Inspection Reports for TerraBella Knightdale
2408 Hodge Road Knightdale, NC 27545, Knightdale, NC, 27545
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 6, 2025, found deficiencies related to fire safety code compliance, specifically with special locking doors not unlocking upon fire alarm activation and issues maintaining the fire alarm system in safe operating condition. Earlier inspections showed a consistent pattern of physical plant and fire safety deficiencies, including problems with electromagnetic locks, fire alarm panels, smoke-tight doors, and exhaust ventilation. Prior reports also noted recurring issues with medication administration errors, staff training, resident supervision, and failure to follow physician orders, although no fines, immediate jeopardy findings, or license actions were listed in the available reports. Complaint investigations were generally unsubstantiated or focused on supervision and medication concerns, with no enforcement actions noted. The facility’s physical plant and fire safety compliance issues have persisted over multiple inspections, while some clinical care deficiencies appear less frequent in recent years.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57 residents
Based on a July 2024 inspection.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 6, 2025
Visit Reason
This report documents a Construction Section Biennial Follow Up Survey conducted to assess compliance with physical plant and fire safety code requirements.
Findings
The facility was found non-compliant with code requirements related to special locking doors that must unlock upon fire alarm activation, and there was a failure to maintain the fire alarm system in a safe operating condition, with the fire alarm panel indicating trouble.
Deficiencies (2)
Facility is not in compliance with code requirements for special locking doors to unlock upon activation of the fire alarm system.
Failure to maintain the facility's fire alarm system devices and equipment in a safe operating condition; fire alarm panel was indicating trouble.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to assess compliance with physical plant and fire safety code requirements.
Findings
The facility was found not in compliance with code requirements related to special locking doors and fire alarm system maintenance. The fire alarm panel was in trouble mode due to a faulty detector, preventing testing of the electromagnetic lock release mechanism.
Deficiencies (2)
Facility is not in compliance with code requirements for special locking doors to unlock upon activation of the fire alarm or sprinkler system.
Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; fire alarm panel was in trouble mode due to a faulty detector.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 5
Date: Jul 23, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey of The Addison of Knightdale from July 23 to July 25, 2024.
Findings
The facility was found to have multiple deficiencies including failure to maintain water temperatures within required limits, medication aides lacking properly signed training certificates, uncovered and undated food items in the kitchen cooler, incomplete and inaccurate medication orders for a resident, and medication administration errors including late administration and missing medications.
Deficiencies (5)
Water temperatures in residents' rooms were not maintained between 100 to 116 degrees Fahrenheit, with 5 of 10 fixtures out of range.
Staff administering medications had not completed state-approved medication aide training with properly signed certificates for 2 of 6 sampled staff.
Food items in the kitchen cooler were uncovered and undated, risking contamination.
Failed to ensure verification or clarification of medication orders for 1 of 5 sampled residents, with discrepancies in medication orders and records.
Failed to administer medications as ordered for 2 of 3 residents observed during medication pass, including late administration and missing medications.
Report Facts
Water fixtures out of temperature range: 5
Medication aide training noncompliance: 2
Uncovered food items: 35
Medication administration errors: 6
Residents census: 57
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 8, 2024
Visit Reason
The inspection was a Construction Section Biennial Follow Up Survey conducted to assess compliance with physical plant requirements and code regulations.
Findings
The facility was found not in compliance with code requirements related to electromagnetic locks on doors. Specifically, the locks did not release upon activation of the fire alarm or emergency release switches, and some emergency release switches were momentary, causing doors to lock back within 5 seconds.
Deficiencies (3)
The electromagnetic lock on the SCU Courtyard gate did not release upon activation of the fire alarm.
The electromagnetic lock did not release with the central emergency release switch.
The emergency release switch by Exit C9 is a momentary switch causing the door to lock back within 5 seconds.
Inspection Report
Capacity: 68
Deficiencies: 3
Date: Mar 12, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 2012 North Carolina State Building Code, Institutional Occupancy, and the 2005 Adult Care Home Rules for the facility licensed for 68 Adult Care Home beds including 23 Special Care Unit beds.
