Inspection Report
Capacity: 125
Deficiencies: 14
Feb 16, 2024
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2012 Edition of the North Carolina State Building Code(s), Institutional Occupancy Group I-2, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to meet building code requirements for smoke detection spacing, special locking door components, fire sprinkler coverage, corridor obstructions, lack of wanderer alarms on exit doors, plumbing repairs needed, unsafe and non-operating building equipment such as fire doors and electrical receptacles, missing fire sprinkler escutcheon plates, blocked corridor doors, use of prohibited portable electric heaters, and inadequate exhaust ventilation in required areas.
Deficiencies (14)
| Description |
|---|
| Corridor smoke detectors spaced more than 30 feet apart, not meeting code requirements. |
| Special locking exit doors lacked required components and procedures for proper operation and emergency release. |
| Fire sprinkler system did not protect all required areas, including missing sprinklers in the Copy Machine Room Closet. |
| Corridors obstructed by unattended medication cart, chair, and disassembled bed frame. |
| Exit doors accessible by residents lacked sounding devices to alert staff when opened. |
| Plumbing system not kept in good repair; commode in Breakroom Women Restroom was loose. |
| Fire-resistance-rated stairway doors had holes and were not maintained in safe operating condition. |
| Doors protecting smoke barriers had holes that could not restrict fire and smoke. |
| Fire-resistance-rated construction enclosures and doors were not maintained properly, including missing labels and openings. |
| Emergency exit signs missing directional indicators. |
| Fire sprinkler escutcheon plates missing or not covering openings, allowing spread of fire and smoke. |
| Corridor doors blocked open or held open by unapproved devices such as wedges and mechanical holders. |
| Use of prohibited portable electric heaters found in multiple offices. |
| Exhaust ventilation systems not working or absent in required areas including soiled linen, public restrooms, breakrooms, and laundry. |
Report Facts
Licensed bed capacity: 125
Special Care Unit beds: 37
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper referral and follow-up for a resident who sustained a fall resulting in a fracture and severe pain.
Findings
The facility failed to ensure Resident #1 was referred to the emergency department for evaluation and treatment after a fall that resulted in a hip fracture and severe pain, delaying necessary treatment for approximately 48 hours. This failure constituted a Type A1 violation.
Complaint Details
The complaint investigation found that Resident #1 sustained a fall on 11/25/23, was not immediately referred to the emergency department despite severe pain and a diagnosed hip fracture, resulting in delayed treatment until 11/27/23. The facility's failure to notify and act promptly was substantiated as a Type A1 violation.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure Resident #1 was referred to the emergency department for evaluation and treatment after a fall which resulted in a fracture while exhibiting severe pain and skeletal abnormalities. | Type A1 Violation |
Report Facts
Days delayed for treatment: 2
Correction deadline: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Registered Nurse (RN) | Responsible for resident clinical assessments and oversight of Medication Aides; interviewed regarding Resident #1's fall and care. |
Inspection Report
Capacity: 85
Deficiencies: 9
Jun 20, 2018
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2012 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to building code and physical plant requirements including failure to meet special locking system requirements, trip hazards due to floor drain, storage violations, incomplete fire protection in electrical and mechanical ceiling penetrations, non-operational exhaust fan, uncovered electrical junction box, wall openings, and a door that failed to latch.
Deficiencies (9)
| Description |
|---|
| Magnetically locked doors in the Special Care Unit have momentary switches that depend on electronics to interrupt power, not meeting building code requirements for emergency switches. |
| Floor drain in the Laundry Room/Third Floor Level is not recessed into the floor, creating a trip hazard. |
| Storage of items less than 18 inches from the ceiling in the Main Kitchen Pantry Room. |
| Incomplete fire-caulking in electrical wiring ceiling penetrations at multiple locations including Mechanical Room 160, Main Laundry, Mechanical Room 226, Tech Room, and Work Room. |
| Ductwork penetration in the Wellness Coordinator HVAC closet on the Second Level is not sealed around the duct. |
| Exhaust fan in the Janitor Closet in the Main Kitchen is not operational. |
| Electrical junction box without a cover located in Room 166 above the Hall ceiling. |
| Wall openings in the Shampoo Closet on the First Level. |
| Door to Room 2046/Special Care Unit failed to latch. |
Report Facts
Licensed beds: 85
Special Care Unit beds: 33
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 6, 2018
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an Annual Survey on June 6-8, 2018 with an exit conference on June 11, 2018.
Findings
The facility failed to provide personal care and supervision according to care plans, failed to meet acute health care needs including medication refusals and diet orders, failed to serve therapeutic diets as ordered, and failed to ensure medication aides had proper training and employment verification.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide cueing and reminders to Resident #3 during meals as required by care plan. | — |
| Failed to refer to physician to ensure acute health care needs were met for Residents #3, #4, and #5. | — |
| Failed to serve therapeutic diets as ordered for Resident #3, including serving chopped diet instead of mechanical soft and non-thickened dietary supplement shake. | Type B Violation |
| Failed to administer Vitamin D3 as ordered for Resident #4 for 65 days. | — |
| Failed to ensure medication aide Staff D completed required medication training or had employment verification before administering medications. | — |
Report Facts
Weight loss: 20
Medication refusal count: 18
Medication refusal count: 13
Medication refusal count: 6
Days Vitamin D3 not administered: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Failed to complete required medication training or provide employment verification before administering medications. |
| Dietary Manager | Responsible for receiving diet orders and overseeing dietary preparation; acknowledged diet for Resident #3 was prepared incorrectly. | |
| Wellness Coordinator | Responded to Resident #3 choking incident and involved in care plan updates. | |
| Administrator | Provided information on facility policies and awareness of incidents. |
Inspection Report
Original Licensing
Deficiencies: 4
Dec 9, 2016
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an initial survey on 12/07/16, 12/08/16 and 12/09/16 at Waltonwood Cotswold.
Findings
The facility failed to assure that the resident's physician certified the care plan by signing and dating within 15 days of assessment completion for 1 of 5 sampled residents. The facility also failed to assure referral and follow-up to meet routine and acute health care needs for 1 of 5 residents by not notifying the primary physician of elevated blood pressures and not clarifying blood pressure orders and parameters upon readmission. Additionally, the facility failed to assure residents who received meals in their rooms were served on non-disposable service ware.
Severity Breakdown
Type B Violation: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident Care Plan was not signed and dated by the physician within 15 calendar days of assessment completion for Resident #5. | — |
| Failed to assure referral and follow-up to meet routine and acute health care needs for Resident #1 by not notifying the primary physician of elevated blood pressures and not clarifying blood pressure orders and parameters upon readmission. | Type B Violation |
| Residents who received meals in their rooms were served on non-disposable service ware. | — |
| Failed to ensure residents received care and services which are adequate, appropriate, and in compliance with relevant federal and state laws and rules regarding referral and follow up to the primary care physician. | Type B Violation |
Report Facts
Number of sampled residents with deficiencies: 5
Correction date deadline: 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Masl | Executive Director | Signed the statement of deficiencies and plan of correction. |
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