Inspection Reports for The Addison
4713 Garrett Rd, Durham, NC 27707, United States, NC, 27707
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Capacity: 120
Deficiencies: 3
Jan 12, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on January 11 and 12, 2023, to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure proper follow-up with primary care providers for abnormal blood sugar levels and mammogram referrals for sampled residents. Additionally, medications were not administered as ordered for three residents, including missed doses of morphine and insulin, resulting in an Unabated Type B Violation. The facility also failed to maintain adequate staffing levels in the special care unit for one of nine sampled shifts.
Complaint Details
The visit included a complaint investigation related to failure to follow up with primary care providers and medication administration errors.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure follow-up with primary care provider for blood sugar levels greater than written parameters and mammogram referral for 2 of 5 sampled residents. | — |
| Failed to ensure medications were administered as ordered by the primary care provider for 3 of 5 sampled residents, including missed doses of long-acting insulins, narcotic pain reliever, antihypertensive, over the counter pain reliever, and vitamin supplement. | Type B Violation |
| Failed to ensure minimum number of staff were present in the special care unit to meet residents' needs for 1 of 9 shifts sampled. | — |
Report Facts
Facility licensed capacity: 120
Special Care Unit census: 21
Staff shortage hours: 5.5
Missed medication administration days: 3
Missed medication administration days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for making appointments, sending medication orders to pharmacy, and approving medication orders on eMAR; interviewed regarding medication administration and follow-up. | |
| Administrator | Interviewed regarding oversight of medication orders and staffing. | |
| Executive Director | Interviewed regarding staffing and scheduling. | |
| Pharmacist | Contracted pharmacy pharmacist interviewed regarding medication orders, dispensing, and eMAR system issues. | |
| Primary Care Provider | Multiple PCPs interviewed regarding orders and follow-up for residents. | |
| Hospice Nurse | Interviewed regarding medication management and communication. |
Inspection Report
Follow-Up
Census: 57
Capacity: 60
Deficiencies: 6
Jun 17, 2020
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation via off-site desk review on June 2-5, 2020, June 8-12, 2020, and June 15-17, 2020.
Findings
The facility failed to meet staffing requirements on first and second shifts for the Special Care Unit and Assisted Living unit, with multiple documented staffing shortages. Additionally, the facility failed to ensure proper medication administration and follow-up for several residents, including failure to notify hospice of a fall, failure to administer ordered medications, and failure to follow up on lab orders.
Complaint Details
The visit included a complaint investigation related to staffing shortages and medication administration issues.
Deficiencies (6)
| Description |
|---|
| Failed to ensure required staffing hours were met on first and second shifts for the Assisted Living unit and Special Care Unit. |
| Failed to ensure referral and follow-up for residents related to a fall and multiple refusals of weekly blood pressure checks. |
| Failed to implement orders for thrombo-embolic deterrent hose, fingerstick blood sugars, and laboratory findings. |
| Failed to ensure clarification of physician's orders for a diuretic medication. |
| Failed to ensure administration of medications in accordance with licensed practitioner orders for pain, anxiety, sliding scale insulin, and vitamin D deficiency. |
| Failed to ensure each resident was free of neglect related to medication administration. |
Report Facts
Staffing shortages: 27.66
Staffing shortages: 18.7
Staffing shortages: 15.54
Staffing shortages: 12.73
Staffing shortages: 11.61
Staffing shortages: 10.46
Staffing shortages: 9.48
Staffing shortages: 7.34
Staffing shortages: 4.43
Staffing shortages: 13
Staffing shortages: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for scheduling, staffing assignments, and notified of lancet/test strip shortages. |
| Resident Care Director | Resident Care Director (RCD) | Supervised staff, assisted with resident care, responsible for scheduling and staffing, performed medication audits. |
| Memory Care Director | Memory Care Director (MCD) | Prepared schedules, performed medication audits, notified PCPs, assisted with staffing, worked shifts to cover shortages. |
| Administrator | Facility Administrator | Responsible for overall staffing and resident care oversight. |
| Medication Aide | Medication Aide (MA) | Responsible for medication administration, notifying pharmacy of refills, and reporting medication availability issues. |
| Personal Care Aide | Personal Care Aide (PCA) | Provided resident care, assisted with staffing shortages, and reported issues. |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 12, 2020
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted an annual, follow-up survey, and complaint investigation on March 10-12, 2020. The Wake County Department of Social Services initiated the complaint investigation on February 25, 2020.
