Inspection Reports for Terrabella Lake Norman

Report of a Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.

Deficiencies have been corrected. No further action is needed.

The visit was a Construction Section Biennial Survey conducted to ensure the facility meets applicable state regulations and building codes.

The survey identified deficiencies related to electrical outlets in wet locations lacking ground fault interrupters, emergency equipment not maintained safely, and a non-operable exhaust fan causing potential odor and mildew issues.

The Adult Care Licensure Section conducted an annual survey of the facility from 01/17/24 through 01/18/24 to assess compliance with state regulations for adult care homes.

The facility was found deficient in multiple areas including tuberculosis testing upon admission, completion and signing of Resident Registers, annual care plan completion and signatures, licensed health professional support assessments, medication administration, self-administration of medications, and appropriate diagnosis for placement in the Special Care Unit.

This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building code compliance and physical plant requirements.

Multiple deficiencies were found including failure to meet building code for special locking on exit doors, inadequate sanitation policies to prevent bed bugs, damaged ceilings, unprotected penetrations in fire-rated ceilings, and failure to maintain fire safety, HVAC, and electrical systems in safe and operating condition.

This is a Construction Section Biennial Survey conducted to ensure the facility meets applicable building codes, licensing rules, and physical plant requirements.

Multiple deficiencies were cited including failure to meet building code requirements for emergency release keys, inadequate pest control policies and treatment for bed bugs, poor housekeeping and maintenance issues such as damaged ceilings and unclean HVAC components, storage hazards near sprinkler heads, blocked exit pathways, and failure to maintain fire safety, electrical, mechanical, and plumbing equipment in safe and operating condition.

The Adult Care Licensure Section conducted an annual and follow-up survey of the facility from January 23 to 26, 2018.

The facility was found deficient in multiple areas including failure to assure tuberculosis testing upon admission for one resident, inaccurate medication administration records for one resident, failure to implement proper infection control policies regarding glucometer use leading to shared use among residents, and failure to verify medication aide training and employment verification for one staff member.

This is a biennial follow-up construction survey conducted to verify correction of previously cited deficiencies related to physical plant and safety compliance at the facility.

Multiple deficiencies were found including malfunctioning special locking arrangements, corridor obstructions, unsafe and non-operating emergency equipment, improper fire and smoke door maintenance, use of unapproved sealants in fire-resistance-rated assemblies, lack of required inspections and documentation for the commercial kitchen hood's fire suppression system, and failure to maintain proper control over ovens and ranges in resident activity areas.

Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and building code requirements for an adult care home licensed for 120 beds including a 20-bed Special Care Unit.

Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, electrical systems, and ventilation. Issues included non-functioning special locking arrangements, obstructed corridors, plumbing and housekeeping deficiencies, fire alarm and emergency lighting failures, fire door and sprinkler system problems, lack of firestopping around penetrations, improperly maintained fire suppression system, doors held open or not latching, electrical hazards, lack of staff control over ovens, and malfunctioning exhaust ventilation systems.

The Adult Care Licensure Section and the Iredell County Department of Social Services conducted an annual, follow-up survey, and complaint investigation on April 19-22, 2016 and April 25, 2016.

The facility failed to serve texture modified diets as ordered for 2 residents, failed to directly observe medication administration resulting in a medication error, failed to have medication available for one resident, and failed to provide Special Care Unit residents direct access to an outside area.

The visit included a complaint investigation as part of the annual and follow-up survey conducted April 19-22 and April 25, 2016.

Follow-up survey conducted to verify correction of deficiencies related to a previous complaint survey dated 11-4-2014.

All deficiencies related to the complaint survey of 11-4-2014 have been corrected; however, the project HA-3107 construction was still in progress and not yet completed at the time of the follow-up survey.

All deficiencies related to the Complaint Survey of 11-4-2014 have been corrected. No further action is required regarding the Complaint.

Follow-up survey conducted to verify correction of previously cited deficiencies related to physical plant and safety features at Brookdale Churchill.

Most deficiencies were not corrected. The facility failed to properly install and identify emergency release switches and delayed egress locks as required by the NC State Building Code. Several exit doors lacked required sounding devices to prevent resident elopement, and plans for construction or remodeling were not submitted or approved as required. The facility also failed to secure certain doors and patio doors to prevent resident elopement.

Follow-up and consultation visit conducted to address new information related to physical plant and safety deficiencies at the facility.

The facility failed to properly install special locking devices with an emergency release switch at the nurse station, and failed to equip several required exit doors with sounding devices to alert staff when opened. The facility houses residents who are disoriented or wanderers, with documented incidents of elopement.

The inspection was conducted as a complaint survey triggered by allegations that multiple disoriented residents have eloped in recent months.

The complaint was substantiated. The facility failed to properly install special locking devices (magnetic locks) with required emergency release switches and failed to equip several required exit doors with sounding devices to alert staff when opened, increasing the risk of resident elopement and evacuation issues.

The complaint was substantiated. It alleged that multiple disoriented residents have eloped in recent months. Review of documents showed at least 7 residents determined to be disoriented or confused, with 2 residents having eloped beyond property boundaries. Interviews confirmed other residents left the building but were intercepted.