Inspection Reports for Sanford Senior Living
1107 Carthage Street Sanford, NC 27330, Sanford, NC, 27330
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
18.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
258% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
18 residents
Based on a May 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 12, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies related to fire safety and building equipment.
Findings
Deficiencies remain uncorrected including lack of current fire and building safety inspection reports, multiple sprinkler system issues, and failure to maintain fire safety equipment such as door closers and doors that do not fully close and latch.
Deficiencies (4)
Facility did not have current fire and building safety inspection reports maintained in the home and available for review.
Sprinkler System Inspection Report revealed deficiencies including issues with fire backflow shutoffs, missing spare heads, and forty or more pendants that are corroded, painted, or not free of foreign material.
Failure to maintain fire safety equipment in safe operating condition; door closer removed in Florida Room causing door not to automatically close and latch.
Dining room doors did not completely close when released by the fire alarm.
Report Facts
Number of corroded, painted, or foreign material affected sprinkler pendants: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Surveyor who conducted the Construction Section Biennial Follow Up Survey |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 8, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies related to fire safety, sanitation, and physical plant conditions.
Findings
Deficiencies remain uncorrected including lack of current fire and building safety inspection reports, absence of privacy partitions or curtains in community bathrooms, and failure to maintain fire safety equipment such as fire doors that do not close and latch properly.
Deficiencies (3)
Facility did not have current fire and building safety inspection reports maintained in the home and available for review.
Community bathrooms did not have privacy partitions or curtains at the shower or tubs.
Failure to maintain fire safety equipment in a safe operating condition; fire doors did not completely close and latch, potentially exposing occupants to smoke or fire.
Report Facts
Number of corroded, painted or foreign material affected sprinkler pendants: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Construction Section Biennial Follow Up Survey |
Inspection Report
Capacity: 50
Deficiencies: 16
Date: Oct 15, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1993 Rules for Licensing of Domiciliary Homes, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1991 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including lack of current fire and building safety inspection reports, privacy issues in bathrooms, unlocked janitor closets with hazardous materials, unsafe outside premises, poor housekeeping and furnishings maintenance, fire safety rehearsal records missing, and numerous fire safety equipment and building maintenance issues compromising safety and compliance.
Deficiencies (16)
Facility did not have current fire and building safety inspection reports maintained and available for review.
Community bathrooms did not have privacy partitions or curtains at tubs or showers.
Cleaning agents and bleaches were stored in an unlocked closet.
Outside premises were not maintained in a clean and safe condition with openings allowing pests to enter.
Walls, ceilings, floors, and furnishings were not kept clean and in good repair with multiple specific issues noted.
Facility was not maintained free of all obstructions and hazards; latches on interior side of resident bedroom doors prevented staff access in emergencies.
Facility did not have available records of quarterly fire rehearsals including date, time, shift, staff present, and description.
Fire safety equipment was not maintained in a safe operating condition; multiple doors did not close or latch properly, and unapproved devices were used to keep doors open.
Fire safety equipment inspections were not current; fire extinguishers last serviced in March, kitchen hood last inspected in November 2022.
Electrical call bell system in resident rooms was nonfunctional except for bathroom calls.
Mechanical equipment not maintained in safe operating condition; door closer leaking oil and back flow cap missing with debris around dryer vent.
Fire resistant rated ceilings had holes and gaps allowing potential spread of fire and smoke beyond area of origin.
Plumbing equipment not maintained safely; toilet not secure and drain lines for icemaker not installed with required air gap.
Electrical equipment not maintained safely; flickering light in Room 19 and emergency exit sign not illuminating.
Fire safety equipment not maintained in operating condition; leaking valve with temporary piping installed to remove water.
Fire resistant rated doors did not completely close and latch to limit spread of smoke and fire.
Report Facts
Licensed capacity: 50
Number of corroded, painted or foreign material covered sprinkler pendants: 40
Size of hole in exterior soffit: 6
Size of hole in exterior soffit: 24
Size of peeled paint section: 8
Size of peeled paint section: 24
Diameter of hole in ceiling: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 10, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from 07/09/24 to 07/10/24, initiated by the Lee County Department of Social Services on 06/11/24.
Complaint Details
Complaint investigation was initiated by the Lee County Department of Social Services on 06/11/24 and included medication administration errors and failure to report an incident.