Findings
Deficiencies were cited related to building equipment maintenance and exhaust ventilation. Specifically, smoke-tight corridor doors were not maintained in a safe and operating condition, fire safety systems had gaps allowing potential fire and smoke spread, and exhaust fans in men's guest bathrooms on the 2nd and 3rd floors were not working.
Deficiencies (3)
Smoke-tight corridor doors are not maintained in a safe and operating condition; door hardware missing on 2nd Floor Network Room allowing passage of smoke/fire.
Failure to maintain fire safety systems in a safe condition; gaps around cable penetrations in fire rated ceiling assembly on 2nd Floor Electrical/Mechanical Room.
Facility is not maintaining exhaust fans in operable condition; exhaust fans not working in 2nd Floor and 3rd Floor Men's Guest Bathrooms.
Report Facts
Licensed capacity: 68
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 29, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 03/28/22-03/29/22 to verify correction of previous deficiencies.
Findings
The facility failed to contact the primary care provider for one resident with a reddened lump and swelling on her left foot and lower leg, and failed to administer medications as ordered for the same resident, including errors with an inhaler and two nasal sprays. Medication audits revealed medications dispensed in September and October 2021 were still on the medication cart and not administered as ordered.
Deficiencies (2)
Failed to contact the primary care provider for a resident with a reddened lump and swelling on her left foot and lower leg.
Failed to administer medications as ordered for a resident, including errors with an inhaler and two nasal sprays.
Report Facts
Medication doses remaining: 158
Medication supply duration: 100
Medication supply duration: 30
Medication supply duration: 30
Skin discoloration size: 4
Skin discoloration size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Coordinator | Memory Care Coordinator | Interviewed regarding resident condition and medication ordering process. |
| Health and Wellness Director | Health and Wellness Director | Interviewed regarding resident condition, medication administration, and audits. |
| Medication Aide | Medication Aide | Interviewed regarding medication administration and audits. |
| Administrator in Charge | Administrator in Charge | Interviewed regarding skin rounds, documentation, and medication administration expectations. |
| Pharmacy Technician | Pharmacy Technician | Interviewed regarding medication dispensing and refill processes. |
| Case Manager | Case Manager | Interviewed regarding hospice services and resident condition. |
| Primary Care Provider | Primary Care Provider | Interviewed regarding notification and treatment of resident's condition. |
Inspection Report
Census: 55
Capacity: 96
Deficiencies: 12
Date: Feb 8, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up and complaint investigation with onsite visits from 01/25/22 through 02/08/22, including a reopened investigation and desk review.
Findings
The facility failed to ensure exit doors had functioning sounding devices, maintain adequate staffing levels in assisted living and special care units, implement an emergency disaster plan, maintain an operational call system, provide proper supervision, ensure timely referral and follow-up for residents' health care needs, administer medications accurately and on time, and maintain infection control during medication administration.
Deficiencies (12)
Failed to ensure 7 of 7 exit doors accessible by residents known to be disoriented were equipped with a sounding device activated when opened and staff were not using pagers to receive alerts.
Failed to develop a written Emergency Disaster Plan and have sufficient preparations for impending inclement weather, resulting in only one staff on duty to provide care for 55 residents including 18 residents on a Special Care Unit for at least 10 hours.
Failed to ensure the facility's call system was operational as designed, resulting in at least one resident having to call 911 for assistance after a fall due to lack of staff response.
Failed to ensure required staffing hours for the assisted living area were met for 10 of 21 shifts sampled.
Failed to ensure a supervisor was on duty at all times to provide supervision of direct care staff and implementation of facility policies and procedures.
Failed to ensure referral and follow-up to meet routine and acute health care needs for 3 of 7 sampled residents related to failure to notify PCP, EMS, and hospice as appropriate.
Failed to administer medications as ordered and in accordance with facility policies for 4 of 6 sampled residents, including wrong form of medication, medications almost administered to wrong resident, missed medications, and late administration of a medication used to treat mental and mood disorders.
Failed to ensure infection control measures were implemented during medication pass by a medication aide who failed to wash or sanitize hands before and after medication administration, increasing risk of pathogen transmission during a COVID-19 outbreak.
Failed to ensure minimum number of staff were present at all times to meet needs of residents in the special care unit for 7 of 9 shifts sampled.
