Inspection Reports for The Bluefields
1935 Lincoln Road Leland, NC 28451, Leland, NC, 28451
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
64% occupied
Based on a October 2020 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 13, 2021
Visit Reason
The Adult Care Licensure Section and the Brunswick County Department of Social Services conducted an annual survey and complaint investigation survey on August 10 - 13, 2021. Complaint investigations were initiated by the county on July 22, 2021 and July 26, 2021.
Complaint Details
Complaint investigations were initiated by Brunswick County on July 22, 2021 and July 26, 2021 related to staff qualifications and resident care.
Findings
The facility failed to ensure staff had no substantiated findings on the North Carolina Health Care Personnel Registry, failed to provide personal care and supervision for a total care resident, failed to assure follow-up on residents' health care needs including transportation, failed to protect residents' rights related to privacy and respect, and failed to implement proper COVID-19 staff screening procedures.
Deficiencies (5)
Facility failed to assure 1 of 1 staff (Staff A) had no substantiated findings on the North Carolina Health Care Personnel Registry.
Facility failed to provide personal care for 1 of 5 sampled residents (#2), who was total care related to transfers, including transferring without required two-staff assistance.
Facility failed to assure referral and follow-up to meet routine and acute health care needs of Resident #4, including failure to obtain documentation from orthopedic visit and failure to provide transportation to chiropractic appointment due to broken wheelchair lift.
Facility failed to ensure Resident #6 was treated with respect, dignity, and privacy; Staff H was observed on a facetime call while providing resident care and shower assistance.
Facility failed to implement infection prevention and control program consistent with CDC guidelines related to COVID-19 staff screening; multiple staff did not consistently complete COVID-19 screening logs and temperature checks upon arrival to work.
Report Facts
Deficiencies cited: 5
Resident sample size: 6
Resident #2 bruise size: 12
Resident #2 bruise size: 36
Resident #4 pain rating: 8
Staff missing COVID-19 screening: 5
Staff missing COVID-19 screening: 3
Staff missing COVID-19 screening: 1
Staff missing COVID-19 screening: 2
Staff missing COVID-19 screening: 1
Staff missing COVID-19 screening: 1
Staff missing COVID-19 screening: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Failed to have a documented Health Care Personnel Registry check upon hire and worked without verification. |
| Staff H | Personal Care Aide | Observed on facetime call while providing resident care and shower assistance. |
| Administrator | Responsible for oversight of staff screening and employee verification; terminated on 08/03/21. | |
| Clinical Director | Interviewed regarding failure to complete HCPR check on Staff A. | |
| Business Office Manager | Responsible for completing HCPR checks; failed to complete for Staff A. | |
| Executive Director | Interviewed regarding Resident #2's injury and staff transfer practices. | |
| Physical Therapist | Retrained staff on two-person transfer techniques. | |
| Memory Care Coordinator | Interviewed regarding Resident #2's injury and staff transfer assistance. | |
| Quality Assurance Director | Interviewed regarding COVID-19 screening and Resident #4's transportation. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 78
Deficiencies: 11
Date: Oct 15, 2020
Visit Reason
The Adult Care Licensure Section and Brunswick County Department of Social Services conducted a state-involved complaint investigation, a follow-up survey, and a COVID-19 focused Infection Control survey with onsite visits and desk reviews from September 30, 2020 through October 15, 2020.
Complaint Details
The complaint investigation was initiated by the Brunswick County Department of Social Services on September 9, 2020, leading to multiple onsite visits and desk reviews from September 30 to October 15, 2020. The investigation focused on staffing shortages, resident care deficiencies, infection control practices, and failure to follow policies and procedures.
Findings
The facility failed to ensure adequate staffing, timely resident assessments and care plan updates, proper personal care and supervision, immediate response to incidents, appropriate health care referral and follow-up, and adherence to COVID-19 infection control guidelines. Residents experienced neglect, inadequate supervision, delayed medical care, and risk of COVID-19 transmission.
Deficiencies (11)
Failed to ensure adequate staffing on the Memory Care Unit (MCU) to meet residents' personal care, supervision, and health care needs for multiple shifts.
Failed to update resident assessments and care plans within 10 days following significant changes for residents including dysphagia diagnosis, decline in feeding ability, and swallowing difficulties.
