Inspection Reports for Waterbrooke of Elizabeth City
143 Rosedale Drive Elizabeth City, NC 27909, Elizabeth City, NC, 27909
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
18% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 23
Capacity: 130
Deficiencies: 5
Date: Sep 26, 2024
Visit Reason
The Adult Care Licensure Section and the Pasquotank Department of Social Services conducted an annual survey and complaint investigation from 09/24/24 to 09/26/24. The complaint investigations were initiated by the Pasquotank County Department of Social Services on 07/18/24 and 09/16/24.
Complaint Details
The complaint investigations were initiated by the Pasquotank County Department of Social Services on 07/18/24 and 09/16/24, which triggered the inspection visit from 09/24/24 to 09/26/24.
Findings
The facility failed to maintain hot water temperatures within the required range, failed to ensure a working call bell system for residents on the special care unit (SCU), failed to respond immediately to a resident found unresponsive resulting in death, failed to serve a therapeutic pureed meat diet as ordered, and failed to ensure sufficient staff presence in the SCU at all times.
Deficiencies (5)
Failed to ensure hot water temperatures were maintained between 100° to 116° Fahrenheit for fixtures accessible to residents, with temperatures observed up to 129.2°F.
Failed to ensure a call bell system was in place and operational for residents residing on the special care unit (SCU).
Failed to respond immediately to Resident #6 who was found unresponsive while restrained after eating a sandwich, resulting in death.
Failed to ensure a therapeutic pureed meat only diet was served as ordered for Resident #6, who was served a pork rib hoagie sandwich instead.
Failed to ensure staff were present in the special care unit (SCU) at all times in sufficient number to meet the needs of the residents, evidenced by a PCA working alone during a medical emergency.
Report Facts
Hot water fixtures with temperature violations: 5
Residents on special care unit: 23
Licensed capacity: 130
Residents on special care unit: 26
Staff scheduled on 07/02/24: 3
Duration of chest compressions by PCA: 10
Correction date for Type B violation: 2024
Correction date for Type A1 violation: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #6 | Resident | Resident who was found unresponsive and later died after choking on non-pureed food. |
| Personal Care Aide (PCA) | Personal Care Aide | PCA working alone on SCU who found Resident #6 unresponsive and performed chest compressions without CPR certification. |
| Medication Aide (MA) | Medication Aide | MA who was on break during incident and later assisted with calling 911 and starting CPR. |
| Special Care Director (SCD) | Special Care Director | Interviewed regarding staffing and incident response on SCU. |
| Administrator | Administrator | Provided information on staffing, CPR training, and incident awareness. |
| Kitchen Manager | Kitchen Manager | Provided information on preparation of pureed meals. |
| Personal Care Aide (Agency Staff) | Agency Staff PCA | Attempted interview but unsuccessful. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
Report of a Biennial Follow Up Construction Survey conducted on June 19, 2024.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 28, 2024
Visit Reason
This report documents a Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to physical plant requirements at Waterbrooke of Elizabeth City.
Findings
The facility was found to have unresolved deficiencies including electromagnetic locks without functioning emergency release switches, improperly stored oxygen bottles posing hazards, and plumbing equipment issues such as a loosened toilet in Room 48.
Deficiencies (3)
Electromagnetic locks lacked on/off emergency release switches capable of interrupting power to all electromagnetically locked doors; master override switches did not release the front door.
Oxygen bottles were improperly stored without restraints to prevent falling or being knocked over, presenting a hazard.
Plumbing equipment was not maintained safely; specifically, the toilet in Room 48 Bath was loosened and no longer secure at the floor.
Inspection Report
Routine
Capacity: 130
Deficiencies: 9
Date: Dec 13, 2023
Visit Reason
The facility was surveyed for conformance with applicable licensing and building code requirements as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure of electromagnetic locks to release, lack of wanderer alarms on exit doors, unsafe and unclean physical plant conditions such as water ponding and ceiling damage, improperly stored oxygen tanks, fire safety equipment and building maintenance issues, and inadequate exhaust ventilation in specified areas.
Deficiencies (9)
Electromagnetic locks on the front door did not release with master override switches.
Exit doors accessible by residents known to be disoriented or wanderers lacked functioning sounding devices.
Outside premises were not maintained in a clean and safe condition, including water ponding and damaged porch ceiling.
Ceilings had mildew spots, water stains, and active leaks; furniture was not kept in good repair.
Oxygen bottles were improperly stored without restraints, posing a hazard.
Fire safety equipment and building components were not maintained in safe operating condition, including fire doors not latching, holes in fire-rated walls, damaged ceilings, missing sprinkler escutcheon rings, and uninspected hood suppression system.