Failed to ensure a care coordinator was on duty in the special care unit at least eight hours a day, five days a week to oversee resident care and services.
Failed to ensure staff were available and trained to maintain overall operations of the facility, meet health care and other needs of residents, and ensure care and services were delivered in a safe manner for a total census of at least 55 residents including 17 in the special care unit.
Failed to ensure medication administration records were accurate for 1 of 8 sampled residents related to documentation of administration of medications left at bedside for self-administration.
Report Facts
Residents with dementia or cognitive impairment: 12
Unlocked exit doors accessible to residents: 7
Residents in assisted living unit: 37
Residents in special care unit: 18
Medication error rate: 17
Staff hours shortage: 14.4
Staff hours shortage: 18
Staff hours shortage: 9.25
Staff hours shortage: 8.8
Staff hours shortage: 7.65
Staff hours shortage: 6.4
Staff hours shortage: 10.25
Staff hours shortage: 14.4
Staff hours shortage: 16
Staff hours shortage: 2
Staff hours shortage: 14.4
Residents in assisted living unit: 39
Residents in special care unit: 16
Residents in special care unit: 15
Residents in special care unit: 16
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 14
Date: Nov 12, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual, follow up and complaint investigation survey on November 9, 10 and 12, 2021.
Complaint Details
The survey included complaint investigation related to Resident #6 eloping from the facility on 08/09/21 and concerns about medication refusals and supervision.
Findings
The facility failed to ensure exit doors on the Assisted Living unit were equipped with sounding devices to alert staff, failed to ensure staff had no substantiated findings on the Health Care Personnel Registry upon hire, failed to maintain adequate staffing levels, failed to ensure tuberculosis screening and testing documentation, failed to provide personal care and supervision according to care plans, failed to ensure referral and follow-up for health care needs, failed to administer medications as ordered, failed to properly identify residents prior to medication administration, failed to maintain complete resident records, failed to submit required reports to the Health Care Personnel Registry, and failed to maintain adequate staffing on the Special Care Unit.
Deficiencies (14)
Failed to ensure 7 of 7 exit doors on the Assisted Living Unit were equipped with sounding devices that activated and sounded when opened to alert staff for a resident with cognitive impairment and history of elopement.
Failed to ensure 2 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry upon hire.
Failed to ensure 1 of 3 sampled staff had a criminal background check completed upon hire.
Failed to maintain accurate staffing records to meet minimum staffing requirements for the Assisted Living and Special Care Units.
Failed to ensure documentation of tuberculosis screening and testing for 2 of 5 sampled residents.
Failed to provide toileting assistance and incontinence care according to residents' needs and care plans for 1 of 5 sampled residents.
Failed to provide supervision for 2 of 6 sampled residents with history of falls and wandering behaviors.
Failed to ensure referral and follow-up for 3 of 5 sampled residents including failure to notify endocrinologist of high blood sugar, failure to notify primary care provider of medication refusals, and failure to ensure physical therapy referral was implemented.
Failed to ensure physician orders were implemented for 2 of 6 sampled residents regarding finger stick blood sugar checks and weekly weights.
Failed to ensure a system was in place to properly identify residents prior to medication administration, including giving medication in a cup labeled with another resident's name and medication aide asking residents to identify themselves.
Failed to maintain documentation of contact and visit notes with licensed providers and written orders in residents' records for 2 of 5 sampled residents.
Failed to submit a completed 24 hour report to the Health Care Personnel Registry followed by an investigation and 5 Day report for injuries of unknown origin for 1 of 1 sampled residents.
Failed to ensure accident and incident reports were completed with required information including name of staff who discovered the incident, time of incident, and signature of administrator for 2 of 6 sampled residents.
Failed to ensure accurate documentation verifying minimum staffing ratios on the Special Care Unit for 8 sampled days.
