Inspection Reports for The Landings of Mills River
4143 Haywood Road Mills River, NC 28759, Mills River, NC, 28759
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Census: 20
Deficiencies: 2
Date: Feb 11, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation from 02/11/2025 to 02/13/2025.
Complaint Details
The visit included a complaint investigation regarding the delayed refund to the Estate Administrator of Resident #4. The refund was not processed within the required 30-day timeframe but was eventually received after inquiry.
Findings
The facility failed to ensure timely refund of room and board to the Estate Administrator of a deceased resident and failed to have a care coordinator on duty in the Special Care Unit as required by regulations.
Deficiencies (2)
Failed to ensure the Estate Administrator for 1 of 1 sampled resident was given a room and board refund within 30 days after the resident's death.
Failed to ensure there was a care coordinator on the Special Care Unit on duty at least eight hours a day, five days a week.
Report Facts
Resident count on Special Care Unit: 20
Dates of survey: 02/11/25 to 02/13/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding refund process and Special Care Unit staffing | |
| Administrator | Interviewed regarding refund process and Special Care Unit staffing | |
| Clinical Nurse Consultant | Interviewed regarding Special Care Unit staffing | |
| Medication Aide | Interviewed regarding Special Care Unit staffing and tasks |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 17, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on 04/16/24 - 04/17/24. The complaint investigation was initiated by the Henderson County Department of Social Services on 03/20/24.
Complaint Details
The complaint investigation was initiated by the Henderson County Department of Social Services on 03/20/24 regarding supervision failures leading to a resident with dementia eloping from the facility.
Findings
The facility failed to provide adequate supervision for a resident with dementia who eloped, failed to maintain sanitation in the kitchen, failed to offer snacks to residents as required, and failed to discontinue a medication as ordered for a resident.
Deficiencies (4)
Failed to provide supervision based on current symptoms for a resident with dementia who eloped from the facility without staff knowledge.
Failed to ensure food services comply with sanitation rules related to dirty kitchen floors and dish machine floor drains.
Failed to offer or make available to all residents snacks between each meal for a total of three snacks per day.
Failed to administer medications as ordered for a resident related to a discontinued antipsychotic medication.
Report Facts
Residents sampled: 5
Resident #2 admission date: Jan 17, 2024
Resident #3 admission date: Jan 12, 2024
Discontinued medication administration period: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for reviewing medication orders and faxing to pharmacy; involved in medication administration deficiency |
| Special Care Coordinator | Special Care Coordinator (SCC) | Involved in supervision and medication administration processes |
| Medication Aide | Medication Aide (MA) | Interviewed regarding supervision and medication administration; unaware of discontinued medication |
| Maintenance Director | Maintenance Director | Interviewed regarding exit door locks and alarms |
| Administrator | Administrator | Interviewed regarding supervision, exit seeking behaviors, and medication administration |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding kitchen sanitation and snack service |
| Lead Cook | Lead Cook | Interviewed regarding kitchen sanitation and cleaning duties |
| Dietary Manager | Dietary Manager | Interviewed regarding snack preparation and service |
| Executive Director | Executive Director (ED) | Interviewed regarding snack service and medication administration oversight |
| Mental Health Provider | Mental Health Provider (MHP) | Ordered and discontinued antipsychotic medication for Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 8, 2019
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services completed a complaint survey on 08/06/19, 08/07/19 and 08/08/19 related to a failure to implement a physician's order for a dementia resident.
Complaint Details
The complaint investigation revealed that the facility failed to implement a physician's order to keep Resident #1 inside during elevated temperatures. The resident was found outside unresponsive and was treated for dehydration and heat exhaustion. Staff interviews showed lack of awareness of the order, and the facility acknowledged failure in communication and follow-through.
Findings
The facility failed to implement a physician's order to keep a dementia resident inside the facility, resulting in the resident being found outside for an undetermined amount of time and sent to the hospital for dehydration and heat exhaustion. Multiple staff were unaware of the order, indicating a lack of communication and follow-through.
Deficiencies (2)
Failed to implement a physician's order related to keeping a dementia resident inside the facility, resulting in harm.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to personal care and supervision and health care.
Report Facts
Resident count: 5
Temperature: 104.2
Blood pressure: 89
Blood pressure: 45
Pulse: 97
Correction date: Sep 22, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Interviewed regarding Resident #1's condition and orders | |
| Resident Care Coordinator (RCC) | Responsible for order verification and communication; unaware of the order to keep Resident #1 inside | |
| Administrator | Interviewed and unaware of the order to keep Resident #1 inside | |
| Personal Care Aides (PCA) | Multiple PCAs interviewed, none aware of the order to keep Resident #1 inside | |
| Medication Aide (MA) | Interviewed and unaware of the order to keep Resident #1 inside | |
| Evening Supervisor | Interviewed and unaware of the order to keep Resident #1 inside |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 20, 2018
Visit Reason
The Adult Care Licensure Section conducted an initial survey and complaint investigation completed on 11/19/18 and 11/20/18 at The Landings of Mills River.
Complaint Details
The visit was complaint-related as the Adult Care Licensure Section conducted an initial survey and complaint investigation on 11/19/18 and 11/20/18.
Findings
The facility failed to ensure the physician was notified of medication refusals for one resident, failed to protect food from contamination due to lack of date marking, failed to serve therapeutic diets as ordered for one resident, and failed to administer medications as ordered for three sampled residents, resulting in a Type B violation.
Deficiencies (4)
Failed to ensure the physician was notified of medication refusals for Resident #3 related to tamsulosin.
Failed to ensure food and beverages were protected from contamination due to lack of date marking on opened food items.
Failed to ensure therapeutic diets were served as ordered for Resident #4 with a physician's order for ground meat and pureed vegetables.
Failed to administer medications as ordered for Residents #1, #2, and #3 related to Lovenox, glipizide, donepezil, and Haldol.
Report Facts
Medication administration opportunities: 43
Medication administration opportunities: 30
Medication administration opportunities: 23
Medication administration opportunities: 30
Medication administration opportunities: 30
Medication administration opportunities: 14
Medication administration opportunities: 7
Medication administration opportunities: 7
Medication administration opportunities: 7
Medication administration opportunities: 7
Kitchen sanitation score: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Informed Resident Care Coordinator about medication refusals and medication administration issues | |
| Resident Care Coordinator | Responsible for notifying physician and managing medication issues | |
| Administrator | Unaware of medication refusals and back-up pharmacy procedures | |
| Cook/Dietary Manager | Responsible for kitchen staff training and food date marking | |
| Personal Care Assistant Preceptor | Delivered meals and aware of residents' diet orders | |
| Home Health Nurse | Responsible for administering Lovenox injections | |
| Nurse Practitioner | Notified about medication administration issues |
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