Electrical equipment was not maintained safely, including dying batteries in screamer boxes and missing cover plate screws.
Plumbing equipment was not maintained safely; a toilet was not securely mounted.
Exhaust ventilation was not maintained in specified spaces, causing humidity buildup and odor issues.
Report Facts
Total licensed capacity: 130
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 6, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from January 4, 2023 to January 6, 2023, initiated by the Pasquotank Department of Social Services due to complaints received in November 2022.
Complaint Details
The complaint investigation was initiated by the Pasquotank Department of Social Services on November 15, 2022 and November 23, 2022.
Findings
The facility failed to ensure personal care for 2 of 5 sampled residents (#1 and #3). Resident #3 did not receive urinary catheter care as ordered, resulting in multiple hospital visits and infections. Resident #1 did not receive wound care and repositioning as ordered, leading to worsening wounds and hospital admission. The facility also failed to ensure timely referral and follow-up for these residents, resulting in serious physical harm and neglect.
Deficiencies (3)
Failed to ensure personal care including urinary catheter care for Resident #3 and wound care and repositioning for Resident #1.
Failed to ensure referral and follow-up for Resident #1's worsening pressure wounds and Resident #3's urology follow-up appointment.
Failed to ensure documentation of physician orders and implementation of wound care for Resident #1.
Report Facts
Deficiencies cited: 3
Dates of survey: 3
Resident sample size: 5
Hospital admission date: 2023
Inspection Report
Annual Inspection
Census: 45
Capacity: 130
Deficiencies: 7
Date: Feb 4, 2022
Visit Reason
The Adult Care Licensure Section and the Pasquotank County Department of Social Services conducted an annual, follow-up, and complaint investigation survey from February 2, 2022 to February 4, 2022, including complaint investigations initiated in November 2021 and January 2022.
Complaint Details
Complaint investigations were initiated by the Pasquotank County Department of Social Services on November 11, 2021, January 18, 2022, and January 25, 2022.
Findings
The facility failed to ensure exit doors on the Assisted Living unit had functioning sounding devices for resident safety, failed to secure a common bathroom under construction in the Special Care Unit, failed to provide adequate supervision and health care follow-up for residents with falls and pain, failed to provide a safe discharge for a resident, and failed to ensure medication aides had completed required training.
Deficiencies (7)
Failed to ensure 2 of 8 exit doors on the Assisted Living unit had a sounding device activated for safety for 15 residents intermittently disoriented and 1 resident constantly disoriented.
Failed to ensure the Special Care Unit was free of hazards accessible to 28 residents including an unsecured common bathroom under construction containing hazardous tools and items.
Failed to provide a safe and orderly discharge with 30-day notice and appeal rights for a resident discharged to the emergency room for leg pain and a fall.
Failed to provide supervision to 2 of 7 sampled residents resulting in multiple falls and injuries including a hip fracture and hospitalization.
Failed to ensure physician notification and follow-up for 2 of 7 sampled residents related to pain, specialty follow-up, and multiple falls requiring hospitalization.
Failed to implement medication orders for 3 of 5 residents observed during medication passes including errors with acid reflux medication, inhaled medication, anxiety and narcotic pain medications.
Failed to ensure 2 of 5 medication aides had completed required medication aide training prior to administering medications.
Report Facts
Residents intermittently disoriented: 15
Residents constantly disoriented: 1
Exit doors without functioning alarms: 2
Residents on Special Care Unit: 28
Facility licensed capacity: 130
Residents on Special Care Unit: 26
Medication error rate: 11
Medication administration errors: 3
Medication doses administered less than one hour apart: 14
Medication aides without required training: 2
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 24, 2020
Visit Reason
The Adult Care Licensure Section conducted a desk review follow-up survey from April 21, 2020 to April 24, 2020 to assess medication administration compliance.
Findings
The facility failed to ensure medications were administered as ordered for 2 of 5 residents sampled (#2 and #5), with multiple instances of medications not documented as administered due to medications not being on the medication cart. The issue was linked to the cycle fill medication change-out process.
Deficiencies (3)
Failed to ensure medications were administered as ordered for 2 of 5 residents sampled (#2, #5).
No documentation related to reordering of cycle fill medications.
No documentation related to stocking of cycle fill medications.
Report Facts
Residents sampled: 5
Residents with medication errors: 2
Medication supply cycle: 28
Cycle fill start day: 20
Medication delivery dates: 2
Medication reorder notification timeframe: 3
Change out duration: 1.5
Inspection Report
Capacity: 130
Deficiencies: 6
Date: Dec 13, 2017
Visit Reason
The facility was surveyed for conformance with applicable portions of the 2005 Rules and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy.
