication storage was secure, and infection prevention policies were properly implemented, including proper use and cleaning of glucometers.
Deficiencies (6)
Failed to ensure 1 of 6 medication staff passed the written medication aide exam within 60 days of completing clinical skills validation.
Failed to ensure 3 of 7 residents with therapeutic diet orders were served diets as ordered.
Failed to ensure 1 of 5 residents was treated with respect and dignity related to blood sugar monitoring device use and resident refusal.
Failed to ensure medications were administered as ordered for 1 of 4 residents related to missed anti-anxiety medication and 2 of 5 residents related to sliding scale insulin errors.
Failed to ensure all medications were maintained under locked security except when under direct physical supervision of staff in charge of medication administration.
Failed to implement infection control policies consistent with CDC guidelines for glucometer use, resulting in sharing of glucometers between residents and improper cleaning.
Report Facts
Facility licensed capacity: 93
Facility census: 65
Medication administration errors: 15
Medication not administered days: 8
FSBS documented vs glucometer history mismatches: 24
FSBS documented vs glucometer history mismatches: 21
FSBS documented vs glucometer history mismatches: 25
FSBS documented vs glucometer history mismatches: 24
FSBS documented vs glucometer history mismatches: 2
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jun 1, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 06/01/2022 and 06/02/2022 to verify correction of previous deficiencies related to medication administration and other compliance issues.
Findings
The facility failed to administer medications as ordered for one resident (#4), including errors with anti-anxiety medication administration and documentation discrepancies. The facility also failed to ensure proper self-administration policies, medication disposition, controlled substance record reconciliation, and adherence to COVID-19 mask policies for staff.
Deficiencies (5)
Failed to administer medications as ordered for Resident #4, including errors with ABH 1-25-1 gel for agitation.
Failed to ensure Resident #1 had a physician's order to self-administer inhaler, nasal spray, and topical cream; medications were found at bedside without proper orders or labels.
Failed to store expired or discontinued medications separately from active medications for Resident #1.
Failed to maintain a readily retrievable and accurate record of receipt, administration, and disposition of controlled substances for Resident #4, with discrepancies between eMAR and controlled substance count sheets.
Failed to ensure staff wore facemasks properly as source control during the COVID-19 pandemic, with multiple staff observed not wearing masks or wearing masks improperly despite facility policy and CDC guidance.
Report Facts
Controlled substance syringes dispensed: 90
Controlled substance syringes dispensed: 30
Controlled substance syringes dispensed: 45
Controlled substance syringes dispensed: 30
Controlled substance tablets dispensed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #4's hospice registered nurse | Registered Nurse | Interviewed regarding medication orders and administration for Resident #4 |
| Resident Care Coordinator | Interviewed regarding medication administration expectations and documentation for Resident #4 | |
| Administrator | Interviewed regarding facility policies and knowledge of medication administration and COVID-19 mask guidance | |
| Medication Aide | Interviewed regarding medication administration, controlled substance documentation, and knowledge of medication orders | |
| Personal Care Aide | Interviewed regarding observation of medications in resident rooms and mask wearing | |
| Activity Assistant | Interviewed regarding mask wearing during resident activities | |
| Dietary Manager | Interviewed regarding mask wearing in dining room | |
| Housekeeper | Interviewed regarding mask wearing while cleaning | |
| Supervisor-in-Charge | Interviewed regarding mask policy enforcement |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 4, 2022
Visit Reason
The Adult Care Licensure Section and the Guilford County Department of Social Services conducted a follow-up survey and complaint investigation on 03/02/22, 03/03/22, and 03/04/22.
Complaint Details
The visit was a follow-up survey and complaint investigation conducted over three days in March 2022.
Findings
The facility failed to ensure staff qualifications, criminal background checks, supervision, health care follow-up, medication administration, and controlled substance record keeping met regulatory requirements. Specific failures included substantiated findings on the Health Care Personnel Registry for staff, missing criminal background checks, inadequate supervision resulting in multiple resident falls, failure to notify primary care providers timely, medication administration errors, and inaccurate controlled substance records.
