Inspection Reports for The Bradford Village of Kernersville – West
602 Piney Grove Road Kernersville, NC 27284, Kernersville, NC, 27284
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies remain uncorrected related to the facility's plumbing system. Specifically, showers in Group Bathroom B (Front Hall) and Group Bathroom A (Back Hall) were found not to be in operational condition.
Deficiencies (1)
Facility failed to maintain its plumbing system in a safe and operating manner; showers in Group Bathroom B and Group Bathroom A are not operational.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on September 18-19, 2024 to assess compliance with medication staff qualifications and medication administration regulations.
Findings
The facility failed to ensure proper documentation of medication aide training and examination for two sampled medication aides, and failed to administer medications as ordered for one resident related to insulin administration and documentation of fingerstick blood sugars. Additionally, the electronic medication administration record (eMAR) was found inaccurate for two residents regarding documentation of blood sugar levels and medication administration.
Deficiencies (3)
Failed to ensure documentation for 1 of 3 sampled medication aides who administered medications completed required state approved medication aide training and passed the written examination within required timeframe.
Failed to administer medications as ordered for 1 of 5 sampled residents related to administering fast-acting insulin for fingerstick blood sugars over 450.
Failed to ensure the electronic medication administration record (eMAR) was accurate for 2 of 5 sampled residents related to documenting fingerstick blood sugars and medication to treat insomnia.
Report Facts
Medication administration occasions: 31
Medication administration occasions: 55
FSBS values: 6
FSBS values: 4
Missed medication documentation: 27
Missed medication documentation: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to pass the written medication aide examination within 60 days of clinical validation skills checklist completion. |
| Staff B | Medication Aide | Lacked documentation of completion of required 10-hour medication aide training before administering medications. |
| Business Office Manager | Responsible for maintaining employee training documentation; lacked documentation for Staff A and Staff B. | |
| Administrator | Responsible for ensuring employee records were complete and medication administration compliance; acknowledged issues with medication aide examination and medication administration audits. | |
| Resident Care Coordinator | Responsible for auditing medications and eMAR documentation; had not set up auditing process and missed missing documentation. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
Report of Construction Section Follow Up Biennial Survey conducted on February 14, 2024.
Findings
Corrections have been made. No further action is needed.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to the facility's fire alarm system.
Findings
The facility failed to provide a complete fire alarm system as required for buildings licensed before April 1, 1984, and constructed prior to January 1, 1975. Specifically, heat detectors or smoke detectors were missing in storage rooms outside the kitchen's back door, and the issue was more extensive than initially thought.
Deficiencies (1)
Failure to provide heat detectors or products of combustion detectors in all storage rooms, kitchens, living rooms, dining rooms, and laundries as part of the fire alarm system.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jul 19, 2023
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to the facility's fire alarm system and building safety.
Findings
The facility failed to provide a complete fire alarm system as required for buildings licensed before 1984 and constructed prior to 1975, specifically lacking heat or smoke detectors in storage rooms. Additionally, several fire safety and building maintenance issues were noted, including smoke barrier doors that do not close properly, unsealed penetrations in walls and ceilings, and corridor doors requiring extra effort to operate.
Deficiencies (5)
No fire detecting devices (heat or smoke detectors connected to the existing fire alarm system) provided in storage rooms outside of kitchen's back door.
Doors protecting openings in the smoke barrier do not close completely on their own power and latch to restrict fire and smoke.
Holes in ceiling where cables penetrate near laundry door and unsealed penetration in corridor wall of Soiled Linen Room.
Hole with cable not sealed as it penetrates the wall in Nurse Station Office.
Smoke tight corridor door in Beauty Shop requires extra effort to close and open; door rubbing along the top despite sanding.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jun 22, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 06/21/23 through 06/22/23 to verify correction of previous deficiencies.
Findings
The facility failed to ensure competency validation for licensed health professional support tasks for one staff member, failed to ensure referral and follow-up for a resident's pain clinic appointment, failed to administer medications as ordered for one resident related to vitamin supplements, failed to maintain accurate electronic medication administration records for insulin administration for two residents, and failed to store refrigerated medications at proper temperatures.
Deficiencies (5)
Failed to ensure a licensed health professional support (LHPS) competency validation had been completed for tasks including checking fingerstick blood sugar and administration of medication via injection for one staff member.
