Inspection Reports for
Tyrrell House
950 US Highway 64 E Columbia, NC 27925, Columbia, NC, 27925
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
This is a follow-up construction survey conducted by documentation to verify correction of previously cited deficiencies.
Findings
Based on documentation received on November 13, 2024, all previously cited deficiencies have been corrected and no further action is required at this time.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Dec 8, 2022
Visit Reason
The Adult Care Licensure Section and the Tyrrell County Department of Social Services conducted a follow-up survey and complaint investigations on December 7-8, 2022, initiated by the Tyrrell County Department of Social Services on November 8, 2022.
Complaint Details
Complaint investigations were initiated by the Tyrrell County Department of Social Services on November 8, 2022, leading to a follow-up survey on December 7-8, 2022.
Findings
The facility failed to ensure staff qualifications were verified upon hire, failed to ensure referral and follow-up for a resident with acute health needs, failed to implement physician orders for dressing changes, and failed to administer medications as ordered for multiple residents. Additionally, the facility failed to notify the local county Department of Social Services of a resident fall with injury requiring hospital treatment.
Deficiencies (6)
Failed to ensure 2 of 6 sampled staff were verified and had no findings on the Health Care Personnel Registry upon hire.
Failed to ensure referral and follow-up to meet the acute health care needs of a resident who was vomiting for 3 days and was admitted to the hospital with small bowel obstruction.
Failed to ensure implementation of an order for dressing change for a resident with a skin cancer removal.
Failed to ensure medications were administered as ordered for 3 of 7 residents including delays in starting medications after hospital discharge, failure to administer prescribed medications, and continued administration of discontinued medication.
Failed to ensure medication administration records were complete and accurate for 2 of 7 residents.
Failed to notify the local county Department of Social Services of a resident fall with injury requiring hospital treatment.
Report Facts
Sampled staff: 6
Staff with missing verification: 2
Sampled residents: 6
Days vomiting: 3
Deficiency correction date: 2023
Sampled residents: 7
Missed doses: 37
Missed doses: 9
Fall date: Oct 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Responsible for running Health Care Personnel Registry checks; unaware of missing checks for Staff B and Staff E |
| Previous Administrator | Administrator | Administrator until 11/10/22; unaware of missing HCPR checks and responsible for incident report submission |
| Administrator | Administrator | Current Administrator as of 12/08/22; expected HCPR checks and medication administration as ordered |
| Special Care Coordinator | Special Care Coordinator | Provided information on medication administration and communication with PCP |
| Medication Aide | Medication Aide | Involved in medication administration and dressing changes; provided information on medication availability and administration |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 1, 2022
Visit Reason
The Adult Care Licensure Section and the Tyrrell County Department of Social Services conducted an annual, follow-up and complaint investigation on 08/31/22 and 09/01/22. The complaint investigation was initiated by the Tyrrell County Department of Social Services on 08/09/22.
Complaint Details
The complaint investigation was initiated by the Tyrrell County Department of Social Services on 08/09/22 related to concerns about resident care including pressure wounds and medication management.
Findings
The facility failed to ensure provider notification and follow-up for 2 of 5 sampled residents related to a worsening pressure wound not reported to the primary care provider and a resident on blood thinning medications sent to the emergency department without PCP notification upon return. Additionally, there were failures in medication administration, documentation, and implementation of physician orders.
Deficiencies (5)
Failed to ensure provider notification and follow-up for residents with worsening pressure wounds and blood in urine.
Failed to ensure orders were implemented timely for dressing changes for a resident with pressure wounds.
Failed to administer medications as ordered for a resident related to a heart medication loading dose and maintenance dose.
Medication administration records were incomplete and inaccurate including duplicate documentation and failure to document administration of standing orders.
Failed to ensure residents received adequate and appropriate care and services in compliance with relevant laws and regulations related to health care.
Report Facts
Deficiencies cited: 5
Pressure wound measurements: 4.25
Medication dosage: 2
Medication dosage: 1
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 27, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and an annual survey from 04/27/21 to 04/28/21.
Findings
The facility failed to ensure it was free of hazards as four portable oxygen tanks were stored unsecured on the floor in a resident's room. Interviews revealed staff were unaware of proper storage procedures. By 04/28/21, the tanks were secured in a storage rack.