Findings
The facility failed to ensure medications were administered as ordered and failed to maintain accurate medication administration records for Resident #4, including missed nebulizer treatments and documentation discrepancies. Additionally, the facility failed to report an accident involving Resident #2 to the department of social services as required.
Deficiencies (3)
Failed to ensure medications were administered as ordered for Resident #4, including an error with a nebulizer treatment for COPD.
Failed to ensure accurate documentation on the electronic medication administration record (eMAR) for Resident #4, including nebulizer treatments.
Failed to ensure an accident and incident report was sent to the department of social services for Resident #2 who required emergency room evaluation after a fall.
Report Facts
Medication error rate: 3
Medication doses not documented as administered: 15
Medication doses administered: 183
Incident report date: 1
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and complaint investigation survey from 03/12/24 to 03/13/24 at Sanford Senior Living.
Complaint Details
The survey included a complaint investigation related to medication administration and incident reporting. The complaint was substantiated based on observations, record reviews, and interviews confirming medication administration errors and failure to report an incident.
Findings
The facility failed to ensure proper medication administration documentation for one resident, where a medication aide signed off medication administration that was not given, and failed to notify the next shift. Additionally, the facility failed to notify the county department of social services of an incident involving a resident's injury requiring emergency medical evaluation.
Deficiencies (2)
Failed to ensure the documentation on the electronic medication administration record was recorded by the medication aide that administered the medication to 1 of 4 residents observed during medication pass related to hypothyroidism medication.
Failed to notify the county department of social services of an incident resulting in injury requiring emergency medical evaluation for 1 of 3 sampled residents.
Report Facts
Residents observed during medication pass: 4
Sampled residents: 3
Date of medication administration error observation: Mar 13, 2024
Date of incident: Dec 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| first shift medication aide | Administered Levothyroxine to Resident #4 and discussed medication administration error. | |
| third shift medication aide | Signed off medication administration that was not given and failed to notify next shift. | |
| Resident Care Coordinator (RCC) | Interviewed regarding medication administration verification and incident reporting responsibilities. | |
| Administrator | Interviewed regarding resident awareness and incident reporting protocols. | |
| Special Care Coordinator (SCC) | Responsible for completing incident note for Resident #2 and discussed incident report completion. |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 11, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on August 9-11, 2022 to verify correction of previous deficiencies and assess ongoing compliance.
Findings
The facility failed to maintain substantial compliance with rules governing personal care, supervision, health care, nutrition, food services, and infection control. Deficiencies included failure to provide adequate personal care, follow-up on acute health care needs, maintain kitchen cleanliness, implement infection control measures, and ensure resident rights related to care and supervision.
Deficiencies (8)
Failure to provide personal care assistance including showers, shaving, grooming, hand washing with fingernail care and incontinence care for 3 of 4 sampled residents (#1, #2, #4).
Failure to follow up on acute health care needs and coordinate health care for 2 of 4 sampled residents (#2, #4) with issues including severely low blood sugar, falls with injuries, and skin breakdown.
Failure to ensure the kitchen and dining area were clean and protected from contamination related to live and dead roaches, black spots resembling roach excrement, dirt and pink film on the ice machine, grease and dust accumulation on oven and vent, and dirty dishes left in the dining room for two hours after lunch.
Failure to implement CDC and local health department guidance for COVID-19 infection prevention including staff not wearing required PPE, not completing required self COVID-19 screening prior to shifts, and failure to remove gloves and perform hand hygiene between patients.
Failure to provide assistance with eating meals upon arrival and in an unhurried manner maintaining dignity and respect for 1 sampled resident (#2) dependent on staff for eating assistance.
Failure to ensure residents were free of neglect related to personal care and supervision.
Failure to administer medications as ordered for 1 sampled resident (#4) receiving insulin to control blood glucose levels.
Failure to ensure accurate documentation on the medication administration record for 1 sampled resident (#4) for application and removal of compression stockings.
