Inspection Reports for The Springs of Ballentine
40 Rawls Club Road Fuquay-Varina, NC 27526, Fuquay-Varina, NC, 27526
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 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
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 12, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and a complaint investigation on August 11 - 12, 2021.
Complaint Details
The visit included a complaint investigation related to therapeutic diet and medication administration issues for residents #5 and #6.
Findings
The facility failed to ensure therapeutic diets were served as ordered for one resident requiring a pureed diet with nectar thickened liquids, and failed to ensure one resident received medications as ordered by the primary care physician, including a medication used to treat high blood pressure.
Deficiencies (2)
Failed to ensure therapeutic diets were served as ordered for 1 of 2 sampled residents who had an order for a pureed diet with nectar thickened liquids.
Failed to ensure 1 of 2 residents observed during the medication pass received their medications as ordered by the primary care physician including a medication used to treat high blood pressure.
Report Facts
Medication error rate: 4
Medication doses not administered as ordered: 127
Medication cart audits completed: 1
Medication cart audits completed: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Discussed risk of aspiration pneumonia and was notified of medication concerns but did not receive notification of medication errors. |
| Dietary Manager | Dietary Manager (DM) | Believed ice cream was a thick liquid and was involved in diet-related findings. |
| Personal Care Aide | Personal Care Aide (PCA) | Fed Resident #5 ice cream despite diet order for nectar thickened liquids. |
| Medication Aide | Medication Aide (MA) | Administered incorrect dose of Hydralazine and did not complete medication cart audits as scheduled. |
| Administrator | Administrator | Provided information on medication cart audit policy and was unaware of medication administration errors. |
Inspection Report
Capacity: 50
Deficiencies: 7
Date: Mar 6, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1967 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1971 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Deficiencies were cited related to bathroom privacy, housekeeping hazards, fire safety, plumbing fixtures, and exhaust ventilation. Specific issues included missing privacy curtains, trip hazards, non-operational emergency lights, unsecured toilets and sinks, holes in fire-rated ceiling tiles, and a non-functioning exhaust fan.
Deficiencies (7)
Privacy curtains have been removed at the Bathroom adjacent to Room 9-SOUTH HALL.
Plumbing clean out cover & opening recessed into the floor about 1" creating a trip hazard outside Room 5-NORTH HALL.
Emergency light did not illuminate when tested in the Kitchen.
There is a 2" x 4" hole in the fire-rated ceiling tile in the Kitchen above the dish drying station.
Toilets are not secured to the floor at Employee's Women's Bathroom and Restroom adjacent to Room 9-SOUTH HALL.
Wall mounted hand wash sink in the Kitchen is not secured to the wall.
Mechanical exhaust fan does not operate in the Employee's Women's Bathroom.
Report Facts
Total licensed capacity: 50
Trip hazard depth: 1
Hole size: 2
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 9
Date: Jul 14, 2017
Visit Reason
A complaint investigation was conducted by the Adult Care Licensure Section on July 6-14, 2017 related to concerns about resident care, supervision, health care, incident reporting, staffing, housekeeping, and training.
Complaint Details
Complaint investigation conducted July 6-14, 2017 regarding multiple concerns including resident care, supervision, health care, incident reporting, staffing, housekeeping, and training.
Findings
The facility failed to provide adequate personal care, supervision, health care follow-up, incident reporting, and staffing. Deficiencies included failure to provide two-hour incontinence and safety checks resulting in resident harm and death, failure to report resident-to-resident assault timely, inadequate staff training and orientation, and poor housekeeping and maintenance.
Deficiencies (9)
Failed to provide safety and incontinence care checks every two hours for 3 of 6 sampled residents resulting in Resident #1's death being unnoticed until full rigor mortis, Resident #5 hospitalized with sepsis, and Resident #3 sustaining skin breakdown.
Failed to provide supervision for 2 of 6 sampled residents according to their needs resulting in bruises from falls and failed to provide supervision of up to 23 residents in common areas.
Failed to assure contact with medical professionals for acute needs of 4 of 6 residents resulting in delayed treatment and hospitalization.
Failed to report resident-to-resident assault to Mental Health Provider timely and seek emergency medical treatment for injured resident.
Failed to assure adequate staffing on 18 of 48 shifts resulting in failure to provide two-hour incontinence care and safety checks and lack of intervention for injuries, illness and falls.
Failed to assure 6 of 6 sampled staff assigned to special care unit received required orientation and training within first week and six months of employment.
Failed to assure walls and floors were kept clean and in good repair on men's hall including broken tiles, stained and rotted caulking, broken fixtures, and grime buildup.
Failed to assure residents' rooms on men's hall were kept clean and free of hazards including nonworking light fixture, uncovered door stop hardware, and cluttered storage of incontinence supplies.
Failed to assure one staff member was tested for tuberculosis upon hire in compliance with control measures.