Deficiencies (1)
Storage of four portable oxygen tanks not secured in racks in a resident's room.
Report Facts
Number of portable oxygen tanks: 4
Inspection Report
Follow-Up
Census: 38
Deficiencies: 10
Date: Jan 20, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation with onsite visits and desk reviews to assess compliance with personal care, health care, medication administration, infection control, and reporting requirements.
Findings
The facility failed to provide adequate personal care and supervision, ensure timely health care follow-up, administer medications correctly, maintain infection control during medication administration, properly document medication administration and controlled substances, and report a suspected COVID-19 outbreak to the local health department.
Deficiencies (10)
Failed to ensure 1 of 5 residents received assistance with showering as per care plan.
Failed to ensure notification of primary care provider for 3 of 5 residents related to weight loss, broken nebulizer, and missed follow-up appointment.
Failed to ensure water was served with meals to all residents.
Failed to administer medications as ordered for 6 residents including errors with medication timing, dosage, and omissions.
Failed to ensure medication aides observed residents taking medications and did not pre-chart medication administration.
Failed to implement infection control measures during medication passes including hand hygiene and sharing eye drops between residents.
Failed to ensure medications borrowed for administration were only borrowed in an emergency, replaced promptly, and documented.
Failed to maintain accurate and readily retrievable controlled substance records including reconciliation of receipt, disposition, and administration for 3 residents.
Failed to report suspected COVID-19 outbreak to local health department when two staff members tested positive.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to medication administration and communicable disease reporting.
Report Facts
Residents present: 38
Medication error rate: 6
Weight measurements: 178
Weight measurements: 162
Weight measurements: 164
Weight measurements: 132
Weight measurements: 152
Medication counts: 55
Medication counts: 127
Medication counts: 37
Medication counts: 120
Medication counts: 75
Medication counts: 35
Medication counts: 30
Medication counts: 22
Medication counts: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lead Medication Aide | Lead Medication Aide / Memory Care Manager | Named in multiple interviews related to medication administration errors, controlled substance counts, and borrowing medications |
| Memory Care Manager | Memory Care Manager | Named in interviews related to medication administration, controlled substance counts, and infection control |
| Administrator | Facility Administrator | Named in interviews related to COVID-19 reporting and medication administration oversight |
| Medication Aide | Medication Aide | Named in interviews related to medication administration and controlled substance documentation |
| Primary Care Provider | Facility's Contracted Primary Care Provider | Named in interviews related to medication administration and infection control concerns |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 30, 2020
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation and a COVID-19 focused Infection Control survey with an onsite visit from 11/18/20 to 11/20/20, a desk review survey from 11/23/20 to 11/25/20, and a telephone exit on 11/30/20.
Complaint Details
Complaint investigation included allegations of inadequate supervision leading to multiple falls and injuries, failure to follow physician orders, medication errors, medication storage issues, and infection control deficiencies during the COVID-19 pandemic.
Findings
The facility failed to provide adequate supervision for a resident with multiple falls and serious injuries, failed to ensure physician notification and follow-up for residents with falls and impaired vision, failed to implement physician orders for stool specimen collection, failed to administer medications as ordered including inappropriate use of morphine and incorrect fentanyl patch administration, failed to secure medications properly, and failed to implement infection prevention and control measures including quarantine, mask wearing, social distancing, and staff screening during the COVID-19 pandemic.
Deficiencies (6)
Failed to provide supervision for 1 of 5 residents sampled (#1) who had at least ten falls resulting in serious injuries including fractures and head injuries.
Failed to ensure physician notification for 2 of 5 sampled residents regarding falls and impaired visual perception.
Failed to ensure implementation of physician's orders for stool specimen collection for Resident #6 on 4 separate occasions.
Failed to administer medications as ordered for 2 of 5 sampled residents (#1, #6) including inappropriate administration of PRN morphine for behavioral issues and incorrect fentanyl patch administration.
Failed to ensure medications were maintained under locked security when medication cart was left unlocked and unattended in the special care unit.
Failed to implement infection prevention and control program consistent with CDC and NC DHHS guidelines including failure to quarantine a resident after ER visit, staff failing to wear masks properly, failure to screen staff for COVID-19, and failure to ensure residents wore masks and social distanced.
