Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 2, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding allegations of mishandling and an unwitnessed fall of a resident with dementia at The Addison of Indian Trail.
Findings
The facility failed to provide medical assistance to a resident with dementia who complained of abdominal and back pain after being mishandled by a staff member and experiencing an unwitnessed fall. This failure resulted in serious neglect and physical harm, including three rib fractures and a hemothorax, constituting a Type A1 violation.
Complaint Details
The complaint investigation substantiated that Resident #1 was mishandled by a staff member, resulting in an unwitnessed fall and serious injuries including rib fractures and a hemothorax. The facility failed to provide timely medical treatment and proper notification to the responsible party and medical providers.
Severity Breakdown
TYPE A1 VIOLATION: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to assure referral and follow-up to meet the routine and acute health care needs of residents, specifically failing to provide medical assistance to a resident with dementia after mishandling and an unwitnessed fall. | TYPE A1 VIOLATION |
Report Facts
Dates of Visit: 10/2/24, 10/3/24, 10/9/24, 10/18/24, & 10/24/24
Correction Date: Correction date for Type A1 violation shall not exceed December 8, 2024
Incident Time: Incident occurred at 8:15am on 09/30/24
Incident Time: Emergency call made at 7:00pm on 09/30/24
Rib Fractures: 3
Fine Amount: 400
Fine Amount: 1000
Inspection Report
Annual Inspection
Deficiencies: 9
May 2, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow up survey and complaint investigation on April 30 through May 2, 2024.
Findings
The facility had multiple deficiencies including failure to maintain water temperatures within required range, inadequate personal care related to toenail care for a resident, failure to follow up on therapy and orthopedic appointments, restrictions on resident visitation rights, unclear medication orders, medication administration errors, inaccurate medication administration records, and unsecured medication storage.
Complaint Details
The survey included a complaint investigation related to personal care and medication administration.
Deficiencies (9)
| Description |
|---|
| Water temperatures in residents' rooms exceeded the required range of 100 to 116 degrees Fahrenheit, with observed temperatures ranging from 118.0 to 118.4 degrees F. |
| Failure to ensure personal care needs were met related to toenail care for 1 of 5 sampled residents (#2), resulting in grossly overgrown toenails. |
| Failure to follow up on physical and occupational therapy evaluation and orthopedic appointments in a reasonable timeframe following a wrist fracture for 1 of 5 sampled residents (#2). |
| Failure to ensure 2 of 3 sampled residents (#2 and #4) on the Special Care Unit had the right to associate and communicate privately and without restriction with family members at reasonable hours. |
| Failure to clarify medication orders for 1 of 5 sampled residents (#1) for finger stick blood sugar checks and blood pressure checks. |
| Failure to ensure controlled substances ordered as needed had detailed behavior-specific indications for use for 2 of 5 sampled residents (#2, #4). |
| Failure to administer medications as ordered for 1 of 4 residents (#6) and errors in medication administration for 3 of 5 residents (#1, #2, #4) including pulmonary disease medication, laxative, cholesterol medication, and others. |
| Failure to ensure electronic medication administration records (eMAR) were accurate for 2 of 5 sampled residents (#1 and #2) related to administration of pulmonary disease medication, nasal spray, and laxative. |
| Failure to ensure medications were stored securely when a medication cart was left unlocked and unattended in the Special Care Unit and medications were stored unsecured on the medication cart for 1 of 5 sampled residents (#1). |
Report Facts
Medication error rate: 6
Water temperature readings: 5
Medication doses administered: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for verifying and clarifying medication orders, reviewing medication administration records, and completing medication cart audits. | |
| Health and Wellness Director | Responsible for clinical related matters including medications, medication orders, reviewing medication administration records, and medication cart audits. | |
| Memory Care Director | Responsible for clinical related matters including medications and medication orders, and oversight of Special Care Unit. | |
| Administrator | Oversight of facility operations, including medication administration and visitation policies. | |
| Medication Aide | Administered medications, responsible for medication cart audits, and medication administration documentation. |
Inspection Report
Follow-Up
Deficiencies: 3
Apr 16, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies.
Findings
The facility has unresolved deficiencies from the prior Biennial Construction Survey and one new deficiency related to housekeeping and furnishings. Additionally, the facility failed to maintain fire safety and electrical systems in a safe and operational condition, including trouble with the fire alarm control panel and non-operational foyer lights.