Report Facts
Correction date: Sep 10, 2022
Correction date: Sep 25, 2022
Temperature: 96
Temperature: 97
Temperature: 91
Resident weight: 89
Blood sugar values >450: 9
Blood sugar values <80: 4
Missed insulin doses: 8
Missed blood pressure checks: 5
Missed monthly weights: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Coordinator | MCC | Responsible for oversight of both facilities, monitoring personal care, meal observations, and training Resident Care Coordinator. |
| Medication Aide | MA | Resident Care Coordinator, responsible for medication administration, resident care coordination, and reporting refusals. |
| Kitchen Supervisor | Responsible for kitchen cleanliness and monitoring dietary staff. | |
| Administrator | Administrator | Failed to ensure management and total operations of the facility, including compliance with rules and regulations. |
| Personal Care Aide | PCA | Responsible for assisting residents with activities of daily living including feeding and personal care. |
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 9
Date: May 5, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow up survey on May 3 - 5, 2022 with an exit conference via telephone on May 5, 2022.
Findings
The facility failed to ensure proper physical environment safety, management and total operations, personal care and supervision, health care follow-up, medication administration, and food safety. Specific deficiencies included lack of exit door alarms for disoriented residents, inadequate management and supervision, failure to provide personal care and supervision, failure to follow up on healthcare referrals and appointments, medication administration errors, and pest contamination in the kitchen.
Deficiencies (9)
Failed to ensure 3 of 4 exit doors accessible to a disoriented resident were equipped with a sounding device.
Administrator failed to ensure management and total operations, resulting in failure to maintain substantial compliance with rules governing personal care, supervision, and health care.
Failed to provide personal care for 2 of 3 sampled residents related to catheter care, feeding assistance, grooming, bathing, incontinence care, repositioning, nail care, and dressing.
Failed to provide supervision for 1 of 3 sampled residents with history of falls resulting in injuries including pelvis fracture and arm laceration.
Failed to ensure referral and follow-up to meet healthcare needs for 3 of 3 sampled residents related to physical therapy, occupational therapy, orthopedic specialist, podiatry, urology, hematology, ophthalmology, and medication refusals.
Failed to ensure kitchen was clean and protected from contamination related to live and dead roaches in the kitchen.
Failed to maintain medication orders in 1 of 4 sampled resident records.
Failed to administer medications as ordered and in accordance with facility policies for 2 of 2 residents observed during medication pass including errors with mental/mood disorder medications, blood glucose monitoring, and medications for hypothyroidism, ulcers, and pain; and for 1 of 3 residents for record review including errors with medications for low magnesium, low Vitamin B12, and enlarged prostate symptoms.
Failed to ensure residents were free of mental and physical abuse, neglect, and exploitation related to personal care and supervision.
Report Facts
Medication error rate: 19
Residents present: 18
Facility score: 96.5
Pest control visits: 2
Medication doses refused: 8
Medication doses refused: 7
Medication doses refused: 7
Medication doses refused: 7
Medication doses refused: 7
Medication doses refused: 7
Medication doses refused: 7
Medication doses refused: 6
Medication doses refused: 9
Medication doses refused: 5
Medication doses refused: 5
Medication doses refused: 5
Medication doses refused: 5
Medication doses refused: 5
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 16, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on December 11-12 and 16, 2019 to verify correction of previous deficiencies.
Findings
The facility failed to ensure that a criminal background check was completed prior to hire for one staff member and failed to ensure medication aides observed residents take their medications, as medications were left in residents' rooms without proper observation.
Deficiencies (2)
Facility failed to assure 1 of 3 sampled staff had a criminal background check completed prior to hire.
Facility failed to ensure medication aides observed 2 of 2 residents take their medications related to leaving medications in the residents' rooms.
Report Facts
Number of sampled staff: 3
Number of residents observed: 2
Date of staff hire: Sep 30, 2019
Date of criminal background check completion: Dec 11, 2019
Date of medication administration observations: Dec 11, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Named in deficiency for missing criminal background check prior to hire |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 11, 2019
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to construction and safety compliance at Royal Oaks Assisted Living.
Findings
The facility was found not in compliance with sanitary requirements due to ineffective measures to prevent bed bugs, including presence of fecal stains and trash in resident rooms. Additionally, fire safety components were not maintained in a safe and operating condition, including missing fire damper assembly, lack of monthly fire extinguisher inspections, removal of door closure bars on fire-rated doors, and sprinkler system pressure loss.
Deficiencies (5)
Facility did not have effective measures to prevent bed bugs from being present on the premises, with fecal stains and trash observed in resident rooms.
Failure to maintain fire safety components in a safe and operating condition, including removal of fire damper assembly unit.
