Inspection Reports for Willow Ridge

Report of a Construction Section Biennial Follow Up Survey conducted on May 13, 2025.

Deficiencies identified in the prior survey have been corrected. No further action is needed.

The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to building safety and equipment maintenance.

The facility was found to have multiple deficiencies including fire-rated openings in firewalls not maintained properly, smoke-tight corridor doors not latching, plumbing leaks causing ceiling damage and potential microbial growth, and non-functioning exhaust ventilation systems in required areas.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on November 5 - 6, 2024.

The facility failed to administer medications as ordered for 2 of 5 sampled residents related to medications used to treat breathing difficulties (Resident #4) and dementia and hypertension (Resident #2). Additionally, the facility failed to ensure electronic medication administration records (eMAR) were accurate for Resident #2 regarding documentation of amlodipine and donepezil administration.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on February 23 and 24, 2022 to assess compliance with personal care, supervision, and health care regulations.

The facility failed to ensure personal care assistance including nail care, bathing, and skin assessments were provided to 4 of 5 sampled residents, resulting in skin breakdown and discomfort. Additionally, the facility failed to notify the primary care provider about skin breakdown on Resident #1's feet, delaying treatment and risking infection. The facility also failed to provide adequate nail care for residents, causing pain and potential health risks.

The visit included a complaint investigation triggered by concerns about inadequate personal care and failure to address skin breakdown and nail care needs for residents.

The Adult Care Licensure Section conducted an annual survey and complaint investigation on 06/21/21-06/23/21.

The facility failed to provide an orderly discharge for one resident, failed to provide personal care and supervision to three residents including catheter care, failed to meet health care needs for two residents related to urologist follow-up and emergency care, failed to ensure food safety and proper menu documentation, failed to serve therapeutic diets as ordered, failed to provide adequate activities for residents, failed to maintain accurate controlled substance records for one resident, and failed to ensure special care unit staff completed required training hours.

The complaint investigation was related to failure to provide an orderly discharge for Resident #2, who was discharged to a hospital without proper planning or communication, resulting in the resident remaining in the hospital observation unit for 18 days without placement.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey and complaint investigation from 07/10/2019 through 07/12/2019.

The facility failed to respond immediately to a resident incident requiring CPR, failed to implement physician orders for compression stockings, lacked matching therapeutic diet menus, failed to administer medications as ordered for multiple residents, sent incorrect resident record information with a resident transported to the hospital, and failed to ensure staff completed mandatory annual infection control training.

The visit included a complaint investigation related to failure to respond immediately to a resident incident requiring CPR.

The report documents a Biennial Follow Up Construction Survey conducted to verify compliance with physical plant requirements and building code standards.

The facility failed to meet the NC State Building Code requirements for doors with special locking systems and had corridor doors that did not close and latch properly, potentially compromising fire safety.

This is a Construction Section Follow-up Survey to verify correction of previously cited deficiencies at Willow Ridge Assisted Living.

Some previously cited deficiencies have been corrected; however, outstanding deficiencies remain related to physical plant requirements, including missing wiring diagram at the fire alarm panel and corridor doors that do not close and latch properly, compromising fire and smoke safety.

This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant and safety requirements at Willow Ridge Assisted Living.

Multiple deficiencies were found including missing wiring diagrams for special locking system doors, hazardous latching hardware on closet doors, missing latch assembly parts on smoke barrier doors, inadequate fire safety rehearsal documentation, malfunctioning battery powered emergency lights, corridor doors not closing or latching properly, electrical panel obstructions, and non-working exhaust ventilation in a bathroom.

The facility was surveyed for conformance with applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1978 North Carolina Building Code, and the 1987 Minimum Standards and Regulations for Homes for the Aged, as part of a Construction Section Biennial Survey.

Multiple deficiencies were identified including failure to meet building code requirements for special locking system doors, improper handling and storage of portable medical oxygen cylinders, missing latch hardware on smoke barrier doors, ice machine drain contamination risk, incomplete fire safety rehearsals, malfunctioning emergency lights, corridor doors not closing and latching properly, electrical panel obstructions, and non-functioning exhaust ventilation in a bathroom.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 05/15/18-05/16/18 to verify correction of previous deficiencies related to tuberculosis testing, medication administration, and resident profile updates.

The facility failed to ensure tuberculosis testing upon hire for 3 of 3 sampled staff, failed to ensure 1 of 5 sampled residents was tested for tuberculosis upon admission, failed to observe medication administration properly for 1 of 5 sampled residents, and failed to complete quarterly resident profile reviews for 2 of 5 sampled residents.

The inspection was conducted as an annual, follow-up, and complaint investigation survey initiated by the Mecklenburg County Department of Social Services on January 12, 2018.

The facility failed to ensure staff were tested for tuberculosis upon hire, failed to complete required criminal background checks, did not assure residents were tested for tuberculosis upon admission, failed to complete Licensed Health Professional Support assessments, did not serve milk twice daily as required, and failed to ensure medication aides observed residents taking medications. Multiple deficiencies were identified placing residents at risk.

The complaint investigation was initiated by the Mecklenburg County Department of Social Services on January 12, 2018, and the survey included complaint investigation components related to tuberculosis testing of staff and residents.

This is a Biennial Construction Survey Follow Up conducted to verify compliance with physical plant requirements and building safety codes.

The facility failed to meet the NC State Building Code requirements for doors with special (magnetic) locking due to the absence of a wiring diagram posted at the fire alarm panel. Additionally, there were deficiencies in housekeeping and furnishings, including torn and missing floor covering in a bathroom, and the building was not maintained safely with respect to hot water temperature in an employee-only bathroom.

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 North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged, as part of a Biennial Construction Survey.

The survey identified multiple deficiencies related to physical plant and safety issues including missing wiring diagrams for special locking doors, torn floor covering, ice machine drain contamination risk, dry waste traps, irregular fire safety rehearsals, unsafe hot water temperature, non-functioning emergency lights, compromised fire-rated walls and ceilings, doors not closing or latching properly to resist fire and smoke, and non-functioning exhaust ventilation in a bathroom.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on June 1-2, 2016.

The facility failed to ensure that two staff members had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hiring, failed to clarify conflicting physician orders for one resident regarding blood pressure monitoring and medication, and failed to assure medications were administered as ordered for two residents regarding insulin and an antibiotic.