Failed to provide personal care assistance to residents including incontinent and nonambulatory residents with open wounds, residents put to bed in street clothes, residents requiring feeding assistance and choking, and residents not bathed as scheduled.
Failed to provide supervision for a resident with history of multiple falls resulting in injuries, leading to repeated falls and injuries.
Failed to respond immediately to a resident's fall with possible injury, including failure to call EMS and failure to perform CPR when resident was found unresponsive without a DNR order.
Failed to assure health care referral and follow-up for residents with acute respiratory symptoms, weight loss, and delayed reporting of illness leading to hospital admission and death.
Failed to implement and maintain CDC and DHHS COVID-19 guidelines including screening of visitors and staff, monitoring symptomatic residents, isolation of COVID-19 positive residents, use of masks and PPE, social distancing, and infection control measures.
Failed to have a Memory Care Manager (MCM) working 8 hours per day, 5 days per week to supervise care and staff on the MCU.
Failed to ensure residents were treated with respect, consideration and dignity related to meal services including serving a resident breakfast without a table setting and in lying position and delayed meal delivery to quarantined residents.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws and regulations related to personal care, supervision, health care, resident assessment and care plan, special care unit staffing, resident rights, and management of facilities.
Failed to assure residents were free from mental and physical abuse, neglect, and exploitation related to resident assessment and care plans, personal care and supervision, health care, and resident rights.
Report Facts
Resident census: 50
Total capacity: 78
Staffing shortage hours: 11.75
Staffing shortage hours: 10.75
Staffing shortage hours: 9.75
Resident census: 20
Resident census: 31
Staffing shortage hours: 6
Staffing shortage hours: 10
Staffing shortage hours: 11
Staffing shortage hours: 7.25
Staffing shortage hours: 3.5
Staffing shortage hours: 5
Staffing shortage hours: 4
Staffing shortage hours: 4.25
Staffing shortage hours: 9.75
Staffing shortage hours: 11
Staffing shortage hours: 6
Staffing shortage hours: 7
Staffing shortage hours: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Medication Aide | Worked 3rd shift on 09/29/20 and was interviewed multiple times regarding staffing and care. |
| Director of Development and Acquisitions | Provided clinical support, responsible for chart and medication audits, trainings, and covered Memory Care Manager position. | |
| Memory Care Manager | Hired 08/31/20, worked one week, left after 4 days; position vacant for months prior. | |
| Administrator | Multiple interviews regarding staffing, care, and management issues. | |
| Divisional Director of Clinical Services | Worked as direct care staff on MCU 10/08/20 and 10/09/20; interviewed about staffing and care. | |
| Dietary Manager | Responsible for meal service monitoring; interviewed about meal delivery and delays. | |
| Personal Care Aide | Multiple PCAs interviewed regarding staffing, care, and infection control. | |
| Medication Aide | Multiple MAs interviewed regarding staffing, care, and infection control. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 20, 2020
Visit Reason
The Adult Care Licensure Section conducted a Desk Review follow-up survey on April 09, 2020, April 13-17, 2020, and April 20, 2020 to assess compliance with health care regulations.
Findings
The facility failed to assure the acute and chronic health care needs were met for 1 of 5 sampled residents (#3) related to failure to notify the urologist of the resident passing blood in her urine, coordination of care, and missed urology appointments. This failure resulted in a 25 day delay in treatment for a urinary tract infection and placed the resident at increased risk for urinary symptoms and sepsis.
Deficiencies (2)
Failure to notify Resident #3's urologist when the resident was passing blood in her urine for three days between 01/14/20 to 01/17/20, failure to ensure attendance at scheduled urology appointments, and failure to coordinate care between PCP and urologist.
Failure to assure residents received care and services which were adequate, appropriate, and in compliance with relevant federal and state laws and rules and regulations related to health care.
Report Facts
Days delay in treatment: 25
Sampled residents: 5
Resident #3: 1
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
The Adult Care Licensure Section and the Brunswick County Department of Social Services conducted a follow-up survey from 11/19/19 to 11/21/19 to verify correction of previous deficiencies related to health care needs of residents.