Report Facts
Residents on Assisted Living side: 37
Residents on Special Care Unit: 17
Residents in common area: 11
Medication refusals: 20
Clonazepam tablets dispensed: 28
Clonazepam tablets remaining: 9
Medication administration missing: 10
Medication administration missing: 2
Medication refusals: 6
Staff on SCU: 3
Staff on SCU: 2
Total facility census: 55
Staff scheduled for entire building: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Named in medication error and supervision findings |
| Health and Wellness Director | Health and Wellness Director | Named in multiple findings including supervision, medication, and reporting |
| Administrator | Administrator | Named in multiple findings including supervision, medication, and reporting |
| Clinical Operations Specialist | Clinical Operations Specialist | Named in medication and record keeping findings |
| Medication Aide | Medication Aide | Named in medication administration and supervision findings |
| Personal Care Aide | Personal Care Aide | Named in supervision and personal care findings |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 24, 2020
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and a COVID-19 focused Infection Control survey with an onsite visit on 07/24/20 and desk reviews between 07/14/20 and 07/24/20, to assess compliance with health care regulations following a prior Type A1 violation.
Findings
The facility failed to notify the primary care provider (PCP) of a resident's (Resident #1) complaints and lab results related to a suspected urinary tract infection (UTI), despite multiple attempts and documentation. The UA results ordered on 05/20/20 were never received by the PCP due to a failure in the lab results transmission process. The facility lacked processes to ensure lab results were received by providers, and noncompliance with referral and follow-up requirements continued.
Deficiencies (1)
Failure to notify the primary care provider of complaints and lab results related to a urinary tract infection for Resident #1.
Report Facts
Dates of UA order and lab results: May 20, 2020
Dates of UA order and lab results: May 26, 2020
Resident sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | RCC | Named in relation to failure to notify PCP and scheduling appointments |
| Health and Wellness Director | HWD | Interviewed regarding lab result processes and responsibilities |
| Medication Aide | MA | Reported attempts to notify PCP and documented resident complaints |
| Primary Care Provider | PCP | Notified of failure to receive UA results and expected notification |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 16, 2020
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Service conducted an annual and follow-up survey from 01/13/20 to 01/16/20.
Findings
The facility was found to have multiple deficiencies including unsafe storage and transport of portable oxygen cylinders, failure to document tuberculosis testing for staff, failure to check health care personnel registry for staff, failure to assure referral and follow-up for residents with health issues including falls and therapy needs, failure to implement primary care provider orders, medication administration errors including failure to assess pulse prior to digoxin administration, failure to report accidents and incidents to the county department of social services, and failure to provide adequate care and services in compliance with regulations.
Deficiencies (9)
Storage of multiple portable oxygen cylinders in an unsafe manner, unsecured on the floor and transported by propping in resident rollators while in use.
Failure to document a two-step tuberculin skin test for 1 of 7 sampled staff upon hire.
Failure to access and document North Carolina Health Care Personnel Registry check for 2 of 7 staff prior to employment.
Failure to assure referral and follow-up for 2 of 5 sampled residents who had falls and therapy needs, resulting in serious injury and neglect.
Failure to assure primary care provider orders were implemented for 2 of 5 sampled residents including missed laboratory tests and failure to reassess blood pressure.
Failure to administer medications as ordered and in accordance with facility policies for 1 of 6 residents including failure to assess pulse prior to digoxin administration and failure to administer a vitamin supplement.
Failure to complete observations for 1 of 5 residents taking ordered medications in accordance with facility medication policies.
Failure to notify the county department of social services of accidents or incidents resulting in resident injury or hospitalization for 2 of 5 sampled residents.
Failure to ensure residents received care and services that were adequate, appropriate and in compliance with relevant laws related to housekeeping, furnishings, and medication administration.
Report Facts
Medication error rate: 7
Oxygen cylinders: 19
Staff sampled: 7
Residents sampled: 5
Medication doses observed: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Interviewed regarding oxygen cylinder storage and medication administration |
| Health and Wellness Director | Health and Wellness Director | Interviewed regarding tuberculosis testing, medication administration, referrals, and incident reporting |
| Executive Director | Executive Director | Interviewed regarding staff qualifications, medication administration, referrals, and incident reporting |
| Medication Aide | Medication Aide | Interviewed regarding oxygen cylinder handling and medication administration |
| Business Office Manager | Business Office Manager | Interviewed regarding tuberculosis testing and health care personnel registry checks |
| Memory Care Director | Memory Care Director | Interviewed regarding oxygen cylinder handling |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 16, 2019
Visit Reason
The Adult Care Licensure Section and Wake County Human Services conducted a follow-up survey on October 15-16, 2019 to verify correction of previous deficiencies related to medication administration.