Deficiencies (3)
| Description |
|---|
| Carpet in corridors has dark stains; carpet outside Dining area is torn and creating a trip hazard. |
| Fire Alarm Control Panel indicating trouble due to new leaks at smoke detectors and pull station. |
| Electrical system not maintained safely; foyer lights not operational. |
Report Facts
Number of new leaks: 3
Circuit number: 12
Date fire alarm system serviced: January 24, 2024 (date mentioned but not numeric)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Surveyor | Conducted the Biennial Follow Up Construction Survey |
| Maintenance Director | Interviewed regarding electrical system maintenance |
Inspection Report
Capacity: 96
Deficiencies: 11
Dec 18, 2023
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, fire safety, and building maintenance standards.
Findings
Multiple deficiencies were cited including failure of magnetic locks to disengage, lack of current fire and sanitation inspection reports, absence of fire safety rehearsals records, electrical outlets without ground fault protection, malfunctioning fire safety and emergency equipment, unmaintained plumbing and exhaust ventilation systems, and missing documentation for fire extinguisher inspections.
Deficiencies (11)
| Description |
|---|
| Magnetic locks at nurse station failed to disengage via master override switch. |
| Facility failed to maintain current annual fire and sanitation inspection reports. |
| No records of quarterly fire safety rehearsals on each shift were maintained. |
| Electrical outlets in wet locations lacked ground fault interrupters; receptacles behind washing machines did not trip on test. |
| Fire Alarm Control Panel indicated trouble with duct detector at Air Handling Unit #3. |
| Plumbing system not maintained safely; ice machine drain lacked required 2" air gap. |
| Emergency equipment not maintained safely; exit sign at employee break room not illuminated. |
| Fire safety components not maintained; holes in rated wall and ceiling assemblies in electrical and mechanical rooms. |
| Electrical system not maintained; non-operational lights in foyer and building system closet. |
| Portable fire extinguishers lacked required monthly inspection documentation. |
| Exhaust fans in utility and janitor closets not working, causing poor ventilation. |
Report Facts
Licensed bed capacity: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Surveyor | Conducted the Construction Section Biennial Survey. |
| Maintenance Director | Interviewed regarding deficiencies related to special locking doors and electrical system maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 20, 2023
Visit Reason
The visit was conducted as a complaint investigation regarding a resident who eloped from the facility through an unlocked Special Care Unit (SCU) door without staff knowledge.
Findings
The facility failed to lock four exit doors accessible to residents in the SCU, including the door through which a resident with a history of wandering eloped. The facility also failed to provide adequate supervision to the resident, resulting in the resident being found unsupervised on a busy road. These failures constituted a Type A2 violation and a standard deficiency.
Complaint Details
The complaint involved a resident who eloped from the facility on 06/15/2023 at approximately 8:15pm. Multiple interviews and observations confirmed the resident left through an unlocked SCU door during shift change when staff failed to lock the door. The resident was found approximately 200 yards from the facility on a busy road. Law enforcement and staff interviews corroborated the incident and the facility's failure to secure the exit doors and supervise the resident.
Severity Breakdown
Type A2 Violation: 1
Standard Deficiency: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to lock four exit doors accessible to residents in the SCU, including one used by a resident with a history of wandering who eloped. | Type A2 Violation |
| Facility failed to provide supervision to a resident with a history of wandering who eloped without staff knowledge. | Standard Deficiency |
Report Facts
Number of exit doors failed to lock: 4
Sampled residents with wandering history: 1
Distance resident found from facility: 200
Speed limit: 45
Number of cars counted passing: 7
Number of observations of SCU exit door: 4
Seconds for SCU main exit door to close: 4.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Lynn Holobor | DSS Signature | Signed the corrective action report |
| Ursula Torres | Administrator | Submitted plan of correction and received CAR |
| Health and Wellness Director | Gathered staff statements and interviewed regarding elopement | |
| Memory Care Director | Interviewed regarding SCU door observations and elopement | |
| Project Manager-Third Party Vendor | Responsible for carpet installation and resetting alarms on exit doors | |
| Primary Care Provider | Interviewed regarding resident's condition post-incident |
Inspection Report
Annual Inspection
Deficiencies: 2
May 24, 2023
Visit Reason
The Adult Care Licensure Section and the Union County Department of Social Services conducted an annual and complaint investigation from 05/23/23 to 05/24/23 at The Addison of Indian Trail.