Failed to ensure referral and follow-up to meet the health care needs for one resident who had a referral to the pain clinic ordered but no appointment was scheduled.
Failed to administer vitamin D3 and vitamin B12 supplements as ordered, continuing administration after orders to discontinue.
Failed to ensure electronic medication administration records (eMAR) were accurate for two residents related to documenting the amount of insulin administered.
Failed to ensure medications requiring refrigeration were stored at temperatures between 36 degrees F to 46 degrees F; refrigerator temperature was observed as low as 20 degrees F with frozen medications present.
Report Facts
Dates of survey: 2023-06-21 to 2023-06-22
Staff B hired date: Apr 13, 2023
FSBS checks documented by Staff B: 38
Insulin administrations documented by Staff B: 36
FSBS checks documented by Staff B: 24
Insulin administrations documented by Staff B: 24
Vitamin D3 doses administered after discontinuation: 19
Vitamin B12 doses administered after discontinuation: 19
Novolog insulin administration opportunities undocumented: 27
Novolog insulin administration opportunities undocumented: 38
Medication refrigerator temperature: 28
Medication refrigerator temperature low: 20
Frost build-up thickness: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Named in competency validation deficiency for LHPS tasks |
| Administrator | Interviewed regarding competency validation, referral scheduling, medication administration, and medication refrigerator issues | |
| Resident Care Coordinator | RCC | Interviewed regarding referral scheduling, medication administration, and audits |
| Pharmacist | Contracted pharmacy pharmacist interviewed regarding medication orders and insulin storage | |
| Medication Aide | MA | Interviewed regarding medication administration and eMAR documentation |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 16, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 03/14/23 through 03/16/23 to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in multiple areas including failure to complete annual care plans for residents, inadequate supervision after resident falls, failure to ensure referrals and follow-up for acute health care needs, failure to provide matching therapeutic diets, and failure to administer medications as ordered including documentation errors in medication administration records.
Deficiencies (6)
Facility failed to ensure 2 of 5 sampled residents had care plans completed annually.
Facility failed to provide supervision for 1 of 5 sampled residents who had multiple falls without increased supervision or interventions.
Facility failed to ensure referral and follow-up to meet acute health care needs for 2 of 5 sampled residents related to an eye probe referral and refusals of finger stick blood sugars and pain patch.
Facility failed to ensure there was a matching therapeutic diet menu for 4 of 5 sampled residents with physician ordered therapeutic diets.
Facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents including insulin, iron supplement, pain medication, and estrogen steroid cream.
Facility failed to ensure electronic medication administration records were accurate for 3 of 5 residents related to documenting discontinued eyedrops and insulin administration amounts.
Report Facts
Sampled residents with missing annual care plans: 2
Sampled residents with therapeutic diet issues: 4
Sampled residents with medication administration issues: 2
Falls for Resident #3: 5
Opportunities with no insulin amount documented: 15
Opportunities with no insulin amount documented: 22
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 8, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 07/06/22 to 07/08/22 to verify correction of previous deficiencies related to health care referrals, medication administration, resident rights, and medication administration compliance.
Findings
The facility failed to ensure follow-up on health care referrals, proper medication administration including insulin and diuretics, provision of nutritional supplements as ordered, and residents' rights to be free from verbal abuse and neglect. Multiple residents did not receive ordered portable oxygen tanks or medications, and a medication aide was verbally abusive and refused medications to residents. These failures resulted in increased pain, fear, and potential health risks for residents.
Deficiencies (4)
Failed to ensure health care referrals were followed up for residents with orders for pain specialist referral, daily laxative, and oxygen use with portable tanks.
Failed to ensure nutritional supplements were served as ordered for a resident with an order for nutritional shakes.
Failed to ensure residents were free from verbal abuse and neglect related to a medication aide who was rude, yelled, and refused PRN medications to residents.
Failed to administer medications as ordered for residents including errors in insulin administration and failure to administer diuretic medications as ordered.
Report Facts
Medication refusals: 16
Morphine syringes available: 3
Insulin doses administered: 28
Resident weights: 264.2
Resident weights: 258
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in verbal abuse and refusal to administer PRN medications to residents. |
| Resident Care Coordinator | Responsible for reviewing orders, scheduling referrals, and medication administration audits. | |
| Scheduler | Responsible for scheduling appointments and referrals. | |
| Primary Care Provider | Referenced in relation to orders and expectations for medication administration and referrals. |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Apr 7, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 04/05/22 to 04/07/22 to verify correction of previous deficiencies.