Findings
The facility failed to ensure supervision for a resident with frequent falls, resulting in multiple injuries. Medication administration errors were found for several residents, including missed or incorrect medications and documentation issues. Additional deficiencies included failure to provide adequate nutrition, improper food handling, and inadequate feeding assistance. The facility also failed to maintain accurate medication administration records.
Complaint Details
The complaint investigation was initiated by the Wake County Department of Social Services on February 25, 2020, related to concerns about resident care and medication administration.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure supervision in accordance with current symptoms for a resident with ten falls within three months, resulting in injuries. | Type A2 Violation |
| Failed to ensure medications were administered as ordered for multiple residents, including errors with high blood pressure medication, anxiety medication, and discontinued medications. | Type B Violation |
| Failed to ensure accuracy of electronic medication administration records for multiple residents. | — |
Report Facts
Falls: 10
Medication error rate: 10
Residents in dining room: 28
Residents in dining room: 45
Milk required: 218
Milk gallons delivered: 12
Milk gallons delivered: 16
Medication doses: 7
Medication doses: 30
Medication doses: 15
Medication doses: 15
Medication doses: 30
Medication doses: 30
Medication doses: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Responsible for verifying medication orders, conducting cart audits, and ensuring medication administration accuracy. |
| Special Care Coordinator | Special Care Coordinator | Responsible for medication order verification, medication cart audits, and assisting with resident care. |
| Director of Resident Care | Director of Resident Care | Oversight of medication administration, resident care, and staff training. |
| Administrator | Administrator | Facility oversight, responsible for ensuring compliance with care and medication administration standards. |
| Medication Aide | Medication Aide | Observed administering medications and responsible for medication pass accuracy. |
| Dietary Manager | Dietary Manager | Responsible for food preparation, menu adherence, and food safety. |
Inspection Report
Follow-Up
Deficiencies: 5
Oct 16, 2019
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building maintenance and safety.
Findings
The survey found ongoing deficiencies including unclean and damaged ceilings and floors, failure to maintain the building's suspended ceiling system, and inadequate exhaust ventilation in required areas due to non-functioning exhaust fans and unsealed cable penetrations.
Deficiencies (5)
| Description |
|---|
| Ceilings were not kept clean and in good repair, including water stains and leaks in the Lower Level Living Room. |
| Floors were stained and in disrepair, specifically around the Ground Floor Men's Toilet. |
| Failure to maintain the building's suspended ceiling system, including an unsealed 1" cable penetration in the Riser Room. |
| Mechanical equipment was not maintained in a clean condition, with dust accumulation on the bathroom exhaust fan vent in Room 144. |
| Facility did not maintain exhaust ventilation in required areas; multiple exhaust fans were not working or improperly functioning in bathrooms and utility rooms. |
Inspection Report
Capacity: 120
Deficiencies: 11
Aug 28, 2019
Visit Reason
Biennial construction section survey conducted to assess compliance with building, fire safety, sanitation, and physical plant regulations for an adult care home licensed for 120 residents.
Findings
Multiple deficiencies were identified including lack of current fire and building safety inspection reports, poor housekeeping and maintenance issues such as water stains, holes in walls, slippery floors, unsecured oxygen bottles, fire safety equipment failures, plumbing and ventilation problems, and inadequate hot water temperatures.
Deficiencies (11)
| Description |
|---|
| Facility did not have current building safety inspection reports maintained and available for review. |
| Ceilings, walls, and floors were not kept clean and in good repair, including water stains and holes in sheetrock. |
| Facility was not maintained free of hazards including wet slippery floors without caution signage, trap hazard door locks, and unsecured oxygen bottles. |
| Failure to maintain fire safety equipment in safe operating condition; doors did not close or latch properly, ceiling tiles removed or shifted leaving openings, and storage obstructing sprinkler heads. |
| Mechanical equipment not maintained clean; dust accumulation on exhaust fan vents. |
| Resident room doors had holes or gaps compromising smoke resistance. |
| Plumbing piping not installed or maintained with required 2" air gap, risking contamination. |
| Unapproved devices used to hold doors open, impeding fire safety. |
| Plumbing equipment not maintained in safe and operating condition; toilet not secured to floor. |
| Hot water temperatures at resident fixtures were below required minimum of 100°F. |
| Exhaust ventilation not maintained in required areas; multiple exhaust fans not working. |
Report Facts
Licensed capacity: 120
Special care residents: 60
Water temperature: 89
Clearance to sprinkler heads: 18
Storage clearance to ceiling: 12
Storage clearance to ceiling: 6
Inspection Report
Follow-Up
Deficiencies: 3
Sep 28, 2017
Visit Reason
Biennial Follow-up Construction Survey to verify correction of previously cited deficiencies and assess outstanding issues.
