Inspection Reports for TerraBella Southern Pines

This document is a corrective action report addressing multiple violations identified during a prior inspection of a regulated adult care facility.

The report details multiple Type A1 and Type B violations related to personal care, supervision, healthcare, medication administration, staffing, and resident safety. It includes extensive findings on resident care deficiencies, failure to provide adequate supervision, medication errors, and inadequate staffing levels.

The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies and to identify any new deficiencies related to construction and physical plant compliance.

The survey found that deficiencies from the prior Biennial Construction Survey remain uncorrected, including failure to submit required construction documents for a call system replacement, improper use of resident bathrooms for storage, and a newly identified deficiency regarding the call system not being operated safely due to non-functional pagers and inadequate alert audibility.

The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.

Multiple deficiencies were cited including failure to submit construction plans for approval, improper use of resident bathrooms for storage, corridors obstructed by equipment, mechanical systems not clean or in good repair, compressed gas cylinders not properly secured, fire alarm system and fire safety equipment not maintained in safe and operating condition, electrical and plumbing systems deficiencies, corridor doors held open improperly, fire sprinkler system issues, exhaust ventilation failures, and an incomplete call system in the Special Care Unit building.

The Adult Care Licensure Section conducted a follow-up survey, annual survey, and complaint investigation on 08/24/24-08/29/24 at Terrabella Southern Pines assisted living facility.

The facility failed to ensure the main entrance door had an audible alarm to prevent residents with disorientation or wandering behaviors from exiting unnoticed, failed to ensure medication aides completed required training, failed to coordinate and document ordered lab work and urinalysis for residents, failed to document heart rate monitoring as ordered for a resident on heart rate affecting medication, and failed to ensure medication staff observed a resident taking medications during administration.

The visit included a complaint investigation triggered by concerns about resident safety related to wandering behaviors and failure of the main entrance door alarm system.

The Adult Care Licensure Section conducted an annual and follow-up survey from 04/11/23 to 04/13/23 to assess compliance with medication administration and infection control regulations.

The facility failed to ensure medications were administered as ordered for three residents, including crushing a medication that should not be crushed, missing a medication dose, and administering the wrong insulin. Additionally, two medication aides failed to follow infection control measures by not sanitizing or washing hands between residents during medication administration.

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

The facility failed to maintain fire safety equipment in a safe operating condition, specifically smoke compartment doors did not close completely and wedges were found propping open bedroom doors throughout the facility, which could impede fire safety.

This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 Edition of the North Carolina State Building Code.

Multiple deficiencies were cited related to physical plant conditions including outside premises cleanliness, housekeeping and furnishings, maintenance of building equipment and fire safety systems, exhaust ventilation, and plumbing. Specific issues included peeling paint, dust accumulation, unsecured oxygen tank, malfunctioning emergency lighting, fire doors not closing properly, fire safety system gaps, propped open fire doors, damaged smoke detectors, fire sprinkler obstructions, and non-functioning exhaust fans.

This document is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.

Multiple deficiencies were cited requiring a Plan of Correction, including issues with hand grips in bathrooms, housekeeping and furnishings in disrepair, electrical outlets lacking ground fault interrupters, emergency lighting failures, fire safety and smoke barrier door latch failures, firestop sealant deficiencies, electrical panel access obstructions, sprinkler system issues, and exhaust ventilation failures.

The Adult Care Licensure Section conducted an annual survey on 01/26/17 and 01/27/17 to assess compliance with regulations for medication administration, pharmaceutical care, special care unit staff training, infection prevention, and medication aide training and competency.

The facility failed to ensure medications were administered as prescribed to one resident, failed to ensure on-site medication reviews included review of electronic Medication Administration Records, failed to ensure special care unit staff completed required training within six months of employment, failed to ensure medication aides received annual infection control training, and failed to ensure medication aides hired after October 2013 met training and competency requirements.