Report Facts
Falls: 10
Emergency room visits: 5
Medication doses: 11
Medication patches: 4
Staff not screened: 20
Staff not screened: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Medication Aide | Administered morphine to Resident #1 for behavioral issues and fentanyl patches to Resident #6. |
| Memory Care Manager | Memory Care Manager | Involved in medication administration, documentation, and infection control observations. |
| Previous Administrator | Administrator | Provided information about supervision and medication administration practices. |
| Current Administrator | Administrator | Provided information about infection control, staff screening, and medication administration. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 29, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 10/29/19 to 10/30/19 to verify correction of previous deficiencies related to notification of residents and responsible parties about the facility's provisional license.
Findings
The facility failed to ensure residents and/or their responsible parties were properly notified about the issuance of a provisional license. Interviews revealed that many residents and family members were unaware or only learned through gossip, and there was no documented communication or follow-up regarding notification of the provisional license.
Deficiencies (1)
Facility failed to notify residents and/or responsible parties of the issuance of a provisional license.
Report Facts
Provisional license duration: 90
Family meeting attendance: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Coordinator | Discussed notification efforts and family meetings | |
| Administrator | Provided information about notification and resident awareness | |
| Activities Director | Called families to notify about a family meeting but did not disclose meeting purpose |
Inspection Report
Deficiencies: 9
Date: Aug 20, 2019
Visit Reason
The Adult Care Licensure Section and the Tyrrell County Department of Social Services conducted a Follow-Up Survey and Complaint Investigation on 08/14/19 through 08/20/19. The complaint investigation was initiated by the Tyrrell County Department of Social Services on 07/11/19.
Complaint Details
The complaint investigation was initiated by the Tyrrell County Department of Social Services on 07/11/19 related to allegations of inadequate supervision, sexual abuse, and neglect.
Findings
The facility failed to provide supervision in accordance with residents' assessed needs, care plans, and current symptoms, resulting in a sexual encounter between two residents including one adjudicated incompetent resident; a resident being taken out of the facility by a banned visitor without medication or care for 10 days; multiple falls of a resident with injuries; failure to administer medications as ordered including eye drops, antihypertensives, blood thinners, stool softeners, and pain medications; failure to provide assistance with feeding in an unhurried manner; failure to maintain kitchen and refrigerator cleanliness; failure to provide ordered compression hose; failure to provide timely transportation from the emergency department; failure to maintain accurate medication administration records; failure to immediately notify the local Department of Social Services and law enforcement of alleged sexual abuse; and failure of the administrator to ensure implementation of policies and procedures related to supervision, health care, residents' rights, medication administration, reporting of incidents, other care and services, and nutrition and food service.
Deficiencies (9)
Failed to provide supervision in accordance with residents' assessed needs, care plans, and current symptoms, resulting in sexual encounter between residents including one adjudicated incompetent resident, and allowing a resident to leave with a banned visitor.
Failed to protect a resident adjudicated incompetent from exploitation by allowing unsupervised visitation resulting in sexual encounter witnessed and mocked by staff.
Failed to assure medications were administered as ordered including errors with eye drops, antihypertensive medication, blood thinner, stool softener, pain medication, blood pressure medication, and medication for anemia.
Failed to provide assistance with meals in an unhurried manner that promoted dignity and respect for a resident dependent on staff for feeding.
Failed to assure kitchen and walk-in refrigerator were clean and free of contamination including buildup on shelves and walls and uncovered food.
Failed to implement ordered compression hose for a resident.
Failed to provide transportation back to the facility after emergency department visits in a reasonable amount of time for residents transported by EMS.
Failed to maintain accurate medication administration records including documentation of medication administered when not available.
Failed to immediately notify the local Department of Social Services and law enforcement of alleged sexual abuse of a resident.
