Inspection Reports for TerraBella Southport

The inspection was conducted due to complaints regarding inadequate supervision and safety concerns for residents, including a resident who fell and remained on the floor for several hours and another resident with a history of aggressive behaviors.

The facility failed to provide supervision consistent with residents' assessed needs, care plans, and symptoms, resulting in physical harm to residents. Specifically, Resident #5 fell and remained on the floor for approximately seven hours before being discovered, and Resident #2, known for aggressive behaviors, was not adequately supervised, leading to harm to other residents. The facility also failed to protect residents from physical abuse by another resident.

The complaint investigation substantiated that Resident #5 was left on the floor for approximately seven hours after a fall and that Resident #2 had a documented history of resident-to-resident physical and sexual aggressive behaviors that were not adequately supervised, resulting in harm to other residents.

The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure referral and follow-up to meet the acute health care needs of a resident who exhibited symptoms of shortness of breath, chest pain, and atrial fibrillation and subsequently died at the facility.

The facility failed to ensure referral to meet the acute health care needs of Resident #2, who had symptoms of shortness of breath, chest pain, and atrial fibrillation on 03/08/24 and died two days later. The facility did not notify the resident's primary care physician, and EMS was called but the resident was not transported to the hospital. This failure resulted in serious physical harm and neglect, constituting a Type A1 Violation.

The complaint investigation substantiated that the facility failed to notify Resident #2's primary care physician of his symptoms beginning on 03/08/24, failed to send him to the hospital for evaluation despite EMS being called, and Resident #2 died at the facility on 03/10/24. This failure resulted in serious physical harm and neglect.

The facility was surveyed for conformance with applicable portions of the 2002 Edition of the North Carolina Building Code(s), Institutional Occupancy, and for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.

Multiple deficiencies were cited related to physical plant and safety code compliance, including failure to properly operate special locking doors, obstructions at facility exits, inadequate outdoor lighting on egress paths, lack of ground fault circuit interrupter protection at electrical outlets near water sources, and failure to maintain fire safety equipment in safe operating condition.

The Adult Care Licensure Section and the Brunswick County Department of Social Services conducted an annual survey and complaint investigation on 11/29/23 and 11/30/23. The complaint investigation was initiated by the Brunswick County Department of Social Services on 11/09/23.

The facility failed to ensure tuberculosis testing compliance for one resident, failed to meet personal care needs for a memory care resident regarding showering, and failed to provide adequate supervision for a resident who sustained multiple falls. The facility lacked proper documentation, interventions, and follow-up related to these issues.

Complaint investigation was initiated by the Brunswick County Department of Social Services on 11/09/23 and was part of the annual survey conducted on 11/29/23 and 11/30/23.

The visit was conducted due to a fall incident involving Resident #2, focusing on the facility's response to the fall and compliance with policies regarding immediate care and notification.

The facility failed to respond immediately to a fall incident involving Resident #2, including delayed emergency medical services notification and failure to provide timely care, resulting in the resident remaining in the facility for over 10 hours before hospital transfer. The facility submitted a Plan of Correction for a Type A1 violation related to these failures.

The Adult Care Licensure Section conducted an annual survey on October 26 and 27, 2021 to assess compliance with licensing and regulatory requirements.

The facility failed to maintain hot water temperatures within the required range at multiple fixtures, and failed to ensure the primary care provider was notified of abnormal blood sugar results for certain residents. Additionally, snacks were not offered to residents as required. These deficiencies posed risks to resident health and safety.

Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to facility construction and physical plant requirements.

The facility failed to maintain the exhaust ventilation system in proper working order in multiple areas including the C Hall Toilet Room, C Hall Laundry, and C Hall Janitor Closet. Staff reported the exhaust fan was repaired but has since failed again and parts are awaited.

The facility was surveyed for conformance with applicable portions of the 2002 Edition of the North Carolina Building Code(s), Institutional Occupancy, and for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.

Multiple deficiencies were cited related to physical plant conditions including corridor obstructions, unsafe outside premises, housekeeping and furnishings not maintained, electrical outlets lacking ground fault interrupters, building equipment and fire safety systems not maintained in safe and operating condition, fire sprinkler system issues, improper storage increasing fire load, corridor doors not latching properly, and exhaust ventilation systems not functioning properly.

The Adult Care Licensure Section and Brunswick County Department of Social Services conducted an annual survey from 10/04/2017 to 10/06/2017 at Carillon Assisted Living of Southport.

The facility was found deficient in staff qualifications, including failure to assure substantiated findings were checked on the North Carolina Health Care Personnel Registry prior to employment, failure to conduct timely criminal background checks upon hire, failure to competency validate staff for licensed health professional support tasks, and failure to administer medications as ordered for a resident.

Biennial Construction Survey conducted to assess conformance with the 2002 Edition of the North Carolina Building Code(s) and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds.

The facility was found not free from hazards due to improper use of multi-plug power strips as extension cords. Fire safety systems were not maintained in a safe condition, including unapproved fire resistant materials, missing latching hardware on a laundry room door, and non-functioning emergency lighting.

The Adult Care Licensure Section and the Brunswick County Department of Social Services conducted an annual survey on February 9 - 11, 2016.

The facility failed to assure referral and follow-up for routine and acute health care needs related to ordered laboratory testing for one resident, failed to clarify medication orders resulting in continuation of discontinued medication for one resident, failed to administer medications according to provider orders for two residents, and failed to ensure medication aides met training and competency requirements.