Findings
The facility failed to ensure medication aides completed required training, failed to notify physicians timely for resident health changes, failed to administer medications as ordered including insulin and ulcer medication, failed to maintain accurate controlled substances records, and failed to implement proper COVID-19 source control measures.
Deficiencies (7)
Failed to ensure 1 of 3 sampled medication aides completed training on care of diabetic residents prior to insulin administration.
Failed to ensure physician notification for 2 of 5 residents related to elopement, self-injurious behaviors, missed appointment, and medication refusals.
Failed to administer medications as ordered for 2 of 7 residents observed including insulin and ulcer medication; and errors in insulin administration and documentation for 2 of 5 residents reviewed.
Failed to maintain a readily retrievable and accurate record of controlled substances for 3 of 5 sampled residents related to pain, anxiety, and sleep medications.
Failed to ensure implementation of CDC and NCDHHS COVID-19 infection prevention guidance related to proper use of facemasks and source control.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant federal and state laws and rules related to health care and medication administration.
Failed to ensure medication aide completed required state-approved training or had verification of prior employment within previous 24 months.
Report Facts
Medication administration error rate: 7
Lactulose refusal: 43
Norco tablets dispensed: 51
Norco tablets missing documentation: 9
Ambien tablets dispensed: 30
Humalog insulin doses missed: 7
Humalog insulin doses incorrectly administered: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete required diabetic care training and state-approved medication aide training; administered medications without proper training documentation |
| Business Office Manager | Responsible for ensuring staff completed required training and maintaining personnel records; unaware of missing training documentation for Staff A | |
| Administrator | Responsible for staff training oversight and ensuring medication administration compliance; unaware of training and medication administration deficiencies | |
| Resident Care Coordinator | Responsible for staff training oversight, medication order review, and controlled substance reconciliation; unaware of medication administration and controlled substance discrepancies |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jan 7, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from January 5, 2022 through January 7, 2022.
Complaint Details
The visit was a follow-up survey and complaint investigation triggered by allegations of inadequate personal care, medication administration issues, controlled substance record inaccuracies, verbal abuse by staff, and disrespectful treatment of residents.
Findings
The facility failed to ensure personal care was provided for 5 of 8 residents who needed assistance with bathing and incontinence care, resulting in a skin ulcer on Resident #1's right heel that could have become limb threatening. Medication administration records for Resident #1 were incomplete and inaccurate for sliding scale insulin. The facility also failed to maintain accurate controlled substance records for Resident #1. Additionally, the facility failed to submit timely reports of verbal abuse allegations by staff to the Health Care Personnel Registry and failed to ensure residents were treated with respect and dignity, with reports of verbal abuse and rough care by staff.
Deficiencies (5)
Failed to ensure personal care was provided for 5 of 8 residents who needed assistance with bathing and incontinence care.
Failed to ensure medication administration records were complete and accurate for Resident #1 with an order for sliding scale insulin.
Failed to ensure a readily retrievable record that accurately reconciled the receipt, administration, and disposition of controlled substances for Resident #1.
Failed to submit a report of allegations of verbal abuse by 2 staff to the Health Care Personnel Registry within 24 hours of becoming aware.
Failed to ensure all residents were treated with respect and dignity related to verbal disrespect and rough care by staff.
Report Facts
Residents needing assistance with bathing and incontinence care: 5
Opportunities with no documentation of bathing assistance: 77
Opportunities with no documentation of toileting assistance: 43
Opportunities with no documentation of oral care: 70
Opportunities with no documentation of bathing assistance: 84
Opportunities with no documentation of toileting assistance: 68
Opportunities with no documentation of oral care: 82
Opportunities with no documentation of bathing assistance: 14
Opportunities with no documentation of toileting assistance: 11
Opportunities with no documentation of oral care: 12
Opportunities with no documentation of bathing assistance: 56
Opportunities with no documentation of toileting assistance: 80
Opportunities with no documentation of oral care: 91
Opportunities with no documentation of bathing assistance: 11
Opportunities with no documentation of toileting assistance: 11
Opportunities with no documentation of oral care: 12
Opportunities with no documentation of skin care: 15
Quantity of Ambien tablets dispensed: 30
Quantity of Norco tablets dispensed: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Staffing Coordinator | Named in verbal abuse and rough care allegations, failed to submit report to HCPR, and involved in mistreatment of residents. |
| Staff C | Personal Care Aide | Named in verbal abuse allegations and failure to submit report to HCPR. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for eMAR audits and medication documentation oversight. |
| Administrator | Facility Administrator | Interviewed regarding knowledge of complaints, oversight of documentation and reporting. |
Inspection Report
Follow-Up
Census: 49
Deficiencies: 7
Date: Oct 12, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on October 6-8, 2021 and October 11-12, 2021 to verify correction of previous deficiencies and investigate complaints.