Findings
The facility failed to administer medications as ordered and in accordance with facility policies for 2 of 5 residents observed during medication passes, resulting in a 19% medication error rate with 6 errors out of 31 opportunities. Errors included improper administration of inhalers, antipsychotic medication, vitamin D supplement, calcium with vitamin D supplement, and medication for overactive bladder.
Deficiencies (1)
Failed to administer medications as ordered and in accordance with facility policies for 2 of 5 residents (#6, #7) observed during medication passes including errors with an antipsychotic, two inhalers for breathing problems, a vitamin D supplement, a calcium with vitamin D supplement, and a medication for overactive bladder.
Report Facts
Medication error rate: 19
Medication errors: 6
Medication administration opportunities: 31
Residents observed: 5
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 10, 2019
Visit Reason
The Adult Care Licensure Section and the Wake County Human Services conducted a follow-up survey on April 8 - 10, 2019 to verify correction of previous deficiencies and compliance with regulations.
Findings
The facility failed to ensure that one resident was treated with respect and dignity related to an inappropriate admission to the special care unit. Medication administration errors were found for two residents, including crushing medications improperly and incorrect administration times. Additionally, two residents admitted to the special care unit did not have the required diagnosis or pre-admission screening documentation.
Deficiencies (3)
Failed to ensure that 1 of 5 sampled residents was treated with respect, consideration and dignity related to inappropriate admission to the special care unit.
Failed to administer medications as ordered and in accordance with facility policies for 2 residents, including crushing medications improperly and incorrect administration times.
Failed to assure that 2 residents admitted to the special care unit had a diagnosis meeting the conditions of the specific group and lacked documentation of pre-admission screening.
Report Facts
Medication error rate: 20
Residents sampled for medication review: 5
Residents sampled for respect and dignity review: 5
Residents sampled for special care unit admission review: 2
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 1, 2018
Visit Reason
Biennial Follow-up Construction Survey to assess corrective actions on previously identified deficiencies.
Findings
Deficiencies remain in the physical plant including lack of hand grips at tubs and showers, ceilings not maintained in good repair with mildew stains, and multiple gaps or holes around sprinkler head escutcheon plates and electrical junction boxes that compromise fire safety.
Deficiencies (3)
Hand grips were not provided at all tubs and showers used by or accessible to residents; suction cup grip in B Hall Spa tub is unreliable.
Ceilings were not maintained in good repair; black mildew stains observed around smoke detectors and sprinkler heads in D Hall including Activity Room and corridors.
Failure to maintain building's fire safety systems in a safe condition due to holes or gaps at penetrations through fire resistant rated ceilings allowing fire and smoke to spread beyond area of origin.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 4, 2018
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted a follow-up survey and complaint investigation from 10/02/18 to 10/04/18, initiated by a complaint on 09/18/18.
Complaint Details
The complaint investigation was initiated by the Wake County Department of Social Services on 09/18/18 related to supervision and care concerns.
Findings
The facility failed to provide adequate supervision to residents with a history of falls and behavioral issues, resulting in serious injuries including a cervical fracture and hip fracture. Medication administration errors were observed, including failure to hold diuretics based on weight changes and incorrect administration of diabetic medication. The facility also failed to ensure proper physician orders for residents self-administering medications and failed to notify the county department of social services of a serious fall incident.
Deficiencies (7)
Facility failed to assure 1 of 6 staff had no substantiated findings on the North Carolina Health Care Personnel Registry.
Facility failed to provide needed supervision to 3 of 5 residents with history of falls and agitation, resulting in serious injuries including a cervical fracture and hip fracture.
Facility failed to administer medications as ordered and in accordance with policies for 2 of 6 residents, including errors with diuretic and diabetic medications, and for 1 of 5 residents with errors in blood pressure and eye medications.
Facility failed to assure 2 of 3 residents had physician orders to self-administer medications, including an oral inhaler and an over-the-counter nasal spray.