Findings
The facility failed to assure the acute and chronic health care needs were met for 2 of 5 sampled residents related to failure to notify the endocrinologist of elevated finger stick blood sugar results outside of ordered parameters and delays in notification. The Type A1 violation was abated but non-compliance continues as a Type B violation. The facility also failed to assure medications were administered as ordered for 3 of 5 residents, resulting in a 12% medication error rate.
Deficiencies (2)
Failure to notify the endocrinologist of elevated finger stick blood sugar (FSBS) results outside of ordered parameters and delays in notification for 2 of 5 sampled residents.
Failure to assure medications were administered as ordered by a licensed prescribing practitioner and in accordance with facility policies for 3 of 5 residents, including errors with insulin administration and delays in implementing orders.
Report Facts
Medication error rate: 12
Sampled residents: 5
Elevated FSBS results: 7
Medication errors: 4
Inspection Report
Annual Inspection
Census: 74
Capacity: 78
Deficiencies: 10
Date: Aug 6, 2019
Visit Reason
The Adult Care Licensure Section and Brunswick County Department of Social Services conducted an annual survey and complaint investigation from July 31, 2019 to August 6, 2019, including a complaint investigation initiated on July 19, 2019.
Complaint Details
Complaint investigation initiated on July 19, 2019, included review of CPR training compliance and health care coordination issues.
Findings
The facility failed to assure at least one staff person on third shift had current CPR certification for 14 of 15 shifts; failed to assure a Supervisor of personal care aides was on duty for 19 of 24 shifts sampled; failed to meet acute and chronic health care needs for 5 residents related to delayed or missed medical appointments, lack of coordination between providers, and delayed medication administration; failed to maintain safe medication administration policies and procedures resulting in a 35% medication error rate including insulin and antibiotic errors; failed to document medication administration immediately after giving medications; failed to maintain accurate electronic medication administration records with duplicate entries and missing documentation; failed to notify resident responsible parties of hospitalizations; and failed to maintain adequate staffing levels in the Special Care Unit for 15 of 24 shifts sampled.
Deficiencies (10)
Facility failed to assure at least one staff person on third shift had current CPR certification for 14 of 15 shifts from July 1-15, 2019.
Facility failed to assure a Supervisor of personal care aides was on duty and available for 19 of 24 shifts sampled from May to August 2019.
Facility failed to meet acute and chronic health care needs for 5 residents related to delayed or missed medical appointments, lack of coordination between providers, and delayed medication administration.
Facility failed to maintain safe medication administration policies and procedures; failed to assure medications were administered as ordered for 2 of 6 residents observed during medication passes including insulin and antibiotic errors; and for 4 of 7 residents sampled for record reviews including delays and missed doses of antibiotics, antifungals, antidepressants, and thyroid medication.
Facility failed to document medications immediately after administration for 7 of 8 sampled residents and failed to maintain a safe system to assure documentation at time of administration.
Facility failed to assure accuracy of electronic medication administration records for 3 residents related to as needed orders without indication for administration, duplicate entries for finger stick blood sugars and antiplatelet medication, duplicate administration times for a gastric reflux medication, and incorrect dose transcribed for thyroid medication.
Facility failed to notify resident responsible party of hospitalizations for 1 of 2 sampled residents after incidents requiring emergent hospital evaluation.
Facility failed to assure minimum staffing levels in the Special Care Unit for 15 of 24 shifts sampled from May to August 2019, resulting in inadequate care and supervision.
Facility failed to maintain written policies and procedures for safe medication administration including documentation when electronic medication administration system was not operational.
Executive Director/Administrator failed to assure overall management of facility operations and policies to maintain residents' rights and compliance with rules and statutes related to medication administration, health care, and CPR training, resulting in serious neglect and harm.
Report Facts
Medication error rate: 35
Staffing shortage hours: 6.7
Staffing shortage hours: 6.75
Staffing shortage hours: 5.45
Staffing shortage hours: 5.28
Staffing shortage hours: 9.47
Staffing shortage hours: 0.2
Staffing shortage hours: 7.77
Staffing shortage hours: 6
Staffing shortage hours: 2
Staffing shortage hours: 1.6
Staffing shortage hours: 1.85
Staffing shortage hours: 8.5
Staffing shortage hours: 4.75
Staffing shortage hours: 5.75
Staffing shortage hours: 11.75
Inspection Report
Capacity: 78
Deficiencies: 4
Date: Jan 9, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 1996 North Carolina State Building Code, and the 2005 Rules for Adult Care Homes.