Findings
Multiple deficiencies were cited including failure to maintain current fire marshal inspection reports, damaged ceilings and peeling paint on HVAC grilles, improperly stored oxygen bottles, missing towel bars in shared bathrooms, missing fire sprinkler head escutcheons, and lack of required exhaust ventilation in the housekeeping/mop closet.
Deficiencies (6)
Failure to maintain current (within the calendar year) and required inspection reports on site; specifically, a current fire marshal's inspection report was not available.
Ceilings were not maintained in good repair; library ceiling finish damaged and peeling paint around ceiling mounted HVAC grilles.
Facility was not maintained free from hazards due to improperly stored oxygen bottles and a closet door with a barrel type bolt that could trap a person inside.
A towel bar has not been furnished for each resident in shared bathrooms.
Failure to maintain the building's fire safety systems in a safe condition; missing fire sprinkler head escutcheons creating holes in fire resistant rated ceilings.
Facility failed to provide required exhaust ventilation equipment; housekeeping/mop closet did not have an exhaust fan installed.
Report Facts
Total licensed capacity: 130
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 24, 2016
Visit Reason
The Adult Care Licensure Section and the Pasquotank County Department of Social Services conducted an annual survey on May 24-25, 2016 to assess compliance with regulations.
Findings
The facility failed to maintain cleanliness and protect kitchen equipment from contamination, including the reach-in cooler, walk-in refrigerator and freezer, stove/oven, toaster, ice-maker, kitchen and pantry shelving, and dishwasher. Observations revealed rust, grime, sticky substances, and lack of a current cleaning schedule. Interviews confirmed lapses in cleaning schedules and maintenance responsibilities.
Deficiencies (1)
Kitchen's reach-in cooler, walk-in refrigerator, walk-in freezer, oven, toaster, ice-maker, kitchen shelving, pantry shelving and dishwasher were not cleaned and protected from contamination.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 9, 2016
Visit Reason
This report is of a Followup Survey conducted to verify if previously identified deficiencies have been corrected. The followup survey revealed that all deficiencies have not been completed, requiring a new plan of correction.
Findings
The facility was found to have multiple unresolved deficiencies including hazards from loose and raised exterior tiles in exit paths, failure to provide individual towel racks in shared bathrooms, lack of a centrally posted fire evacuation plan approved by local code officials, and failure to maintain the emergency fire alarm system in safe operating condition, specifically the central override switches not de-energizing magnetic door locks.
Deficiencies (4)
Loose, detached or raised exterior surface materials in the exit path from and exit door, specifically tiles on the Special Care Unit patio.
Failure to provide individual bathroom furnishings, specifically lack of individual towel racks for each resident in shared bathrooms.
Failure to provide a centrally posted, approved fire evacuation plan showing evacuation routes in large print.
Failure to maintain the emergency fire alarm system devices and equipment in safe operating condition; central override switches did not de-energize magnetic door locks when activated.
Report Facts
Completion percentage: 50
Inspection Report
Annual Inspection
Capacity: 130
Deficiencies: 11
Date: Dec 9, 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 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The inspection identified multiple deficiencies including exit door locks requiring more than a single hand motion to operate, poor housekeeping and maintenance issues such as peeling paint, damaged ceilings and doors, tripping hazards, improper storage of oxygen bottles, obstructed electrical panel access, plumbing issues, inadequate bedroom furnishings, lack of individual towel racks, missing evacuation plan postings, and failures in fire safety systems including malfunctioning fire alarm devices, doors that do not close or latch properly, and gaps in fire resistant ceilings.
Deficiencies (11)
Exit door locks are not operable by a single hand motion; some doors require two or three hand motions to unlock.
Walls, ceilings, and doors are not kept clean and in good repair, including peeling paint, stained ceilings, surface damage, and dust-clogged HVAC grilles.
Facility is not free from hazards due to loose, detached, or raised exterior surface materials in exit paths and improper storage of oxygen bottles without restraining devices.
Electrical panel access is obstructed, preventing quick operation in emergencies.
Failure to maintain plumbing piping in a safe condition; ice machine drain lacks required gap.
Some bedroom furnishings are missing or not in good repair, including insufficient nightstands and chairs.
Lack of individual towel racks for each resident in shared bathrooms.
No evacuation plan with diagrammed drawing approved by local code official posted in a central location for the building's central corridor area.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; magnetic locks on exit doors do not release upon fire alarm activation.
Doors do not completely close and latch, including cross corridor doors dragging on the floor and not releasing from magnetic hold open devices.
Gaps and open penetrations in fire resistant rated ceilings, including an open-ended pipe sleeve for data cabling.
Report Facts
Total licensed capacity: 130
Special Care Unit beds: 26
Report
Jan 14, 2020
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