Facility failed to report to the County Department of Social Services a fall resulting in a spinal fracture for 1 of 5 residents.
Facility failed to notify the responsible party for a resident who had an unwitnessed fall with a head injury requiring emergency room visit.
Facility failed to assure residents received adequate and appropriate care and services in compliance with laws and regulations related to supervision.
Report Facts
Medication error rate: 7
Falls: 6
Weight decrease: 3
Medication doses: 2
Medication doses: 1
Medication doses: 2
Nasal spray usage: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide/Supervisor | Named in failure to assure HCPR check was completed |
| Business Office Manager | Responsible for maintaining employee records | |
| Resident Care Coordinator | Responsible for maintaining personnel records and accuracy | |
| Administrator | Responsible for employee records and audits | |
| Resident Care Director | Licensed Practical Nurse | Responsible for pre-assessments and supervision needs |
| Regional Nurse | Responsible for fall prevention protocol and monitoring | |
| Medication Aide | Involved in medication administration errors | |
| Resident Care Coordinator | Involved in medication administration and self-administration oversight | |
| Resident Care Director | Newly hired, involved in medication and self-administration oversight | |
| Administrator | Involved in incident reporting and notification |
Inspection Report
Capacity: 96
Deficiencies: 14
Date: Aug 30, 2018
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure. This was a Construction Section Biennial Survey.
Findings
Multiple deficiencies were noted including lack of hand grips in bathrooms, ceilings and floors not maintained in good repair, chronic unpleasant odors, hazards such as unsecured oxygen bottles, failure to maintain fire safety and electrical equipment in safe operating condition, fire safety components with gaps and missing latches, and inadequate exhaust ventilation due to dust accumulation.
Deficiencies (14)
Hand grips were not provided at all tubs and showers used by or accessible to residents.
Ceilings were not maintained in good repair, including peeling ceiling finish and mildew stains.
Floors were not maintained clean and in good repair, with heavy staining and vinyl floor seam separation.
Furnishings were not maintained in good repair, including broken door knobs and damaged dispensers.
Facility was not maintained free of chronic unpleasant odors, including strong urine smell and dirty briefs in bathroom garbage.
Walls were not maintained clean and in good repair, including falling wall base and disrepair in resident rooms.
Facility was not maintained free of hazards, including unsecured oxygen bottles on the floor.
Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition, including fire alarm panel trouble and non-illuminating emergency lights and exit signs.
Holes or gaps at penetrations through fire resistant rated ceilings could allow fire and smoke to spread beyond the area of origin.
Unapproved devices used to keep doors open, impeding quick closing to limit spread of smoke and fire.
Electrical equipment not maintained in safe and operating condition, including missing light covers and outlet cover plates.
Fire safety equipment not maintained in operating condition due to sprinkler heads being obstructed or improperly installed.
Doors did not completely close and latch, limiting ability to contain smoke or fire.
Facility did not maintain exhaust ventilation in required areas, with dust accumulation on exhaust fans.
Report Facts
Total licensed capacity: 96
Special Care Unit beds: 36
Unsecured oxygen bottles: 4
Missing light covers: 4
Partially attached light covers: 2
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 11, 2018
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from June 5, 2018 through June 8, 2018 with an exit conference on June 11, 2018.
Complaint Details
The visit included a complaint investigation triggered by allegations of medication errors, missed doses, and improper medication storage.
Findings
The facility failed to administer medications as ordered for multiple residents, including missed doses of pain medications resulting in severe pain for one resident. Medications were left unattended with residents, and medication administration was often late. Additionally, one resident self-administered medication without physician orders, and medication storage was not secure for a resident with dementia. Several medication aides had not completed required training and competency evaluations before administering medications.
Deficiencies (4)
Failed to administer medications as ordered for 5 of 6 residents observed during medication pass and 4 of 7 sampled residents with missed doses of pain medications resulting in severe pain for one resident; medications left unattended in medication cups on dining room tables.
Resident self-administered medications without physician orders and medication was accessible in resident's room.
Medication aides administered medications without completing clinical skills validation or passing written exam.
Resident's cardiac medication was not stored in a safe and secure manner and was accessible to the resident with dementia.
