Inspection Reports for Terrabella Little Avenue

The visit was a follow-up incident report to verify correction of previous deficiencies related to supervision and staff qualifications at Terra Bella at Little Avenue.

The facility failed to provide adequate supervision for a resident with wandering behaviors, resulting in an elopement incident, constituting a Type A2 violation. Additionally, the facility failed to ensure Health Care Personnel Registry checks were completed for five staff members prior to hire, resulting in a citation.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey from 01/28/25 to 01/29/25 to assess compliance with health care and medication administration regulations.

The facility failed to ensure referral and follow-up to meet routine healthcare needs for one resident related to notifying the Primary Care Provider of high finger stick blood sugar levels. Additionally, the facility failed to ensure medications, specifically sliding scale insulin, were administered as ordered for the same resident due to errors in medication order entry and administration documentation.

Biennial Construction Survey conducted to assess compliance with applicable physical plant, fire safety, and building code requirements for the licensed adult care home facility.

Multiple deficiencies were identified related to physical plant, fire safety, housekeeping, electrical safety, plumbing, and ventilation. These included non-compliant locking mechanisms on doors, lack of required bathroom facilities, obstructions in corridors, improper storage of oxygen bottles, malfunctioning emergency lighting and exit signs, fire safety system failures, holes in fire-resistant ceilings and walls, plumbing without proper air gaps, and non-functioning exhaust fans.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey, follow-up survey, and complaint investigation initiated on 2023-07-28.

The facility failed to provide adequate supervision for Resident #7, who had dementia and wandering behaviors, allowing her to exit through an unlocked and disarmed exit door leading to the outside parking lot. Resident #7 was found outside approximately one and a half hours later with minor injuries. The facility did not have a specific supervision policy and failed to ensure exit door alarms were properly checked and engaged.

Complaint investigation was initiated by the Mecklenburg County Department of Social Services on 2023-07-28 regarding Resident #7's elopement from the Special Care Unit.

The Adult Care Licensure Section conducted an annual survey and complaint investigation from 08/24/21 to 08/30/21.

The facility failed to ensure medications were administered within one hour before or after the scheduled time for 2 sampled residents, and failed to ensure full bedrails were used only with proper assessment, planning, documentation, and physician order for 1 sampled resident. Multiple interviews and observations confirmed these deficiencies.

The inspection included a complaint investigation related to medication administration timing and use of restraints.

The Adult Care Licensure Section conducted a follow-up survey to verify correction of previously cited deficiencies related to therapeutic diets.

The facility failed to have a matching therapeutic diet menu for a low residue diet for Resident #1 and failed to serve therapeutic diets as ordered for Resident #3 with a mechanical soft diet. Dietary staff lacked proper instructions and did not prepare meals according to diet orders, including serving shredded instead of ground meat and not substituting alternative meals when necessary.

The Adult Care Licensure Section conducted an annual and follow-up survey of Elmcroft of Little Avenue on 11/25/19-11/26/19 to assess compliance with regulations related to nutrition and food service, including therapeutic diets.

The facility failed to have matching therapeutic diet menus for residents with physician-ordered therapeutic diets and failed to serve therapeutic diets as ordered for 4 of 4 sampled residents. Specific issues included lack of therapeutic menus for mechanical soft, carbohydrate controlled (CCHO), vitamin K restricted, and pureed diets, and failure to prepare or serve meals according to these orders, posing risks such as aspiration or choking. Nutritional supplements were also not consistently provided as ordered.

The visit was a biennial follow-up construction survey to verify correction of previously identified deficiencies.

The facility failed to correct some deficiencies related to physical plant and fire safety. Specifically, a former bedroom used for storage did not meet NC Building Code requirements, and several corridor doors were prevented from closing and latching properly, including a fire-rated door that was propped open.

Biennial Construction Survey to assess compliance with physical plant, fire safety, and building code requirements for the facility licensed for 62 beds including a Special Care Unit.

The facility failed to meet multiple North Carolina Building Code and Adult Care Home regulations including delayed egress locking not functioning properly, storage rooms exceeding size limits with combustible items, blocked electrical panel access, lack of current fire marshal inspection reports, corridor obstructions, exterior exit path hazards, inadequate fire drill rehearsals, compromised fire-rated walls and doors, malfunctioning exit signs, and non-functioning exhaust ventilation in several bathrooms.

Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to physical plant and fire safety components.

Some deficiencies were not corrected, including issues with the special locking system on fire alarm control panel doors and improper placement of delayed egress signs, which were posted beside doors instead of on the doors as required by code.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on February 15 and 16, 2017 to assess compliance with medication administration and other regulatory requirements.

The facility failed to ensure medications were administered as ordered for multiple residents, including issues with medication administration timing, inaccurate medication administration records, and failure to administer medications according to physician orders due to eMAR system and communication problems.

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

The facility failed to correct multiple deficiencies related to special locking arrangements on doors, emergency release switches, fire safety equipment maintenance, firestopping of penetrations, electrical system safety, and exhaust ventilation in specified areas. These deficiencies could affect the safety of residents, staff, and visitors in emergencies and by exposure to odors.

Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code for Institutional Occupancy.

Multiple deficiencies were cited related to physical plant and safety including improper operation and labeling of special locking arrangements, delayed egress door issues, exit door locks requiring more than a single hand motion, housekeeping hazards, emergency lighting failures, fire safety door maintenance issues, firestopping deficiencies, sprinkler system problems, electrical panel obstructions, and inadequate exhaust ventilation in several areas.