Deficiencies (6)
Failed to ensure no substantiated findings on the North Carolina Health Care Personnel Registry for 3 of 6 sampled staff (Staff C, D and E).
Failed to ensure 2 of 6 sampled staff (Staff C and E) had a statewide criminal background check completed upon hire.
Failed to provide supervision for 1 of 5 sampled residents (#5) resulting in 10 falls in 3 months.
Failed to contact the primary care provider for 2 of 5 sampled residents (#1 and #5) related to episodes of nausea and vomiting and abdominal pain (#1) and a missed laboratory order (#5).
Failed to administer medications as ordered for 2 of 3 residents (#6 and #7) observed during medication pass and for 2 of 5 residents sampled (#1 and #5) for record review including errors with seizure and mental disorder medications and not holding blood pressure medication according to ordered parameters.
Failed to maintain a readily retrievable record that accurately reconciled the receipt, administration, and disposition of controlled substances for 2 of 3 sampled residents (#5 and #8).
Report Facts
Falls: 10
Medication error rate: 16
Oxycodone tablets unaccounted: 69
Oxycodone tablets not accurately accounted: 3
Missed phenytoin doses: 11
Missed trazodone doses: 12
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 11, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 08/11/21 through 08/12/21 to verify correction of a previous Type B violation related to health care.
Findings
The facility failed to ensure physician notification for one of five sampled residents regarding swollen legs and ankles. Resident #1 had documented swelling and pain, but there was no documentation of physician notification or treatment until the survey date when the physician reordered TED Hose.
Deficiencies (1)
Failure to ensure physician notification for Resident #1 with swollen legs and ankles.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 29, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up and annual survey on 03/25/21 through 03/26/21 and 03/29/21 with an exit via telephone on 03/29/21.
Findings
The facility failed to ensure referral to a mental health provider and follow up with the primary care provider for one resident related to psychiatric medication management and mood stabilizer availability, resulting in increased behaviors and hospitalization. The facility also failed to ensure medications were administered as ordered for six of seven sampled residents, including mood stabilizers, insulin, anti-anxiety medication, topical pain medication, and blood thinner, resulting in substantial risk of harm.
Deficiencies (4)
Failed to refer a resident to a mental health provider and follow up with the primary care provider for management of psychiatric medications and a mood stabilizer not being available for administration resulting in increased behaviors.
Failed to implement physician's orders for weights and reporting weight gain of more than 3 pounds in 24 hours to the primary care provider for one resident.
Failed to ensure medications were administered as ordered by a licensed practitioner for six of seven sampled residents with orders for mood stabilizer, rapid acting insulin, anti-anxiety medication, topical pain medication, and blood thinner.
Failed to ensure the electronic Medication Administration Records (eMARs) were accurate related to documentation of systolic blood pressure and heart rate for one resident.
Report Facts
Missed doses of Depakote: 6
Missed doses of Alprazolam: 40
Missed doses of Aspirin: 15
Metoprolol doses dispensed: 67
Humalog doses not documented: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Unit Coordinator (SCUC) | Responsible for reviewing orders and auditing eMARs monthly; unaware of missing documentation for blood pressure and heart rate. | |
| Resident Care Coordinator (RCC) | Responsible for reviewing physician orders and medication administration records; followed up on medication refill issues. | |
| Medication Aide (MA) | Documented 'Medication Not Available' when medications were missing; did not reorder medications; did not document blood pressure or heart rate. | |
| Pharmacist | Provided information about medication dispensing and refill processes; noted lack of documentation and refill delays. | |
| Executive Director (ED) | Provided information about facility medication management policies and oversight responsibilities. | |
| Mental Health Provider (MHP) | Provided mental health services and recommendations; first saw Resident #3 on 03/26/21. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 10, 2020
Visit Reason
The Adult Care Licensure Section conducted a follow-up, COVID-19 focused infection control and complaint investigation survey with onsite visits on 12/10/20 and 12/11/20, desk review on 12/14/20 to 12/15/20, and an exit via telephone on 12/15/20.