Report Facts
Medication error rate: 29
Medication errors observed: 10
Residents with medication errors: 5
Residents with missed pain medication doses: 4
Medication administration delay: 129
Medication administration delay: 209
Medication administration delay: 154
Medication administration delay: 135
Medication administration delay: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Was administering medications without completed clinical skills validation on 06/06/2018. |
| Staff B | Personal Care Aide | Failed medication aide test multiple times but administered medications on 06/04/2018. |
| Staff C | Medication Aide | Had not completed clinical skills validation but administered medications on 06/06/2018. |
| Resident Care Coordinator | Responsible for medication aide training and oversight; did not remove unqualified staff from medication cart. | |
| Executive Director | Was not aware of medication aide training status and medication administration issues. | |
| Medication Aide | Interviewed regarding medication administration practices and errors. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 21, 2017
Visit Reason
The Adult Care Licensure Section and Wake County Human Services conducted a follow-up survey and a complaint investigation on 12/19/17, 12/20/17 and 12/21/17.
Complaint Details
The visit included a complaint investigation related to supervision and healthcare needs of residents.
Findings
The facility failed to provide proper supervision for a resident with a history of falls, resulting in multiple falls including one with a scalp laceration requiring staples. Additionally, the facility failed to follow physician orders for blood sugar monitoring and referrals for cardiology and physical therapy for another resident, and failed to administer prescribed morphine medication as ordered.
Deficiencies (3)
Failed to assure 1 of 5 sampled residents with a history of falls received proper supervision based on assessed needs, resulting in nine falls in three months including a scalp laceration requiring staples.
Failed to assure healthcare needs of 1 of 5 sampled residents were met by not following physician's order to call endocrinology for blood sugars outside ordered parameters and not making referrals for cardiology and physical therapy.
Failed to assure that 1 of 5 residents had all prescribed medications administered as ordered, specifically morphine sulfate was not administered for several weeks.
Report Facts
Falls: 9
FSBS readings above 350: 8
Morphine doses not administered: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Mentioned in relation to failure to supervise Resident #2 and failure to follow physician orders for Resident #3 | |
| Assistant Resident Care Director | Mentioned in relation to failure to supervise Resident #2 and failure to follow physician orders for Resident #3 | |
| Primary Care Provider | Provided orders and recommendations for Resident #3 | |
| Hospice Nurse | Interviewed regarding Resident #2's care and falls | |
| Personal Care Aide | Interviewed regarding Resident #2's supervision and falls | |
| Medication Aide | Interviewed regarding Resident #3's blood sugar monitoring and notifications | |
| Corporate Regional Nurse | Interviewed regarding follow-up on referrals and appointments for Resident #3 | |
| Administrator | Interviewed regarding oversight responsibilities |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 3, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 8/2/17 and 8/3/17 to assess compliance with medication administration and infection prevention regulations.
Findings
The facility failed to ensure the accuracy of electronic medication administration records (EMARs) for finger stick blood sugar (FSBS) readings for 5 of 8 sampled residents, with discrepancies between glucometer histories and EMAR entries. Additionally, the facility failed to maintain infection control procedures, evidenced by shared glucometers between 2 residents, risking transmission of bloodborne pathogens.
Deficiencies (2)
Failure to assure accuracy of electronic medication administration records (EMARs) for finger stick blood sugar (FSBS) readings for 5 of 8 sampled residents.
Failure to maintain infection control procedures to prevent transmission of bloodborne pathogens as evidenced by shared glucometers for 2 residents.
Report Facts
Number of sampled residents with inaccurate FSBS EMAR entries: 5
Number of sampled residents with shared glucometers: 2
Number of diabetic residents at facility: 8
Correction date deadline: Sep 17, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Initials entered in EMAR for FSBS readings not performed by her | |
| Director of Clinical Operations and Risk Management | Interviewed regarding FSBS and infection control issues; responsible for staff training and corrective actions | |
| Regional Director of Operations | Interviewed regarding glucometer and FSBS issues; responsible for ensuring compliance | |
| Facility's Physician | Interviewed regarding concerns about FSBS accuracy and diabetic care | |
| Medication Aides | Multiple medication aides interviewed regarding FSBS practices and glucometer use |
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