Fire extinguishers were not inspected monthly in-house; only one inspection recorded in June.
Failure to maintain auto closing on fire-rated doors, allowing passage of fire and/or smoke.
Sprinkler system was not maintained in a safe and operating condition; zero pressure observed on accelerator/quick opening device.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 14, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a follow-up survey on August 14-15, 2019, with a telephone exit on August 16, 2019.
Findings
The facility failed to maintain cleanliness and good repair in resident rooms and bathrooms, failed to ensure tuberculosis testing upon admission for one resident, failed to implement physician orders for medications and treatments for one resident, failed to serve therapeutic diets and nutritional supplements as ordered for two residents, failed to administer medications as ordered for two residents, and failed to ensure proper self-administration orders and assessments for one resident. Additionally, the facility failed to document controlled substance screening for one staff member prior to hire.
Deficiencies (7)
Facility failed to maintain floors, walls, ceiling vents, carpets, toilets, shower curtains and doorways clean and in good repair for residents' rooms and bathrooms.
Facility failed to assure 1 of 3 sampled residents was tested for tuberculosis disease upon admission.
Facility failed to assure physician orders were implemented for 1 of 5 sampled residents with orders for portable oxygen and orders to check vital signs twice a month.
Facility failed to assure therapeutic diets were served as ordered for 2 of 5 sampled residents with diet orders for a mechanical soft diet with nectar thick liquids and nutritional supplements.
Facility failed to assure medications were administered as ordered by a licensed prescribing practitioner for 2 of 3 sampled residents related to multiple medications including antiretroviral, anti-hypertensive, anticholinergic, anxiety, and pain medications.
Facility failed to assure 1 of 3 sampled residents had physicians' orders to self-administer two eye drops, an inhaler, and a nebulizer.
Facility failed to assure documentation of an examination and screening for the presence of controlled substances was completed for 1 of 3 sampled staff prior to hire.
Report Facts
Deficiencies cited: 7
Missed medication doses: 3
Missed medication doses: 2
Missed medication doses: 3
Missed medication doses: 2
Missed medication doses: 1
Missed medication doses: 3
Missed medication doses: 2
Missed medication doses: 3
Missed medication doses: 8
Missed medication doses: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | No documentation of controlled substance examination and screening prior to hire |
Inspection Report
Capacity: 50
Deficiencies: 19
Date: Jul 19, 2019
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1993 Rules for Licensing of Domiciliary Homes and applicable adult care home rules, including physical plant and safety requirements.
Findings
The facility was found to have multiple deficiencies including ineffective vermin control with live bed bugs and roaches present, unsafe and unclean physical plant conditions such as blocked egress paths, damaged gutters, dirty kitchen floors with grease buildup, fire safety components compromised including unmaintained fire doors and extinguishers, plumbing and ventilation issues, and excessively high hot water temperatures.
Deficiencies (19)
Facility did not have effective measures to prevent bed bugs from being present on the premises, with live bed bugs observed in resident rooms.
Roaches found at the Staff Lounge behind the refrigerator; staff reported roaches come out at night around the Kitchen area.
Mattresses blocking sidewalk and path of egress out of EAST HALL corridor exit.
Fallen tree limb located outside backside of Kitchen in grounds walking path.
Damaged gutter located at backside of WEST HALL.
Kitchen floors dirty with excessive grease build-up at food preparation areas and under appliances.
Kitchen range has excessive grease build-up and food debris; mold build-up on inside sides of 3-compartment dish wash sinks; frayed carpet at threshold area in Room 15 creating trip hazard.
Fire-rated roof/ceiling assembly compromised in Sprinkler Riser Room due to recent sprinkler piping repair.
Removal of fire damper assembly unit providing make-up air for gas appliance due to sprinkler piping repair.
Sprinkler removed and plugged in Sprinkler Riser Room leaving area unprotected.
Exit sign outside Room 13 not illuminated.
Audio/visual fire alarm device not secured to wall outside Kitchen Pantry.
Fire extinguishers not inspected in-house monthly.
Doors wedged open or out of adjustment allowing passage of fire and/or smoke in multiple locations including Employee Lounge, Vending Room, Kitchen Pantry, Storage Room/WEST HALL, Kitchen Entry.
Door leading into Dining Hall from Kitchen is fire-rated but door closure removed allowing passage of fire and/or smoke.