Complaint Details
Complaint investigation included failure to meet staffing requirements and failure to notify providers for residents with hypoglycemic episodes and psychiatric medication needs.
Findings
The facility failed to meet required staffing hours on third shift, failed to notify providers for residents with hypoglycemic episodes and psychiatric medication needs, failed to implement physician orders for blood sugar monitoring and medication administration, failed to maintain accurate controlled substance records, and failed to implement infection control policies preventing sharing of glucometers between residents.
Deficiencies (7)
Failed to ensure required staffing hours were met on third shift based on census of 49 residents.
Failed to ensure provider notification for residents with hypoglycemic episodes and psychiatric medication needs.
Failed to implement physician orders for fingerstick blood sugars (FSBS) monitoring, rechecks, blood pressure and heart rate checks, and thrombo-embolus deterrent hose use.
Failed to ensure physician notification for clarification of analgesic medication orders.
Failed to administer medications as ordered related to insulin for two residents.
Failed to maintain a readily retrievable record that accurately reconciled receipt, administration, and disposition of controlled substances for two residents.
Failed to implement infection control policy consistent with CDC guidelines to prevent sharing of glucometers between residents, placing residents at risk for bloodborne pathogen exposure.
Report Facts
Staffing shortage: 8
Deficiencies cited: 7
Residents sampled: 6
Residents sampled: 5
Residents sampled: 7
FSBS readings: 10
Controlled substance doses unaccounted: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for scheduling staff, reviewing orders, auditing eMAR and controlled substance count sheets, and monitoring glucometer use. | |
| Executive Director | Responsible for staffing oversight, order verification, and infection control policy enforcement. | |
| Medication Aide | Involved in medication administration, FSBS testing, and documentation; interviewed multiple times regarding deficiencies. | |
| Staffing and Transportation Coordinator | Assisted with personal care and staff scheduling; interviewed regarding staffing shortages. | |
| Third shift medication aide/Supervisor | Interviewed about staffing and medication administration on third shift. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 21, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey, and a complaint investigation from June 16, 2021 to June 18, 2021 with an exit conference on June 21, 2021.
Complaint Details
Complaint investigation was conducted as part of the visit from June 16 to June 18, 2021.
Findings
The facility failed to ensure physician orders were implemented for daily weights for Resident #5, failed to serve therapeutic diets as ordered for Resident #6, required vaccinated residents to wear face masks and restricted their ability to leave the facility, failed to administer medications as ordered for Resident #3 including errors with inhalation nebules, anxiety medication, diuretics, and insulin administration, and failed to maintain accurate controlled substance records for Resident #5. Additionally, the facility failed to implement infection control procedures consistent with CDC guidelines for glucometer use, resulting in sharing glucometers between residents.
Deficiencies (6)
Failed to ensure physician orders were implemented for daily weights for Resident #5.
Failed to serve therapeutic diets as ordered for Resident #6 with a mechanical soft diet order.
Failed to ensure residents were treated with respect and dignity related to mask wearing and restrictions on leaving the facility for vaccinated residents.
Failed to administer medications as ordered for Resident #3 including errors with inhalation nebules, anxiety medication, diuretics, and insulin administration.
Failed to maintain a readily retrievable record that accurately reconciled receipt, administration, and disposition of controlled substances for Resident #5.
Failed to implement infection control procedures consistent with CDC guidelines for glucometer use, resulting in sharing glucometers between residents (#3, #5, and #6).
Report Facts
Medication error rate: 14
Controlled substance tablets: 31
Pregabalin capsules: 52
FSBS values recorded: 61
FSBS values mismatched: 22
FSBS values missing: 27
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 16, 2021
Visit Reason
The Adult Care Licensure Section conducted a Follow-Up Survey and a Complaint Investigation with an onsite visit on 03/16/21 through 03/17/21 and a desk review survey on 03/18/21 through 03/19/21 with an exit via telephone on 03/19/21.