Findings
The facility had several outstanding deficiencies related to building equipment maintenance, including unsafe and non-operating fire alarm and electrical systems, and failure to maintain proper exhaust ventilation in specified areas.
Deficiencies (3)
| Description |
|---|
| Fire Alarm system was not maintained in a safe and operating condition, including inaccessible HVAC duct mounted smoke detector. |
| Electrical system was not maintained in a safe and operating condition, including improper use of power taps and exposed wires without junction boxes. |
| Exhaust ventilation system failed to maintain proper working order, with musty odors in men's and women's public restrooms. |
Inspection Report
Census: 120
Capacity: 120
Deficiencies: 9
Jul 20, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with building, safety, and physical plant regulations for an adult care home licensed for 120 residents.
Findings
Multiple deficiencies were identified including non-functioning wanderer alarms on exit doors, poor housekeeping and maintenance issues such as unclean and damaged walls and furniture, unsafe storage of oxygen cylinders, plumbing and electrical hazards, fire safety system deficiencies including missing sprinkler heads and malfunctioning fire alarm components, doors not closing or latching properly, and inadequate exhaust ventilation causing unpleasant odors.
Deficiencies (9)
| Description |
|---|
| Exit doors accessible by residents lacked functioning sounding devices activated when doors opened. |
| Walls, ceilings, floors, and furniture were not kept clean and in good repair; mounting screws protruding and missing drawers noted. |
| Facility was not maintained free of hazards; improper storage of portable medical oxygen cylinders. |
| Plumbing equipment not maintained safely; sink not secured to wall. |
| Building and fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition; missing sprinkler heads, obstructed smoke detector, malfunctioning emergency lighting, fire safety door issues, and electrical hazards. |
| Interior doors not maintained in safe and operating condition; door knobs unable to release latching devices, doors not closing or latching properly. |
| Doors protecting smoke barrier openings did not close completely and latch. |
| Bathrooms and toilet room doors not maintained in operating condition; bathroom door would not close and latch. |
| Exhaust ventilation system not maintained in proper working order; musty, unpleasant odors present in restrooms. |
Report Facts
Licensed capacity: 120
Special care residents: 60
Date of survey: Jul 20, 2017
Number of fire sprinkler heads removed: 2
Number of portable oxygen cylinder storage crates of beverage type: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 1, 2017
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Human Services conducted an annual and follow-up survey on February 22, 23, 24, 28, 2017 and March 01, 2017.
Findings
The facility was found deficient in safely storing oxygen tanks in a resident's room causing obstructions and hazards, failure to assure tuberculosis testing upon admission for one resident, and failure to provide transportation after an Emergency Department visit for one resident.
Deficiencies (3)
| Description |
|---|
| Facility failed to safely store oxygen tanks for 1 of 2 residents, storing 21 'E' tanks and one large 'M' tank in a resident's room causing lack of floor space and hazards. |
| Facility failed to assure Tuberculosis (TB) disease testing had been completed upon admission for 1 of 7 sampled residents. |
| Facility failed to provide transportation after an Emergency Department visit for 1 of 1 sampled resident who had a fall and was transported to the ED. |
Report Facts
Oxygen tanks stored: 21
Oxygen tanks stored: 1
Residents sampled for TB testing: 7
Residents sampled for transportation issue: 1
Fall date: 2017
Inspection Report
Follow-Up
Deficiencies: 1
Apr 27, 2016
Visit Reason
Follow-Up Construction Survey conducted to verify correction of previously cited deficiencies related to facility housekeeping and furnishings.
Findings
The facility failed to maintain walls, ceilings, and floors or floor coverings in a clean and good repair condition. Most room signage had been removed for renovations or repairs and was not re-installed at the time of the survey.
Deficiencies (1)
| Description |
|---|
| Facility failed to have walls, ceilings, and floors or floor coverings kept clean and in good repair; room signage removed for renovations and not re-installed. |
Inspection Report
Follow-Up
Deficiencies: 5
Feb 10, 2016
Visit Reason
Follow Up Survey conducted to verify correction of deficiencies noted during the previous Follow Up Survey on 2015-11-20.
Findings
The facility failed to correct previously noted deficiencies including housekeeping issues such as flooring coming apart and missing room signage, failure to maintain magnetic locking exit doors, missing fusible link on laundry chute door, plumbing fixtures lacking vacuum breakers, and fire safety system deficiencies including missing fire resistant ceiling tiles and unsealed penetrations.
