Inspection Reports for The Gardens of Pamlico

The facility was found deficient in multiple areas including medication aide qualifications, failure to follow up on acute health care needs related to insulin refusals and elevated blood sugars, failure to implement weekly blood pressure checks as ordered, failure to administer medications as ordered related to a sleep aid, and failure to maintain accurate controlled substance records.

This was a follow-up complaint survey; all deficiencies had not been corrected requiring a Plan of Correction.

The facility failed to maintain fire safety equipment in a safe and operating condition, specifically the fire alarm panel at the nurses station had electrical issues leaving the rear half of the facility unprotected and the facility was placed on fire watch.

The complaint alleging a fire in the kitchen was substantiated.

The complaint was substantiated. Deficiencies were found including failure to maintain the facility free of hazards, specifically a glove left unattended on a shelf caught fire and the fire alarm system was non-operable. Additionally, the fire alarm panel had electrical issues leaving part of the facility unprotected and the facility was placed on fire watch.

The facility failed to correct multiple deficiencies including lack of landings and handrails on ramps, improper dryer venting, exit door locks not operable by single hand motion, absence of a soiled utility room with handwashing facilities, unsafe and unmaintained fire safety equipment including a non-operational sprinkler system and fire alarm issues, and inadequate exhaust ventilation in bathrooms and other specified areas.

Complaint investigation initiated by Pamlico County Department of Social Services on 01/08/24 related to housekeeping and cleanliness concerns.

The facility failed to maintain clean and orderly resident rooms and bathrooms, with housekeeping staff laid off since November 2023 leading to unclean floors, dust, and unclean toilets. Substitutions to meal menus were not documented as required. Residents and families reported concerns about cleanliness and housekeeping duties were inconsistently performed by remaining staff.

The facility was found deficient in multiple areas including failure to ensure timely referral and follow-up for residents' specialty appointments, lack of therapeutic diet menus and accurate diet lists, incomplete and inaccurate medication orders and administration, missing medications on hand, and failure to follow infection control measures during medication administration.

The facility did not meet building code requirements for special locking arrangements; specifically, the entry/exit doors between the SCU and AL unit did not release when the central override was activated, and a magnetic override switch in the dining area did not deactivate any doors.

The facility was found to have multiple deficiencies including failure to meet building code requirements for special locking arrangements, corridor obstructions reducing clear width, unsafe housekeeping with obstructions and hazards, improper storage of portable medical oxygen cylinders, compromised fire-rated walls and ceilings, and corridor doors that do not close or latch properly, increasing fire risk.

Complaint investigations were initiated by the Pamlico County Department of Social Services on October 5, 2017, October 23, 2017, and November 21, 2017. The investigation found substantiated violations related to resident rights and facility conditions.

The facility failed to maintain cleanliness in the kitchen, including the oven and storage shelves covered in grime and sticky substances. Additionally, the facility failed to assure residents' rights were maintained, including dignity and respect, and failed to respond appropriately to residents' requests, resulting in substandard living conditions and emotional distress for some residents.

The visit included a complaint investigation triggered by concerns about failure to follow up with a primary care provider after emergency room visits related to falls for Resident #2.

The facility failed to follow up with a primary care provider after three emergency room visits post falls for one resident, resulting in a Type B Violation. Additionally, the kitchen's oven, deep fryer, ice-maker, and microwave were found unclean and contaminated, and the facility failed to assure all residents received adequate and appropriate care in compliance with relevant laws.

The follow-up survey revealed that not all deficiencies had been corrected. Specifically, fire protection equipment was not maintained safely due to openings in the fire-rated roof/ceiling assembly and missing escutcheons on sprinkler heads. Additionally, plumbing fixtures for personal bathing were not maintained, with missing vacuum breakers on spray hoses in the Central Bath tubs.

The followup survey revealed that not all deficiencies had been corrected. Deficiencies included unmaintained HVAC supply and return air grilles with excessive particulate build-up, fire protection equipment issues such as openings in fire-rated roof/ceiling assembly and damaged sprinkler heads, lack of vacuum breakers on plumbing fixtures, and interior doors that did not latch or were wedged open, compromising fire and smoke containment.

Multiple deficiencies were cited including failure to maintain emergency release keys for magnetic locks, inadequate ventilation causing odors, improper storage of oxygen cylinders, unsecured grab bars, malfunctioning fire suppression system, non-illuminated emergency lighting and exit signs, openings in fire-rated ceiling assemblies, lack of vacuum breakers on plumbing fixtures, and fire doors not latching or being wedged open.

The facility failed to assure that staff had proper Health Care Personnel Registry checks and competency validations for personal care tasks. Additionally, the facility failed to ensure medication aides completed mandatory infection control training and medication administration training within required timeframes.