Complaint Details
Complaint investigation conducted alongside follow-up survey due to medication administration concerns for Resident #4.
Findings
The facility failed to administer medications as ordered for Resident #4, including incorrect administration of Humulin R U500 insulin due to use of inappropriate syringes, and administration of Humalog insulin outside of physician's parameters. Additionally, Resident #3 had an emergency inhaler in her room without a self-administration order. The facility also failed to maintain accurate controlled substance records for Resident #4.
Deficiencies (4)
Failed to administer Humulin R U500 insulin correctly due to use of syringes calibrated for U100 insulin, resulting in 5 times the prescribed dose for multiple administrations.
Administered Humalog insulin to Resident #4 when FSBS was less than 450, contrary to physician's order.
Resident #3 had an emergency inhaler on her nightstand without a physician's order for self-administration.
Failed to maintain accurate and reconciled records of receipt and administration of controlled substances for Resident #4.
Report Facts
Humulin R U500 insulin doses administered incorrectly: 45
Humalog refusals: 60
Humalog administrations outside order parameters: 117
Remaining doses on Advair inhaler: 39
Clonazepam tablets dispensed: 60
Hydrocodone-acetaminophen tablets dispensed: 180
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 23, 2020
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation and a COVID-19 focused Infection Control survey with onsite visits on October 7, 2020 and October 15, 2020, initiated by the Forsyth County Department of Social Services on September 16, 2020.
Complaint Details
The complaint investigation was initiated by the Forsyth County Department of Social Services on September 16, 2020.
Findings
The facility failed to ensure resident bathrooms, window sills, floors, and shower chairs were kept clean and in good repair. The facility also failed to ensure health care needs were met for 3 of 11 sampled residents, including failure to notify primary care providers of medication refusals, resident decline, and weight gain. Additionally, medications were not administered as ordered for 8 of 9 sampled residents, and medication aides lacked required training and competency documentation. Controlled substances records were not accurately maintained for 2 of 4 residents.
Deficiencies (5)
Failed to ensure resident bathrooms, window sills, floors, and shower chairs were kept clean and in good repair.
Failed to ensure health care needs were met for 3 of 11 sampled residents including failure to notify primary care providers for refusal of medications, resident decline, inability to get out of bed, crying due to pain, vomiting, and altered mental status resulting in death, failure to apply anti-thrombotic hose, and failure to notify primary care provider for weight gain.
Failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 8 of 9 sampled residents related to multiple medication errors including seizure control, pain management, bipolar disorder, gastroesophageal reflux, and fluid retention.
Failed to ensure records of receipt and administration of controlled substances were maintained, accurate and reconciled for 2 of 4 residents prescribed controlled substances.
Failed to ensure medication aides had completed required medication administration training and passed the written medication aide exam within 60 days of clinical skills competency validation for 2 of 3 sampled staff.
Report Facts
Medication doses missed: 12
Medication doses missed: 16
Medication doses missed: 20
Medication doses missed: 22
Medication doses missed: 15
Medication doses missed: 7
Medication doses missed: 14
Medication doses missed: 3
Medication doses missed: 3
Medication doses missed: 16
Medication doses missed: 7
Medication doses missed: 5
Medication doses missed: 90
Medication doses missed: 10
Medication doses missed: 90
Medication doses missed: 10
Medication doses missed: 80
Medication doses missed: 10
Medication doses missed: 14
Medication doses missed: 15
Medication doses missed: 7
Medication doses missed: 3
Medication doses missed: 14
Medication doses missed: 16
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Executive Director | Documented medication administration but lacked documentation of required medication aide training and employment verification. |
| Staff C | Medication Aide | Completed clinical skills competency and training but did not pass written medication aide exam within 60 days. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 16, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on October 15 - 16, 2019 to verify correction of previous deficiencies related to medication administration and health care referral.
Findings
The facility failed to notify the primary care provider about six missed doses of omeprazole for Resident #1 and failed to administer medications as ordered for Residents #1 and #3, including continued administration of ibuprofen to Resident #3 after a physician's order to discontinue it, increasing risk for gastrointestinal bleeding.
Deficiencies (3)
Failed to notify the primary care provider for missed doses of omeprazole for Resident #1.
Failed to administer medications as ordered for Residents #1 and #3, including continued administration of ibuprofen after discontinuation order for Resident #3.