Report Facts
Medication pass error rate: 6.8
Missed doses of Clonidine: 15
Missed doses of Senna: 51
Missed doses of Aspirin: 21
Missed doses of Hydralazine: 39
Missed doses of Esomeprazole: 13
Missed doses of Amlodipine: 10
Missed doses of Ferrous Sulfate: 11
Missed doses of Acetaminophen: 9
Resident falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #8's guardian | Named as legal guardian of Resident #8, interviewed about sexual incident and lack of notification | |
| Executive Director | Executive Director | Named as responsible for facility operations, interviewed about supervision, medication administration, and incident reporting failures |
| Care Manager | Care Manager | Named as responsible for medication administration oversight and resident care, interviewed about medication errors and supervision |
| Medication Aide | Medication Aide | Named as responsible for medication administration, interviewed about medication errors and documentation |
| Licensed Health Professional Support Nurse | LHPS Nurse | Named as responsible for training staff and reporting sexual incident |
| Dietary Manager | Dietary Manager | Named as responsible for kitchen cleanliness and food safety |
| Personal Care Aide | PCA | Named in multiple interviews regarding supervision, sexual incident, and feeding assistance |
| Transporter | Transporter | Named as responsible for resident transportation, interviewed about delays in hospital pickups |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2019
Visit Reason
This is a Construction Section Complaint Follow-up report conducted on 07/11/2019 to verify if cited deficiencies from the initial complaint survey had been corrected.
Complaint Details
This visit was a follow-up to a complaint survey. The cited deficiencies from the initial complaint survey had not been corrected, requiring a new Plan of Correction.
Findings
The facility did not meet the building code requirement in effect at the time of alteration. Specifically, the NC State Building Code requires an on/off emergency release switch within 3 feet of any locked exit, which was not present on the door leading from the Interior Courtyard of the SCU to a service exit corridor.
Deficiencies (1)
Facility does not meet building code requirement for an on/off emergency release switch within 3 feet of any locked exit door.
Inspection Report
Annual Inspection
Deficiencies: 19
Date: May 17, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from 05/06/19 through 05/17/19.
Complaint Details
Complaint investigation included allegations of bed bug infestation, physical abuse, inadequate staffing, medication errors, and failure to provide adequate personal care and supervision. Specific substantiation details are not explicitly stated in the report.
Findings
The facility failed to maintain an environment free of hazards including untreated bed bug infestation and a broken window left unrepaired for over 6 weeks. Hot water temperatures were below required levels at multiple fixtures. Staff lacked current CPR training for several shifts. Staffing levels were frequently below minimum requirements, resulting in inadequate supervision and personal care. The facility failed to respond timely to incidents, implement physician orders, and maintain accurate medication and controlled substance records. Residents were not consistently treated with dignity and privacy, and two residents experienced physical abuse. The Administrator failed to ensure compliance with regulations and facility policies.
Deficiencies (19)
Untreated bed bug infestation in Resident #9's room for 7 days and broken window in resident room 209 unrepaired for over 6 weeks.
Hot water temperatures below 100°F at five fixtures in the special care unit.
Lack of CPR trained staff on 3 of 27 sampled shifts in April and May 2019.
Staffing levels below minimum requirements on 15 of 27 shifts for 9 days sampled in April and May 2019.
Failure to respond timely and appropriately to incidents for Resident #1 who fell twice in May 2019.
Failure to implement physician orders for daily postural vital signs for Resident #4 and weekly blood pressure and heart rate checks for Resident #6.
Failure to serve therapeutic diet as ordered for Resident #2 who was on a regular chopped meats diet but was served unchopped food and coughed during meal.
Failure to provide feeding assistance in a manner that maintains dignity and respect for Resident #21, with staff standing over the resident during meals.
Medication administration errors including missed vitamin D doses for Residents #18 and #19; over-administration of Lasix for Resident #3; failure to administer potassium supplement and acid reflux medication as ordered for Resident #2; and failure to administer Ellipta inhaler as ordered for Resident #4.
Inaccurate medication administration records for Residents #2 and #4 including documentation of potassium supplement and inhalers.
Inaccurate controlled substance records for Resident #4 including Oxycodone, Oxycontin and alprazolam with unaccounted tablets and discrepancies in documentation.
Failure to maintain residents' dignity and privacy by leaving doors and window blinds open during personal care for Residents #2, #3, #6, and #15; disrespectful communication to Residents #4 and #14; and failure to provide an acceptable bed for Resident #9 whose room was infested with bedbugs.