Water temperature mixing valve in Mechanical Room is in disrepair and corroded.
Salon hair wash sink sprayer lacks vacuum breaker.
Exhaust fan at Kitchen can wash area is non-operational, lacks protective screening, and has exposed power wiring.
Resident bathroom water temperatures recorded at 140 degrees Fahrenheit, exceeding maximum allowed 116 degrees.
Report Facts
Total licensed capacity: 50
Water temperature: 140
Inspection Report
Capacity: 50
Deficiencies: 12
Date: Aug 3, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with applicable licensing rules and building codes for the facility.
Findings
Multiple deficiencies were cited including failure to maintain current sanitation and fire safety inspection reports, presence of chronic unpleasant odors, walls and ceilings not kept clean and in good repair, building equipment and fire safety systems not maintained in safe and operating condition, electrical system issues, fire sprinkler system deficiencies, inaccessible areas for inspection, improperly maintained fire extinguishers, and inadequate exhaust ventilation.
Deficiencies (12)
Facility failed to maintain current annual sanitation and fire safety inspection reports.
Facility failed to prevent chronic unpleasant odors due to dried-up floor drain allowing sewer gases to enter the building.
Walls and ceilings not kept clean and in good repair; closet wall and door marred, ventilation grille with excessive dust/lint.
Doors protecting smoke barrier did not close completely and latch to restrict smoke.
Emergency exit signs and emergency lighting did not illuminate on backup power.
Gaps around cables and holes not firestopped in fire-resistance-rated ceiling assembly.
Corridor doors did not automatically latch or were obstructed preventing proper closure and latching.
Electrical panel had open slot exposing energized components; light fixture missing bulb.
Fire sprinkler escutcheon plate dropped down exposing opening allowing spread of smoke and heat.
Building areas inaccessible for inspection due to lack of keys.
Fire extinguisher gauge indicated recharging required.
Exhaust ventilation system failed to operate in storage room near kitchen and staff restroom, causing odors.
Report Facts
Total licensed capacity: 50
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 27, 2016
Visit Reason
The Adult Care Licensure Section and the Lee County Department of Social Services conducted an annual, follow-up survey and a complaint investigation on July 27 and July 28, 2016. The complaint investigation was initiated by the Lee County Department of Social Services on July 5, 2016.
Complaint Details
The complaint investigation was initiated by the Lee County Department of Social Services on July 5, 2016, and was part of the survey conducted on July 27 and 28, 2016.
Findings
The facility failed to maintain hot water temperatures within the required range at six fixtures, with temperatures ranging from 124 to 128 degrees F initially, later corrected to acceptable levels. Additionally, the facility failed to ensure written physician diet orders for therapeutic diets for sampled residents and maintain an accurate and current listing of residents with physician-ordered therapeutic diets.
Deficiencies (3)
Hot water temperatures at six fixtures (5 sinks and 1 shower) in resident bathrooms exceeded the maximum allowed temperature of 116 degrees F, ranging from 124 to 128 degrees F.
Failed to assure there was a written physician's diet order for 1 of 3 sampled residents (Resident #3) regarding therapeutic diets including thickened liquids.
Failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets for 3 of 3 sampled residents (Residents #2, #3, and #5).
Report Facts
Number of fixtures with hot water temperature issues: 6
Hot water temperature range: 124
Hot water temperature range: 128
Dates of survey: 2
Number of sampled residents with diet order issues: 3
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 28, 2016
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation on April 27-28, 2016, initiated by the Lee County Department of Social Services on April 8, 2016.
Complaint Details
Complaint investigation initiated by Lee County Department of Social Services on April 8, 2016, conducted April 27-28, 2016.
Findings
The facility failed to ensure physician and pharmacy notification for 2 of 5 sampled residents regarding orders for INR laboratory results and medication orders for high blood pressure, enlarged prostate, anxiety, seizure, blood thinner, and cholesterol medications. Medication administration errors and inaccurate medication administration records were also found.
Deficiencies (5)
Failed to ensure physician and pharmacy notification for residents regarding INR lab results and medication orders.
Failed to assure medications were administered as ordered for 4 of 6 sampled residents related to errors with medications (Lactulose, Nexium, Vitamin B injections, and Coumadin).