Failed to assure each resident received care and services which were adequate, appropriate and in compliance with relevant laws related to medication administration.
Report Facts
Missed doses: 6
Days ibuprofen continued after discontinuation: 38
Doses of ibuprofen received after discontinuation: 112
Residents sampled: 5
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 17, 2019
Visit Reason
The visit was a biennial follow-up construction survey to verify correction of previously identified deficiencies.
Findings
The facility has not maintained building equipment in a safe and operating condition. Specifically, the combustion air supply ceiling ductwork in the Laundry Room was sealed with residential grade fire block instead of materials approved for use in 1 hour fire rated assemblies.
Deficiencies (1)
Combustion air supply ceiling ductwork in the Laundry Room sealed with residential grade fire block instead of approved fire rated materials.
Inspection Report
Capacity: 62
Deficiencies: 9
Date: Jul 31, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1971 and applicable portions of the 2005 Rules 10A NCAC 13F for Licensing of Adult Care Homes and the 1967 North Carolina State Building Code - Section 516 - Institutional Occupancy.
Findings
Multiple deficiencies were cited including lack of hand grips at commodes, peeling paint on the laundry room ceiling, inadequate bedroom furnishings such as a resident sleeping on a bare mattress without linens, missing individual towel bars in several rooms, unsafe and non-operational building equipment including unsecured gas supply lines, unprotected ductwork, unilluminated exit light, gaps in corridor walls allowing passage of fire/smoke, and non-operational exhaust ventilation fans in specified locations.
Deficiencies (9)
No hand grips provided adjacent to commodes in Shower Room/Front Hall and Shower Rooms/Back Hall.
Peeling paint on the ceiling of the Main Laundry Room.
Resident sleeping on a bare mattress in Room 9 without linens or pillow.
Facility has not provided each resident with an individual towel bar in Rooms 5/6, 11/12, and 14/15.
Combustion air supply ceiling ductwork in Laundry Room ceiling lacks fire protection.
Gas supply lines behind gas dryer appliances in Main Laundry are not secured to walls or ceiling.
Corridor walls intersecting exterior concrete block construction have 1/2" gaps not fire protected allowing passage of fire and/or smoke.
Exit light located at Front Lobby is not illuminated.
Mechanical exhaust ventilation fans are not operational in Shower RoomL/Front Hall and Mop Sink Closet/Center Hall.
Report Facts
Total licensed capacity: 62
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 16, 2019
Visit Reason
The Adult Care Licensure Section conducted an Annual and Follow-up survey and Complaint Investigation from 05/14/19 through 05/16/19. The Complaint Investigation was initiated by the Adult Care Licensure Section on 05/14/19.
Complaint Details
Complaint Investigation was initiated on 05/14/19 related to personal care training, supervision, and medication administration issues.
Findings
The facility failed to assure personal care training was completed for one staff member, failed to provide adequate supervision for a resident with dementia and history of falls, and failed to administer medications as ordered for two residents. Documentation of medication administration was also incomplete for multiple medications for two residents.
Deficiencies (5)
Facility failed to assure 1 of 3 sampled staff had documentation of successful completion of an 80 hour personal care training and competency evaluation program.
Facility failed to provide supervision for 1 of 5 sampled residents with dementia, history of repeated falls, and femur fracture, resulting in multiple unwitnessed falls and injuries.
Facility failed to assure physician notification for 1 of 5 sampled residents related to medication not being administered when resident signed out of the facility.
Facility failed to administer medications as ordered by a licensed prescribing practitioner for 2 of 5 sampled residents with orders for anxiety medication, long-acting insulin, appetite stimulant, tiotropium bromide inhalation powder, and rapid acting insulin.
Medication Administration Records (MARs) were inaccurate and incomplete for 2 of 5 sampled residents, with multiple medications not documented as administered on several occasions in March, April, and May 2019.