Physical abuse of Residents #8 and #11 with bruises on Resident #8's hands following incidents with Staff C and bruises inconsistent with falls on Resident #11 admitted to hospital.
Failure to provide adequate personal care assistance for 7 of 8 sampled residents unable to attend to themselves including incontinence care, toileting, bathing and dressing.
Failure to provide adequate supervision for 3 of 11 sampled residents including residents wandering unsupervised and a resident with multiple falls resulting in injuries.
Failure to assure referral and follow-up for routine and acute health care needs for 6 of 10 sampled residents including failure to obtain lab work, report abnormal vital signs, and follow up on falls and wounds.
Failure to complete Health Care Personnel Registry reporting and investigation requirements within required timeframes for 3 of 3 sampled residents sustaining physical abuse and injuries of unknown origin.
Failure to assure enough staff present on the special care unit for 14 of 27 sampled shifts resulting in inadequate personal care, supervision and health care.
Administrator failed to assure implementation of rules and policies for supervision, health care, personal care, staffing, HCPR reporting, medication administration, controlled substances, housekeeping, hot water, CPR training, and nutrition.
Report Facts
Deficiencies cited: 19
Medication error rate: 7
Residents with falls: 29
Staff hours short: 6.52
Staff hours short: 9.08
Staff hours short: 10.58
Staff hours short: 5.22
Staff hours short: 7.75
Staff hours short: 10
Staff hours short: 1.35
Staff hours short: 1.08
Staff hours short: 7.75
Staff hours short: 9
Staff hours short: 1.32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Personal Care Aide | Named in physical abuse incidents involving Resident #8. |
| Administrator | Facility Administrator | Responsible for overall operations and compliance; interviewed multiple times regarding failures in supervision, reporting, and policy implementation. |
| Care Manager | Care Manager | Responsible for reporting abuse, coordinating care, and managing staff; interviewed regarding multiple findings. |
| Regional Clinical Director | Regional Clinical Director | Interviewed regarding clinical oversight and investigations. |
| Medication Aide | Medication Aide | Involved in medication administration errors and reporting. |
| Personal Care Aide | Personal Care Aide | Involved in personal care and supervision findings. |
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 2
Date: May 16, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on three reported complaints: no water (unsubstantiated), bed bugs (substantiated), and Special Care Unit (SCU) residents having access to a service corridor without supervision (substantiated).
Complaint Details
Three complaints were investigated: (1) No water - unsubstantiated, (2) Bed bugs - substantiated, (3) SCU residents have access to service corridor without supervision - substantiated.
Findings
The facility was found to have substantiated deficiencies related to bed bug presence evidenced by dead bed bugs in Room 115A, and failure to equip all SCU exit doors accessible by residents with sounding devices, allowing residents to potentially wander off the unit unsupervised.
Deficiencies (2)
Presence of dead bed bugs around the perimeter wall/floor areas in Room 115A indicating current bed bug presence.
Exit doors from the Special Care Unit accessible by residents were not equipped with sounding devices activated when doors are opened, allowing residents to wander off the unit.
Report Facts
Total licensed beds: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Strickland | Conducted the complaint investigation. |
Inspection Report
Capacity: 50
Deficiencies: 7
Date: Feb 23, 2018
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 2012 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were found related to the maintenance of building exits and fire safety equipment, including blocked exits, malfunctioning magnetic locking system, non-operating emergency lighting, damaged exit signs, cracked window glass, and doors obstructed by wedges.
Deficiencies (7)
The exit in the SCU Courtyard is blocked by the picnic table and chairs restricting access to the exit door.
The exit access corridor is blocked by a table and service cart from the Kitchen not providing adequate clearances.
The gate on the north wall in the AL Courtyard drags and does not release when the magnetic locking system is activated due to failed supports framing.
The emergency lighting in the SCU Courtyard did not operate.
The exit sign outside the entry foyer in the exit access corridor had the chevrons out of the plastic housing to indicate the direction of egress to the exits.
The top storm window sash glass is cracked in Room 109-B Unit.
The following doors have wedges obstructing the operation to close the doors: Kitchen/Dining door, Laundry Hall door, Clean Linen Hall door, Spa Bath in North Hall.
Report Facts
Licensed capacity: 50
Special Care Unit beds: 24
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