Findings
Deficiencies were cited related to failure to meet code requirements at the time of construction or renovation, including lack of wiring diagrams for the special locking system, moldy and dirty HVAC diffusers, storage obstructing sprinkler heads, and a fire-rated laundry room door wedged open compromising fire safety.
Deficiencies (4)
The special locking system is required to have a wiring diagram and a system components location map posted at the FACP.
Ceiling HVAC diffusers are moldy and dirty in multiple locations including Administrator's Offices, Employee Bathroom, and Service Hall.
Items stored on top shelves less than 18 inches from the ceiling are obstructing sprinkler heads in Storage Room and Housekeeping Room.
Laundry Room door (one-hour fire rated) was wedged open, preventing containment of fire and/or smoke.
Report Facts
Licensed capacity: 78
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 7, 2018
Visit Reason
The visit was a complaint follow-up construction survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies.
Complaint Details
This was a complaint follow-up survey. The original complaint deficiencies were corrected, but new deficiencies were cited.
Findings
The original complaint deficiencies were found to be corrected; however, new deficiencies were identified related to the building sprinkler system not meeting code requirements, specifically lacking automatic fire sprinkler protection in Bedroom 112 Closet A and the office near the conference table.
Deficiencies (2)
Building Sprinkler System failed to meet code requirements by not having all required areas protected with sprinklers, including Bedroom 112 Closet A.
Building Sprinkler System failed to meet code requirements by not having all required areas protected with sprinklers, including the office near the conference table.
Inspection Report
Complaint Investigation
Capacity: 78
Deficiencies: 1
Date: Oct 3, 2017
Visit Reason
The inspection was conducted as a complaint survey based on allegations of mold issues at the facility.
Complaint Details
The complaint alleging mold issues was substantiated. DSS identified 8 rooms with problems including black, grey, and greenish gray fungal growth on ceilings, walls, carpets, and furnishings. Remediation is ongoing with affected rooms sealed off and residents relocated.
Findings
The complaint was substantiated with findings of mold and microbial growth caused by roof leaks and faulty air conditioning equipment. Remediation efforts were underway, including sealing off affected rooms and replacing PTAC units.
Deficiencies (1)
Walls, ceilings, and floors or floor coverings were not maintained clean and in good repair due to moisture damage and microbial growth.
Report Facts
Total licensed beds: 78
Rooms with problems identified: 8
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 27, 2017
Visit Reason
The visit was a Biennial Follow Up Construction Section Survey conducted to review compliance with physical plant requirements, specifically sanitation and fire safety reports.
Findings
The facility did not have current required sanitation and fire safety inspection reports available for review at the time of the survey. The annual fire sprinkler inspection was in progress during the survey.
Deficiencies (1)
Facility did not have current sanitation and fire safety inspection reports available for review.
Inspection Report
Capacity: 78
Deficiencies: 9
Date: Nov 23, 2016
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code, Institutional Occupancy, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
The survey identified multiple deficiencies including failure to meet NC State Building Code requirements for emergency release switches at special locked exits, missing current sanitation and fire safety inspection reports, housekeeping hazards, lack of fire safety rehearsal records, compromised fire rated walls and ceilings, corridor doors not closing or latching properly, malfunctioning exit signs, and non-operational warning devices protecting emergency release switches.
Deficiencies (9)
Most staff did not carry emergency release switch keys and some staff were unaware they had keys to operate locked emergency release switches.
No central emergency release switch provided in the Special Care Unit and no wiring diagram or systems components location map posted at the fire alarm panel.
Required sanitation and fire and building safety inspection reports were not available in the home for review, including fire and building safety inspection report, fire alarm inspection, and sprinkler inspection.
Portion of hardware missing from panic release bar on a smoke barrier door exposing sharp edges that could be a laceration hazard.
Warning device ('screamer') protecting emergency release switch was found switched off at the exit in the Activity room and not working at the exit from the Lobby.
Records of fire safety rehearsals on each shift were not available onsite; records must include date, time, shift, staff present, and description of rehearsal.
Required one-hour fire rated walls and/or ceilings were compromised in several locations with holes, unsealed penetrations, and missing or improperly fitted sprinkler escutcheons.