Report Facts
Medication administration opportunities missed: 15
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 1
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 3
Medication administration opportunities missed: 4
Medication administration opportunities missed: 1
Medication administration opportunities missed: 4
Medication administration opportunities missed: 4
Medication administration opportunities missed: 2
Medication administration opportunities missed: 4
Medication administration opportunities missed: 4
Medication administration opportunities missed: 2
Medication administration opportunities missed: 4
Medication administration opportunities missed: 4
Medication administration opportunities missed: 2
Medication administration opportunities missed: 4
Medication administration opportunities missed: 4
Medication administration opportunities missed: 2
Medication administration opportunities missed: 4
Medication administration opportunities missed: 4
Medication administration opportunities missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide (MA), Supervisor, and Personal Care Aide (PCA) | Failed to provide documentation of personal care training. |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for assuring personal care training completion, medication reconciliation, and medication administration record management. |
| Administrator | Facility Administrator | Interviewed regarding supervision, medication administration, and documentation issues. |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration and documentation. |
| Supervisor | Supervisor | Interviewed regarding medication administration and documentation. |
| Medical Assistant | Medical Assistant with Resident #3's Primary Care Provider's (PCP) office | Interviewed regarding medication administration and physician notification. |
| Representative | Representative from the facility contracted pharmacy | Interviewed regarding medication orders, availability, and pharmacy communication. |
| Family Member | Family Member of Resident #1 and Resident #3 | Interviewed regarding resident care and medication administration. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 7, 2017
Visit Reason
The visit was a biennial follow-up construction survey to verify correction of previously identified deficiencies.
Findings
The facility had not corrected several deficiencies including interior doors that do not latch or seal properly, broken ceiling tiles in Room 12 and nearby corridor, and plumbing fixtures such as an unsecured toilet in the bathroom across from Room 29.
Deficiencies (3)
Interior doors out of adjustment and do not latch or seal properly, including missing latch strike and improper fit to resist smoke passage.
Broken lay-in ceiling tiles in Room 12 and corridor near Room 12.
Plumbing fixtures not maintained; toilet not secured to the floor in bathroom across from Room 29.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 7, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey on September 06 and 07, 2017 to assess compliance with health care and nutrition regulations.
Findings
The facility failed to assure referral and follow-up for one resident regarding physician notification of fingerstick blood sugar refusals, and failed to assure therapeutic diets were served as ordered for four residents with physician orders for pureed and mechanical soft diets. The dietary manager was unaware of required training and did not follow therapeutic diet menus or recipes.
Deficiencies (2)
Failed to assure referral and follow-up for 1 of 5 residents regarding physician notification of fingerstick blood sugar refusals with a progressive sliding scale insulin order.
Failed to assure therapeutic diets were served as ordered for 4 of 7 sampled residents with physician orders for pureed diets and mechanical soft diets.
Report Facts
Fingerstick blood sugar refusals: 17
Fingerstick blood sugar refusals: 3
Fingerstick blood sugar refusals: 1
Fingerstick blood sugar refusals: 4
Fingerstick blood sugar refusals: 4
Hemoglobin A1C levels: 7.2
Hemoglobin A1C levels: 7.1
Number of sampled residents with therapeutic diet issues: 4
Years employed: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Primary Care Nurse Practitioner | Interviewed regarding Resident #5's fingerstick blood sugar refusals and follow-up | |
| Resident Care Coordinator | Interviewed regarding medication refusal policies and communication with Dietary Manager | |
| Dietary Manager | Interviewed regarding meal preparation, therapeutic diet compliance, and training | |
| Administrator | Interviewed regarding oversight of Dietary Manager and therapeutic diet compliance |
Inspection Report
Capacity: 62
Deficiencies: 8
Date: Jul 13, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1971 and applicable portions of the 2005 Rules 10A NCAC 13F for Licensing of Adult Care Homes and the 1967 North Carolina State Building Code - Section 516 - Institutional Occupancy.
Findings
The facility was found to have multiple deficiencies including failure to maintain interior floor finishes, broken ceramic tiles in bathing areas, malfunctioning interior doors, broken ceiling tiles, gaps in fire resistant ceilings, dirty HVAC filters, unsecured plumbing fixtures, and exit signs without battery backup.
Deficiencies (8)
Failed to maintain the interior floor finishes; dirt build-up covered in wax in wall corners and door jamb bases in Back Hall corridor.
Ceramic tile missing, broken and damaged in roll-in shower in Back Hall Bathroom.
Interior doors out of adjustment and do not latch or seal properly in Room 34 and Back Hall Laundry Room Corridor door.
Broken lay-in ceiling tiles in Room 12.
Gaps and open penetrations in fire resistant rated ceilings at Back Hall-Washer/Dryer Room and Front Hall-Supply Closet.
Dirty filters in all interior air handling units.
Toilet not secured to the floor in Bathroom across the hall from Room 29.