Findings
The facility failed to notify the primary care provider for a significantly high blood pressure result and a seizure accompanied by a fall for one sampled resident (#4) who had a history of seizures and falls. Documentation and communication deficiencies were noted regarding seizure activity, medication administration, and notification of hospice and care providers.
Complaint Details
The visit included a complaint investigation related to Resident #4's seizure and fall incident. The investigation found failures in notification and documentation related to the incident.
Deficiencies (2)
| Description |
|---|
| Facility failed to notify the primary care provider for a significantly high blood pressure result and a seizure accompanied by a fall for Resident #4. |
| Facility failed to ensure accurate documentation of antiseizure medications on the electronic medication administration record (eMAR) for Resident #4. |
Report Facts
Dates of investigation: Investigation conducted from 05/23/23 to 05/24/23
Blood pressure reading: 184
Blood pressure reading: 145
Medication doses: 6
Medication doses: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide (MA) | Observed Resident #4's condition and documented medication administration; reported failure to notify appropriate staff. | |
| Health and Wellness Director (HWD) | Interviewed regarding notification failures and resident care. | |
| Resident Care Coordinator (RCC) | Involved in reviewing and following up on resident incidents and medication documentation. | |
| Memory Care Coordinator (MCC) | Involved in resident care coordination and incident reporting. | |
| Primary Care Provider (PCP) | Notified late or not at all regarding resident's seizure and blood pressure issues. | |
| Hospice Manager | Interviewed regarding hospice notification and resident care. | |
| Administrator | Interviewed regarding facility's failure to notify PCP or hospice and incident reporting. |
Inspection Report
Follow-Up
Census: 22
Deficiencies: 4
Jan 28, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on January 27-28, 2022 to verify correction of previous deficiencies.
Findings
The facility failed to ensure proper documentation of fingerstick blood sugars and daily weights for one resident, failed to administer medications as ordered for multiple residents, failed to keep the medication cart locked and secure, and failed to ensure medication aides completed required training and competency evaluations prior to administering medications.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure documentation of fingerstick blood sugars before meals and daily weights for Resident #3. | — |
| Failed to administer medications as ordered for 3 of 4 residents, including medication errors such as overdosing and omission. | — |
| Medication cart in the memory care unit was unlocked and accessible to residents during medication pass for 35 minutes. | — |
| Failed to ensure 6 of 6 sampled medication aides completed required medication administration training and competency evaluations prior to administering medications. | Type B Violation |
Report Facts
Medication error rate: 15
Residents in memory care unit: 22
Missed documentation: 21
Missed documentation: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | No documentation of passing medication aide test or clinical skills evaluation prior to administering medications. |
| Staff E | Medication Aide/Supervisor | No documentation of completing required medication administration training prior to administering medications. |
| Staff F | Medication Aide | No documentation of completing required medication administration training or clinical skills evaluation. |
| Staff A | Medication Aide | No documentation of completing 10 or 15-hour medication administration training course. |
| Staff B | Medication Aide | No documentation of completing 5, 10, or 15-hour medication administration training course or employment verification. |
| Staff C | Medication Aide | No documentation of medication clinical skills competency evaluation. |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 5, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey of The Addison of Indian Trail from 11/02/21 to 11/04/21 with a telephone exit on 11/05/21 to assess compliance with state regulations.
Findings
The facility failed to respond immediately to a resident's emergency chest pain, resulting in a heart attack and hospitalization (Type A1 violation). Additionally, the facility failed to implement physician orders for finger stick blood sugar checks and sliding scale insulin administration, and failed to administer blood pressure medications as ordered for another resident (Type B violation). Medication administration records were inaccurate, and some medication aides lacked required training and competency validation.