Deficiencies (5)
| Description |
|---|
| Walls, ceilings, and floors or floor coverings not kept clean and in good repair; seamless flooring coming apart in 2nd floor Staff Station; missing room signage due to renovations. |
| Failure to maintain special locking (magnetic locks) on exit doors; central manual overrides did not release magnetic locks on 2nd floor. |
| Building not maintained in safe and operating condition; laundry chute door missing fusible link. |
| Plumbing fixtures had hoses long enough to reach gray water without vacuum breakers, risking back siphonage. |
| Failure to maintain fire safety systems; gaps and open penetrations in fire resistant ceilings and missing fire resistant ceiling tiles; missing tiles in ground floor water heater room; unsealed penetrations through concrete floor/ceiling slab between upper floors. |
Inspection Report
Follow-Up
Deficiencies: 6
Nov 20, 2015
Visit Reason
Follow Up Survey conducted to verify correction of deficiencies noted during the Biennial Survey on 09/09/2015.
Findings
Deficiencies from the prior Biennial Survey remain uncorrected, including failure to maintain current annual inspection reports, poor housekeeping and repair issues, malfunctioning magnetic locks on exit doors, missing fire safety components, plumbing fixtures lacking vacuum breakers, and fire safety system deficiencies such as missing fire resistant ceiling tiles.
Deficiencies (6)
| Description |
|---|
| Facility failed to maintain current annual inspection reports required. |
| Walls, ceilings, and floors or floor coverings not kept clean and in good repair, including gypsum wall repairs needed, missing closet doors, and flooring coming apart. |
| Special Locking (magnetic locks) on exit doors failed to operate properly; central manual overrides did not release locks on 2nd and 3rd floors. |
| Building not maintained in safe and operating condition; missing fusible link on laundry chute door. |
| Plumbing fixtures had hoses without vacuum breakers, risking backsiphonage of gray water into potable water lines. |
| Failure to maintain fire safety systems; gaps and open penetrations in fire resistant ceilings and missing fire resistant rated ceiling tiles. |
Report Facts
Date of last annual Building Sanitation Inspection Report: Feb 4, 2013
Date of Fire Marshal's report with outstanding items: Mar 31, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Billy S. Bryant | Conducted the Follow Up Survey on 11/20/2015. | |
| Executive Director | Interviewed regarding failure to maintain current annual inspection reports. |
Inspection Report
Plan of Correction
Capacity: 120
Deficiencies: 14
Sep 9, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant, safety, and sanitation regulations applicable to adult care homes.
Findings
Multiple physical plant deficiencies were identified including failure to maintain current annual inspection reports, obstructed corridors, poor housekeeping and maintenance issues, fire safety rehearsal deficiencies, electrical and fire safety equipment problems, improper storage of oxygen cylinders, and inadequate ventilation.
Deficiencies (14)
| Description |
|---|
| Facility failed to maintain current annual inspection reports including Building Sanitation, Fire Marshal, and Fire Sprinkler System Inspection reports. |
| Corridors and stairways obstructed with equipment and storage, blocking clear exit paths. |
| Walls, ceilings, floors, and furnishings not kept clean or in good repair; ceiling tiles displaced or broken; flooring damaged creating tripping hazards; stained ceilings; active leaks; missing room signage. |
| Plumbing equipment not maintained safely; sinks loose; HVAC ventilation grilles dusty; water leaks and odors present. |
| Electrical equipment in disrepair including broken outlet covers, open neutrals, missing cover plates, and loose receptacles. |
| Fire safety rehearsals not conducted quarterly on each shift as required. |
| Electrical outlets in wet locations lacked ground fault interrupters or power, compromising safety. |
| Special locking magnetic exit doors failed to maintain required operation; emergency release switches inaccessible or ineffective; smoke barrier doors did not latch or close properly. |
| Fire sprinkler heads obstructed with lint; some doors stuck open or missing fusible links; egress impeded by locked doors requiring tools or special knowledge. |
| Corridor doors did not resist smoke passage due to improper fitting or failure to latch. |
| Electrical panels obstructed by stored items, violating clearance requirements. |
| Portable medical oxygen cylinders improperly stored unsecured or upside down, creating safety hazards. |
| Plumbing fixtures lacked vacuum breakers, risking backflow contamination. |
| Exhaust ventilation system failed to remove required air volume in bathrooms, causing odor issues. |
Report Facts
Licensed capacity: 120
Fire plan rehearsals documented: 5
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