Exit signs without battery back-up in Back Hall-Office Manager's Office and Room 5.
Report Facts
Total licensed capacity: 62
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 15, 2016
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to therapeutic diets and nutrition service compliance.
Findings
The facility failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets and failed to ensure therapeutic diets (No Concentrated Sweets and mechanical soft) were served as ordered by the physician for 4 of 5 sampled residents. The dietary staff were unaware of the correct diet orders and did not use therapeutic diet spreadsheets as a guide, resulting in residents receiving incorrect diets.
Deficiencies (2)
Failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets for guidance of food service staff.
Failed to ensure therapeutic diets, including nutritional supplements and thickened liquids, were served as ordered by the resident's physician.
Report Facts
Residents sampled: 5
Residents with diet issues: 4
Gallons of 2% milk: 21
FSBS readings: 265
FSBS readings: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding therapeutic diet compliance and meal service | |
| Resident Care Coordinator | Responsible for updating therapeutic diet list; interviewed regarding diet list accuracy and meal service | |
| Administrator | Interviewed regarding oversight of kitchen and meal service |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 13, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 10/13/15 and 10/14/15 to assess compliance with regulations for The Bradford Village of Kernersville - West.
Findings
The facility was found deficient in maintaining a safe environment related to the storage of oxygen cylinders, and failed to maintain accurate and current therapeutic diet orders for residents, including missing or outdated physician diet orders for sampled residents.
Deficiencies (4)
Failed to assure the environment was free of hazards related to safe storage of oxygen cylinders.
Failed to assure there was a written physician's diet order for 1 of 7 sampled residents (Resident #8).
Failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets for 2 of 7 sampled residents (Resident #8 and Resident #9).
Failed to assure resident had the right to receive care and services which are adequate, appropriate and in compliance with rules and regulations as related to storage of oxygen cylinders.
Report Facts
Oxygen cylinders observed: 15
Oxygen cylinders stored in metal stands: 2
Oxygen cylinders stored in metal crate: 5
Oxygen cylinders free standing: 7
Oxygen cylinders full and unopened: 9
Residents sampled for diet orders: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding oxygen storage policy and therapeutic diet list updates. |
| Administrator | Facility Administrator | Interviewed regarding oxygen storage policy and therapeutic diet list updates. |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding therapeutic diet orders and menu preparation. |
| Nurse Practitioner | Nurse Practitioner (NP) | Signed diet orders and interviewed regarding diet order specifics. |
| Cook | Cook | Responsible for updating therapeutic diet list and preparing meals. |
Inspection Report
Plan of Correction
Capacity: 62
Deficiencies: 14
Date: Jul 22, 2015
Visit Reason
This report is of a Biennial Construction Survey conducted to assess compliance with physical plant requirements and building codes applicable to the facility.
Findings
Multiple deficiencies were noted including lack of makeup air for laundry dryers, blocked exit paths, missing hand grips in bathrooms, improper linen storage, corridor obstructions, unprotected fire-resistance penetrations, unsafe electrical systems, improper storage of oxygen cylinders, dusty HVAC detection units, presence of prohibited portable electric heaters, and inadequate exhaust ventilation.
Deficiencies (14)
No makeup air provided for commercial gas dryers in the laundry.
Exit path blocked by courtyard gate with chain and padlock.
Corridor bathroom near room 17 lacks grab bar at the toilet.
Path of soiled linen not maintained to prevent cross contamination; soiled and unsoiled containers mixed and not labeled.
Egress from resident bedrooms blocked by plastic chain and corridor blocked by wheelchair and cart near room 19.
Multiple unprotected penetrations in rated walls and ceilings above drop ceilings in back and front wings.
Barrell bolts found on bathroom door of room 24 and corridor door of room 10, risking residents being locked in.
Unprotected wall penetrations by phone wire, plastic wall patch, damaged gypsum, and conduit in various rooms.
Electrical panel E has an open space in hot water/electrical room.
Lights not working in room 32 shared bathroom and damaged ceiling tiles near room 12 corridor.
Unsecured oxygen bottle in room 5.
Dust-covered sample tubes on duct detection units and air handling equipment did not shut down when alarm activated.
Portable electric heaters found in office storage room 8 and front lobby office.
Hopper Room near room 7 lacks exhaust fan and window for ventilation.
Report Facts
Total licensed capacity: 62
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