Report Facts
Deficiency counts: 10
Staffing shortfall hours: 18
Resident census: 45
Staff training hours: 6
Staff training hours: 20
Incident shifts without CPR trained staff: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Named in findings related to sleeping on duty, inadequate supervision, and training deficiencies |
| Staff B | Personal Care Aide | Named in findings related to staffing and supervision |
| Staff C | Medication Aide | Named in findings related to lack of CPR training and supervision |
| Staff D | Personal Care Aide/Dietary Aide | Named in findings related to sleeping on duty, staffing, and training deficiencies |
| Staff F | Personal Care Aide | Named in findings related to lack of tuberculosis testing and special care unit training |
| Resident Care Coordinator | Named in multiple interviews regarding supervision, staffing, and care concerns | |
| Business Office Manager | Named in multiple interviews regarding staffing, administration, and supervision | |
| Regional Director | Named in interviews regarding oversight and facility management | |
| Administrator | Named in interviews regarding facility management and responsibility for compliance |
Inspection Report
Capacity: 50
Deficiencies: 6
Date: Mar 9, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules as part of a Biennial Construction Survey.
Findings
The survey identified multiple physical plant deficiencies including obstructed corridors, improperly stored oxygen bottles, damaged exit ramp boards, non-operational emergency lighting, penetrations and gaps in fire resistant ceilings, and a non-functioning exhaust fan in a public restroom.
Deficiencies (6)
Corridors were obstructed by a rolling chair, a mobile suspension harness, and a large plastic garbage tub.
Oxygen bottles were stored without any means of restraint to prevent them from falling or being knocked over.
Damaged boards on an exit ramp presented a tripping hazard.
Electrical emergency/safety lighting equipment was not maintained in safe operating condition; no power to emergency light and illuminated exit light at laundry exit door.
Penetrations and gaps in fire resistant rated ceilings, including holes and non-fire resistant foam sealing around conduits, deteriorated and broken ceiling tiles.
Exhaust fan in public restroom adjacent to Room #10N was not working.
Report Facts
Licensed capacity: 50
Inspection Report
Capacity: 50
Deficiencies: 11
Date: Apr 10, 2015
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 1967 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1971 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Biennial Construction Survey.
Findings
The facility failed to maintain ceilings, floors, plumbing fixtures, furniture, and furnishings in good repair, with multiple examples of damage and disrepair noted throughout the building. Additionally, hazards were observed including unrestrained oxygen bottles and obstructed paths of egress. Fire safety and electrical equipment were not maintained in a safe and operating condition, including malfunctioning fire alarm devices, emergency lighting, and electrical wiring. Exhaust ventilation fans in several restrooms were not working.
Deficiencies (11)
Ceilings have damage including uneven ceiling grids, gaps in lay-in tiles, holes, broken tiles, and moldy tiles in multiple locations.
Floors or floor finishes are not kept in good repair with missing tiles and damaged vinyl floor tiles.
Plumbing fixtures are not kept in good repair with gaps in caulking around tubs.
Furniture is not kept in good repair; side chair upholstery torn.
Oxygen bottles stored without restraining devices, presenting a hazard.
Path of egress obstructed by a binding exit gate.
Towel bars missing or damaged in multiple locations.
Fire alarm devices not maintained safely; heat detectors hanging from wiring.
Emergency lighting equipment not maintained; some emergency lights and directional signs not working.
Electrical wiring and equipment not maintained safely; openings in breaker panel, malfunctioning door hardware, water intrusion in generator room.
Exhaust ventilation fans in restrooms and other specified rooms not working.
Report Facts
Licensed capacity: 50
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 22, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Senter's Rest Home on January 22-23, 2015 to assess compliance with regulations.
Findings
The facility failed to maintain cleanliness in the kitchen, including the reach-in cooler, reach-in freezers, walls, floors, and vents. Observations revealed dried food residues, grease, dust, rust, broken tiles, and stains in multiple kitchen areas.
Deficiencies (9)
The reach-in cooler had dried brown and orange food in the corners, racks with dried orange food and black substances, and a fan cover with grease, dust, and rust.
The outside of the reach-in cooler and freezer had greasy door handles and doors with dried food stains, and the top had grease and dust.
The inside bottoms of two reach-in freezers had dried brown and orange food and liquid stains.
The outside of the reach-in freezers had greasy doors and handles with dried food, and dusty tops.
Kitchen floors under coolers and freezers had gray dirt and rust stains; floor behind stove had brown dried grease mixed with black, orange, and brown food stains.
Three broken tiles were observed in front of the back exit door in the kitchen.
Two air conditioner vent covers above the hand sink had dust.
Kitchen floor under the beverage dispenser had brown and orange dried liquid stains.
The wall by the hand sink had a large brown stain from top to bottom.
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