Many corridor doors did not close completely or latch properly, including fire rated doors and smoke barrier doors, which could allow fire and smoke to spread quickly.
Exit sign in corridor near RN office did not illuminate on normal power or battery backup.
Report Facts
Licensed capacity: 78
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 12, 2016
Visit Reason
The Adult Care Licensure Section completed a complaint investigation from 04/05/16 to 04/08/16 and 04/11/16 to 04/12/16 regarding supervision and care concerns at Leland House.
Complaint Details
The complaint investigation was initiated due to concerns about supervision failures in the Assisted Living dining room leading to an incident causing death, failure to notify physicians of resident health care needs, and concerns about resident dignity and respect related to incontinence care.
Findings
The facility failed to supervise 2 of 6 residents in the Assisted Living dining room during the supper meal, resulting in an incident causing death of Resident #2. The facility also failed to notify the physician of Resident #2's health care needs and psychotherapist recommendations. Additionally, the facility failed to treat Resident #5 with dignity and respect related to incontinence care and bed linen changes.
Deficiencies (4)
Failed to supervise 2 of 6 residents in the Assisted Living dining room during supper meal resulting in Resident #2's injury and death.
Failed to notify physician of health care needs and psychotherapist recommendations for Resident #2.
Failed to assure Resident #5 was treated with dignity and respect; staff refused to change soiled bed linen, required resident to sit in chair, and spoke disrespectfully after incontinence episodes.
Failed to assure residents were free from abuse and neglect by failing to supervise residents in the Assisted Living dining room during meals.
Report Facts
Residents sampled: 6
Incident date: Apr 2, 2016
Resident #2 admission date: Dec 22, 2015
Resident #6 admission date: Jan 25, 2016
Psychotherapy visit date: Jan 20, 2016
Psychotherapist recommendation date: Jan 22, 2016
Plan of Correction completion date: May 12, 2016
Plan of Correction completion date: May 27, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Named in dignity and respect deficiency related to refusal to change Resident #5's soiled bed linen and disrespectful communication |
| Executive Director | Interviewed multiple times regarding supervision failures, health care notification failures, and resident care plans | |
| Psychotherapist | Provided evaluation and recommendations for Resident #2 |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 19, 2015
Visit Reason
This is a follow-up complaint survey conducted to verify correction of previously identified deficiencies at Leland House.
Complaint Details
Follow-up complaint survey conducted; deficiencies were not fully corrected.
Findings
The follow-up survey revealed that not all deficiencies have been corrected. The facility failed to maintain cleanliness and was found to have ongoing bed bug activity as recently as November 18, 2015. Preventative treatment was underway in all rooms, with approximately 17 rooms remaining to receive treatment.
Deficiencies (1)
Facility failed to maintain cleanliness and free of hazards, exposing residents, staff, and visitors to bed bug bites.
Report Facts
Rooms remaining for preventative treatment: 17
Date of last documented bed bug activity: Nov 18, 2015
Inspection Report
Complaint Investigation
Capacity: 78
Deficiencies: 2
Date: Aug 18, 2015
Visit Reason
This is a complaint investigation conducted due to allegations that every bathroom was being renovated at once, the facility had bed bugs in at least 20 rooms, and residents who are able were not allowed to come and go freely, having to wait for someone to open the locked door.
Complaint Details
Complaint investigation substantiated complaints of bed bugs in at least 20 rooms and restriction of residents' free movement. The complaint about all bathrooms being renovated at once was unsubstantiated.
Findings
The complaint was substantiated for bed bugs in approximately 20 rooms and for restricting residents' free movement due to locked doors requiring staff assistance. The allegation regarding bathroom renovations was unsubstantiated. The facility failed to maintain cleanliness and free movement rights for residents.
Deficiencies (2)
Facility failed to maintain cleanliness and free of hazards, with approximately 20 resident rooms treated for bed bugs over the last 10 months.
Facility failed to allow residents who are able to exit and re-enter the building freely without staff assistance due to locked entrance/exit doors requiring punch codes not given to residents.
Report Facts
Licensed capacity: 78
Rooms treated for bed bugs: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greg Cates | Conducted the complaint investigation on August 18, 2015 |
Viewing
Loading inspection reports...