Complaint Details
The visit included a complaint investigation component related to infection control and health care issues.
Findings
The facility failed to ensure at least one staff member on premises had current CPR and choking management training for 24 of 42 shifts sampled, failed to ensure referral and follow-up for residents with pacemaker, physical therapy orders, and CPAP use, and failed to implement fingerstick blood sugar orders for a diabetic resident. These failures were detrimental to resident health and safety.
Deficiencies (3)
Facility failed to ensure at least one staff was always on premises with current CPR and choking management training within last 24 months for 24 of 42 shifts sampled.
Facility failed to ensure referral and follow-up for residents with pacemaker, physical therapy orders, and CPAP use, including refusal of fingerstick blood sugar checks.
Facility failed to implement orders for fingerstick blood sugars for a diabetic resident.
Report Facts
Shifts without CPR trained staff: 24
Residents with referral/follow-up issues: 3
Residents sampled: 5
Residents sampled: 6
Refused FSBS checks: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in CPR training deficiency; hired 09/22/20 with expired CPR certification. |
| Staff E | Personal Care Aide | Named in CPR training deficiency; hired 10/28/20 with no CPR training. |
| Staff F | Personal Care Aide | Named in CPR training deficiency; hired 11/02/20 with no CPR training. |
| Memory Care Unit Coordinator | Interviewed regarding CPR training scheduling and staff assignments. | |
| Resident Care Director | Interviewed regarding referral and follow-up failures and CPR training issues. | |
| Administrator | Interviewed regarding CPR training scheduling and referral follow-up responsibilities. | |
| Transportation Staff | Responsible for scheduling resident appointments; failed to schedule cardiologist appointment for Resident #5. | |
| Resident #3's PCP | Primary Care Provider | Interviewed regarding refusal of FSBS checks and CPAP use. |
| Resident #1's PCP | Primary Care Provider | Interviewed regarding failure to implement FSBS orders. |
| Resident #1's Previous PCP | Primary Care Provider | Interviewed regarding expectations for FSBS orders and communication. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 93
Deficiencies: 6
Date: Jun 24, 2020
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation and a COVID-19 focused Infection Control survey with an onsite visit on 06/24/20 and a desk review survey on multiple dates through 07/10/20.
Complaint Details
The visit was complaint-related and included a COVID-19 focused infection control survey. The complaint investigation revealed multiple infection control and staffing deficiencies contributing to COVID-19 transmission and resident deaths.
Findings
The facility failed to ensure staff screening, resident screening, use of PPE, social distancing, infection control procedures, and staffing levels met CDC, NC DHHS, and local health department guidelines during the COVID-19 pandemic. There were multiple deficiencies in infection control practices, staff shortages, inadequate screening, and failure to isolate or cohort residents properly, resulting in 51 residents and 13 staff testing positive for COVID-19 and 12 resident deaths.
Deficiencies (6)
Failed to ensure 3 of 6 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry upon hire.
Failed to assure minimum staffing levels to meet resident needs for 3 of 45 shifts sampled between 04/30/20 and 06/20/20.
Failed to implement CDC, NC DHHS, and local health department COVID-19 infection control guidelines including screening, PPE use, social distancing, and infection control procedures, resulting in 51 residents and 13 staff testing positive and 12 resident deaths.
Failed to assure minimum staffing levels in the Special Care Unit for 4 of 45 shifts sampled between 04/30/20 and 06/20/20.
Failed to ensure residents were provided necessary care and services to maintain physical health and to be free from neglect related to COVID-19 infection control failures.