Failed to assure the electronic Medication Administration Records (eMARs) were accurate for 4 of 5 sampled residents.
Failed to assure adequate medication reviews were completed for 1 of 5 sampled residents in the areas of changing Coumadin orders and incomplete laboratory value follow-up.
Failed to ensure every resident received care and services which were adequate, appropriate, and in compliance with relevant laws related to Health Care.
Report Facts
Deficiencies cited: 5
Medication doses: 8
Medication doses: 4
Medication doses: 10
Dates: Apr 12, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reviewed new orders, verified eMAR entries, and was interviewed multiple times regarding medication administration and record accuracy. | |
| Medication Aide | Interviewed regarding medication administration errors and eMAR documentation. | |
| Contract Pharmacy Representative | Interviewed regarding pharmacy order entries and medication administration system. | |
| Resident Care Coordinator | Responsible for tracking laboratory results and medication orders; left facility several months prior. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 6, 2016
Visit Reason
The visit was a Follow-Up Construction Survey to verify correction of previously cited deficiencies related to building safety and fire protection equipment.
Findings
The survey found that the required one-hour fire rated walls and ceilings were compromised with unsealed holes and missing or inoperable ceiling radiation dampers, posing a fire spread risk. Additionally, the fire alarm panel showed a trouble signal due to a temco 2 error, which was corrected before the surveyors departed.
Deficiencies (2)
Required one-hour fire rated walls and/or ceilings were compromised with holes and penetrations not sealed with approved materials and missing or inoperable ceiling radiation dampers.
Fire protection equipment was in disrepair, including a fire alarm panel showing a trouble signal (temco 2 error).
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 31, 2015
Visit Reason
The visit was a follow-up survey to verify correction of previously noted deficiencies at Royal Oaks Assisted Living.
Findings
The inspection found that the building's fire safety features were compromised, including unsealed holes in fire-rated walls and ceilings, missing or inoperable ceiling radiation dampers, and issues with the sprinkler system such as leaking valves and lint buildup. Additionally, the range hood fire suppression system was not inspected monthly as required.
Deficiencies (3)
Required one-hour fire rated walls and/or ceilings were compromised with holes and penetrations not sealed with approved materials, and missing or inoperable ceiling radiation dampers.
Sprinkler system not maintained in a safe and operating condition, including leaking valves at the backflow preventer and significant lint buildup on sprinkler heads.
Range hood fire suppression system not inspected monthly as required; last documented inspection was in February.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Sep 10, 2015
Visit Reason
Follow-up survey conducted to verify correction of previously noted deficiencies related to building equipment safety and fire protection systems at Royal Oaks Assisted Living.
Findings
The facility was found to have compromised one-hour fire rated walls and ceilings with unsealed holes and missing or inoperable ceiling radiation dampers, a sprinkler system not maintained in safe operating condition including leaking valves and lint buildup, and failure to perform monthly inspections of the range hood fire suppression system.
Deficiencies (4)
Required one-hour fire rated walls and ceilings compromised with unsealed holes and missing or inoperable ceiling radiation dampers.
Sprinkler system not maintained in safe operating condition; valves at backflow preventer leaking and backflow preventer could not be tested.
Significant lint buildup on sprinkler head in laundry.
Range hood fire suppression system not inspected monthly as required; last documented inspection was in February.
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 9
Date: Aug 19, 2015
Visit Reason
The Adult Care Licensure Section and the Lee County Department of Social Services conducted an annual survey, complaint investigation and follow-up survey on 08/19/15 and 08/20/15. The complaint investigation was initiated by the Lee County Department of Social Services on 07/15/15.
Complaint Details
The complaint investigation was initiated by the Lee County Department of Social Services on 07/15/15 related to concerns about resident supervision and care.
Findings
The facility failed to maintain hot water temperatures within the required range for multiple fixtures, failed to provide supervision according to residents' assessed needs resulting in a resident's death, failed to assure medication orders were consistent and administered correctly, failed to provide adequate table service with non-disposable place settings, and failed to provide adequate milk servings as per menu requirements.
Deficiencies (9)
Hot water for 7 of 26 sink fixtures and 5 of 26 shower fixtures in resident bathrooms exceeded the maximum temperature of 116 degrees F, ranging from 128 to 138 degrees F.
Failed to provide supervision in accordance with resident assessed needs, care plan and symptoms for 1 resident who was locked in the bathroom overnight and subsequently expired.