Severity Breakdown
Type A1 Violation: 1
Type B Violation: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to respond immediately and in accordance with facility policy to a resident complaining of chest pain, resulting in delayed emergency response and serious neglect. | Type A1 Violation |
| Failure to implement physician's orders for finger stick blood sugar checks and sliding scale insulin administration for a diabetic resident. | Type B Violation |
| Failure to administer blood pressure medications as ordered for a resident, resulting in elevated blood pressure and potential health risks. | Type B Violation |
| Inaccurate medication administration records (eMAR) including incorrect documentation of medication administration times and administration when resident was not present. | Type B Violation |
| Failure to ensure medication aides completed required state-approved training and clinical skills validation prior to medication administration. | — |
Report Facts
Correction date for Type A1 Violation: 2021
Correction date for Type B Violation: 2021
Medication administration times: 8
Units of insulin: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Agency medication aide who lacked documentation of required medication aide training and clinical skills validation. |
| Staff A | Medication Aide | Agency medication aide who lacked documentation of clinical skills validation. |
| Special Care Director | Obtained finger stick blood sugar and administered insulin when medication aide did not. | |
| Health and Wellness Director | Responsible for audits and ensuring medication orders were implemented. | |
| Administrator | Provided oversight and expectations for medication administration and emergency response. | |
| Resident Care Coordinator | Assisted with obtaining and verifying physician orders and ensuring eMAR accuracy. |
Inspection Report
Capacity: 96
Deficiencies: 14
May 9, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted on May 9, 2018, to assess compliance with physical plant, fire safety, and other regulatory requirements for Carillon Assisted Living at Indian Trail.
Findings
Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, and equipment maintenance. Issues included lack of proper locking system components, missing current fire safety inspection reports, privacy concerns in bathrooms, corridor obstructions, inadequate wanderer alarms, poor housekeeping and maintenance, incomplete fire drill rehearsals, unsafe building equipment and fire safety systems, improper control of kitchen ranges, and ventilation failures.
Deficiencies (14)
| Description |
|---|
| Fire Alarm Control Panel missing system components location map. |
| Facility failed to maintain current annual sprinkler system inspection report. |
| Bathrooms and toilet rooms do not provide adequate privacy; doors cannot latch due to strike plates covered with metal plates. |
| Corridors obstructed by unattended medication cart reducing required width. |
| Exit doors accessible by residents lack sounding devices to alert staff when opened. |
| Lighting fixtures missing globes; plumbing traps dried allowing sewer gases. |
| Building not maintained free of hazards; unsecured oxygen cylinder and potential ice machine drain contamination. |
| Fire drill rehearsals not performed regularly on all shifts quarterly; records incomplete. |
| Emergency lighting and exit signs not functioning properly on backup power; smoke barrier doors not closing or latching properly. |
| Corridor doors held open improperly or missing latch bolts, preventing proper smoke containment. |
| Electrical system deficiencies including missing weather resistant covers and non-enclosed emergency release switch. |
| Fire sprinkler escutcheon plates missing or displaced, some sprinklers covered with tape. |
| Ranges in activity rooms energized without staff supervision. |
| Exhaust ventilation system not working in utility room, causing odor issues. |
Report Facts
Total licensed beds: 96
Special care beds: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor conducting the Construction Section Biennial Survey. | |
| Dennis Harrell | Surveyor conducting the Construction Section Biennial Survey. | |
| Maintenance Technician | Interviewed regarding fire drill rehearsals and inspection reports. | |
| Business Office Manager | Interviewed regarding fire drill rehearsals and inspection reports. |
Inspection Report
Plan of Correction
Capacity: 96
Deficiencies: 8
Jun 22, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 2005 Minimum and Desired Standards and Regulations for Homes for the Aged and Infirmed and the 2006 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including lack of hand grips in bathrooms, electrical outlets in wet locations without ground fault protection, malfunctioning or missing exit signs, inadequate maintenance of the commercial kitchen hood fire extinguishing system, breaches in fire-resistance-rated construction, non-smoke-resisting corridor doors, and impaired fire sprinkler escutcheon plates. Some deficiencies were corrected before surveyors departed.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure all resident commodes, tubs and showers are equipped with hand grips. |
| Electrical power receptacles in wet areas not protected from ground faults. |
| Exit signs did not work properly, relay directional information properly or were missing. |
| Commercial kitchen hood's fire extinguishing system lacked required inspections, maintenance, and documentation. |
| Holes and gaps around penetration through fire-resistance-rated construction compromising integrity. |
| Corridor doors are not smoke resisting and did not latch properly. |
| Doors protecting smoke barrier did not close completely and latch to restrict smoke. |
| Fire sprinkler escutcheon plates were impaired, exposing openings through fire-resistance-rated construction. |
Report Facts
Licensed beds: 96
Loading inspection reports...