Failed to ensure management and total operations of the facility were maintained to ensure compliance with adult care home rules and statutes to protect residents' rights to adequate care and freedom from neglect.
Report Facts
Residents tested positive for COVID-19: 51
Resident deaths after COVID-19 diagnosis: 12
Staff tested positive for COVID-19: 13
Staffing shortage aide hours: 12.25
Staffing shortage aide hours: 6.4
Staffing shortage aide hours: 21.25
Staffing shortage aide hours: 5.6
Inspection Report
Capacity: 93
Deficiencies: 14
Date: Sep 26, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1977 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1958 Edition of the North Carolina Building Code(s), Institutional Occupancy.
Findings
Multiple deficiencies were cited related to physical plant, housekeeping, fire safety, building equipment, electrical system, sprinkler system, door hardware, and ventilation. Issues included unlabeled emergency release switches, corridor obstructions, plumbing backflow hazards, lack of fire safety rehearsals, inadequate emergency lighting and exit signage, firestopping penetrations, unsafe electrical conditions, obstructed sprinkler heads, damaged door hardware, and failure of exhaust ventilation in required areas.
Deficiencies (14)
Unlabeled on/off emergency release switches for the Special Locking system causing potential delay in emergency door release.
Corridors not free of obstructions including chairs blocking exits and furniture blocking access.
Ice machine drain line in direct contact with drainage system allowing potential backflow contamination.
Portable medical oxygen cylinders not physically secured, posing hazard if they fall.
Mop sink hose not equipped with vacuum breaker to prevent backsiphonage of gray water into potable water.
Fire safety rehearsals not performed regularly with missing rehearsals on multiple shifts and quarters.
Emergency equipment not maintained in safe and operating condition including missing or non-illuminating exit signs and emergency lights.
Commercial kitchen hood fire suppression system lacked required inspections, maintenance, and documentation.
Fire safety compromised by unsealed penetrations in fire-resistance-rated assemblies and open junction boxes with energized components.
Electrical system not maintained safely including missing light fixture globes and improper use of power strips.
Smoke tight corridor doors not maintained properly, causing difficulty closing and latching.
Fire sprinkler system not maintained properly with dropped escutcheon plates and obstructions within clearance areas.
Entry door hardware damaged exposing sharp and jagged edges.
Ventilation system failed to maintain required exhaust in specified rooms.
Report Facts
Total licensed beds: 93
Special Care Unit beds: 24
Number of chairs obstructing exit: 10
Number of portable oxygen cylinders unsecured: 5
Fire safety rehearsal missing shifts: 4
Inspection Report
Capacity: 93
Deficiencies: 14
Date: Aug 17, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1977 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1958 Edition of the North Carolina Building Code(s), Institutional Occupancy.
Findings
Multiple deficiencies were cited including failure to meet fire safety code requirements in renovated areas, inadequate fire detection and sprinkler protection in closets, lack of proper exit signage, poor maintenance of outside premises, mold and odors in resident areas, unsafe electrical outlets and hand grips, damaged fire safety equipment and emergency lighting, and inadequate hot water temperature.
Deficiencies (14)
MCU bedroom closets lack automatic fire detection or sprinkler protection.
Two closets added at nurses' station during renovation lack fire detection or sprinkler protection.
Side exit into courtyard by nurses' station lacks lighted exit sign and directional signage.
Outside grounds not maintained in a clean and safe condition; soffit at exit door deteriorating with hole allowing pest entry.
Walls not maintained clean and in good repair; exterior riser room wall black with mold.
Resident bathrooms not maintained free of unpleasant odors; bath off Room 203 had strong odor.
Hand grips not maintained safely; restroom by Room 405 hand grip loose.
Electrical outlets not maintained safely; MCU bathroom had non-GFCI outlet, receptionist's office had pigtailed power cords.
Fire resistant rated ceilings have holes or gaps at penetrations allowing fire and smoke spread.