Failed to assure referral and follow-up to meet routine and acute health care needs for 1 resident related to not obtaining physician ordered lab work.
Failed to assure table service included a non-disposable place setting consisting of at least a knife, fork, spoon, plate, and beverage containers for residents' meals.
Failed to assure residents were provided 8 ounces of pasteurized milk at least twice a day.
Failed to contact the physician for clarification of inconsistent medication orders for 1 resident with multiple admission forms.
Failed to assure medications were administered as ordered by the licensed prescribing practitioner for 2 residents, including errors with multiple medications.
Failed to assure action was taken in response to pharmacist recommendations from the quarterly drug regimen review for 1 resident.
Failed to assure residents were free of neglect related to personal care and supervision.
Report Facts
Hot water fixtures out of temperature range: 12
Resident census: 23
Medication administration errors: 2
Residents served milk: 1
Miralax doses administered: 31
Inspection Report
Capacity: 50
Deficiencies: 12
Date: May 5, 2015
Visit Reason
Biennial Construction Survey performed to assess compliance with applicable adult care home rules and state building codes.
Findings
The facility failed to maintain floor coverings in good repair, had exposed electrical hazards, lacked proper fire safety measures including compromised fire-rated walls, non-functioning exit signs, and improperly maintained sprinkler and fire suppression systems. Additionally, hot water temperatures exceeded safe limits, and fire drill records were incomplete.
Deficiencies (12)
Worn floor coverings presenting trip and fall hazards in multiple locations.
Exposed electrical parts in light fixtures posing shock or electrocution risk.
Radiation damper in ceiling register was very dirty and may not close properly in fire.
Shower wand hose lacked vacuum breaker, risking water contamination.
Broken and unusable towel bar in bath off room 1.
Fire drill records lacked description of what the drill involved.
Compromised one-hour fire rated walls and ceilings with unsealed penetrations and missing radiation dampers.
Exit sign at right end of facility was not illuminated.
Cross-corridor smoke barrier doors failed to latch properly, some doors propped open or wedged preventing closure.
Sprinkler system valves leaking and backflow preventer could not be tested; lint buildup on sprinkler head.
Range hood fire suppression system not inspected monthly as required.
Hot water temperature exceeded 116 degrees F, measured at 121 and 124 degrees F, posing burn risk.
Report Facts
Total licensed capacity: 50
Hot water temperature: 121
Hot water temperature: 124
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 21, 2015
Visit Reason
The Adult Care Licensure Section and the Lee County Department of Social Services conducted a complaint investigation on 4/20/15 and 4/21/15, initiated by a complaint from Lee County Department of Social Services on 4/07/15.
Complaint Details
The complaint investigation was initiated due to concerns about staff interventions with Resident #1, who exhibited aggressive behaviors. The resident became violent, assaulted staff, and died after staff restrained him. The State Medical Examiner ruled the cause of death as asphyxiation with evidence of neck compression. The facility failed to report the abuse allegation to the Health Care Personnel Registry in a timely manner.
Findings
The facility failed to ensure policy and procedures were implemented for one resident with aggressive behaviors, resulting in the resident's death during a violent incident involving staff intervention. Additionally, the facility failed to report an allegation of staff abuse resulting in the resident's death to the North Carolina Health Care Personnel Registry.
Deficiencies (2)
Failed to ensure policy and procedures were implemented for Resident #1 as evidenced by staff interventions for the resident's aggressive behaviors.
Failed to report to the North Carolina Health Care Personnel Registry an allegation of abuse by staff resulting in death of Resident #1.
Report Facts
Facility admission date: Mar 5, 2015
Incident date: Apr 1, 2015
Date survey completed: Apr 21, 2015
Staff training date: Aug 17, 2014
Correction date for Type A1 violation: May 20, 2015
Correction date for Type B violation: Jun 5, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Named in findings related to restraint and failure to report abuse resulting in resident death |
| Staff C | Personal Care Aide | Named in findings related to restraint and resident aggressive behavior incident |
| Staff A | Medication Aide | Named in findings related to resident aggressive behavior incident |
| Activity Director | Witnessed incident and reported events leading to resident death | |
| Administrator | Facility Administrator | Responsible for reporting and investigation; failed to timely report to HCPR |
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