Electrical emergency/safety lighting equipment not maintained; exit lights in courtyard not lit or working.
Electrical emergency/safety equipment not maintained; GFCI outlets in 400 Hall Med Room did not trip on tester.
Fire safety equipment not maintained; corridor door in Room 107 does not latch.
Fire alarm head #18 in main foyer did not activate when tested with canned smoke.
Hot water temperature not maintained at minimum 100°F; 300 Hall water temperature was 90°F due to broken mixing valve.
Report Facts
Total licensed capacity: 93
Special Care Unit beds: 24
Water temperature: 90
Inspection Report
Annual Inspection
Census: 19
Capacity: 24
Deficiencies: 3
Date: Aug 2, 2017
Visit Reason
The Adult Care Licensure Section and the Guilford County Department of Social Services conducted an Annual survey on 08/02/17 to 08/03/17.
Findings
The facility failed to serve eight ounces of pasteurized milk at least twice a day to residents in the Special Care Unit (SCU), failed to assure medications were administered as ordered for one resident, and failed to ensure a care coordinator was on duty in the SCU at least eight hours a day, five days a week.
Deficiencies (3)
Failed to serve eight ounces of pasteurized milk at least twice a day to residents in the Special Care Unit (SCU).
Failed to assure medications were administered as ordered by a licensed prescribing practitioner for 1 of 5 sampled residents (Resident #1) with a physician's order for methotrexate 2.5 mg.
Failed to ensure a care coordinator was on duty in the Special Care Unit (SCU) at least eight hours a day, five days a week.
Report Facts
Residents served in SCU dining room: 19
Licensed capacity: 24
Methotrexate tablets not administered: 5
Methotrexate tablets remaining: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding milk service in the SCU. | |
| Activities Director | Interviewed regarding milk availability and service in the SCU. | |
| Personal Care Aide (PCA) | Interviewed regarding milk service and storage in the SCU. | |
| Administrator | Interviewed regarding milk service and care coordinator staffing. | |
| Resident Care Director (RCD) | Interviewed regarding medication administration and care coordinator duties. | |
| Nurse Practitioner (NP) | Interviewed regarding medication orders and Resident #1's treatment. | |
| Medication Aide (MA) | Interviewed regarding medication administration and awareness of Resident #1's methotrexate order. | |
| Pharmacy Manager | Interviewed regarding medication order entry and methotrexate administration delay. |
Inspection Report
Census: 93
Deficiencies: 5
Date: Oct 7, 2015
Visit Reason
This report is of a Biennial Construction Survey conducted to assess compliance with the 1971 and applicable portions of the 2005 Rules for licensing Adult Care Homes and the 1958 North Carolina State Building Code(s), Institutional Occupancy.
Findings
Multiple deficiencies were noted related to fire-resistance ratings of building components, lack of hand grips in bathrooms, unsafe building equipment maintenance including unprotected penetrations compromising fire resistance, doors not closing and latching properly, non-functioning exit signage and emergency lighting, and inadequate exhaust ventilation.
Deficiencies (5)
Building was not maintained in a safe manner by not maintaining the fire-resistance rating of building components, including missing radiation dampers in HVAC ductwork and unprotected ceiling penetrations.
Bathrooms lacked required hand grips at toilets, tubs, and showers accessible to residents.
Building equipment was not maintained safe and operating, including unprotected penetrations in fire walls and ceilings, use of un-rated foam sealant, and doors that did not close and latch properly.
Exit signage and emergency illumination were not maintained in a safe manner, with several exit signs and emergency lights not working or lacking battery backup.
Exhaust ventilation was not maintained in accordance with requirements; specifically, the exhaust fan was not working in the Soiled Utility room at room 305.
Report Facts
Residents served: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob Getchell | Surveyor conducting the Biennial Construction Survey | |
| Dennis Harrell | Surveyor conducting the Biennial Construction Survey |
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