Name of Facility

Facility/County

DFS Proposed

PRC

Approved

Explanation

Fairview Family Care #4

Buncombe County

Type A

$1,000

Type A

$1,000

The facility left several residents without supervision on 6/14/05 .  One of the residents left alone in the facility has a diagnosis and history of polysubstance abuse.  During the time the home was left unsupervised, the DSS investigator discovered resident medications sitting out in the open on the dining room table.  Because of the varying medical and mental health problems of the residents, this lack of supervision created substantial risk for serious physical harm an/or death.

Forest Hills Rest Home

Penalty #1

Cumberland County

Type A

$2,000

Type A

$2,000

The facility failed to ensure contact of a resident’s physician or prescribing practitioner for verification or clarification of orders for medicines and treatments.  The parameters were not determined on the physician’s orders for sliding scale insulin, and the facility reduced the number of blood sugar checks from the four per day that had been specified with no additional orders to do so.  On 3/15/05 , the resident was taken to the emergency room for hyperglycemia.  The violations created substantial risk for death or serious physical harm.

Forest Hills Rest Home

Penalty #2

Cumberland County

Type B

$850

Type B

$850

The facility failed to assure, where at least one resident is determined by a physician or otherwise known to be a wanderer, each exit door accessible by residents is equipped with a sounding device that is activated when the door is opened.  Violations continued after the date mandated in a Type B Directed Plan of Correction issued by DFS.

Heritage Care of Rocky Mount

Edgecombe

Type A

$9,000

Type A

$3,000

The facility failed to administer CPR when a resident was found unresponsive with vomit on face and mouth.  The autopsy report determined that the resident died from airway obstruction due to aspiration of gastric contents.  The violation increased a substantial risk due to emergency procedures not being followed until medical intervention arrived with the EMS .  The penalty was reduced because it was determined it had been trebled incorrectly.

Hermitage House Rest Home

New Hanover County

Type A

$3,000

Type A

$3,000

The facility failed to assure locking of separate areas for storing cleaning agents, bleaches, pesticides, and other substances which may be hazardous if ingested, inhaled, or handled.  A resident suffered a second degree burn in the buttock area and a first degree burn to the ankle after using industrial type toilet bowl cleaner.

Pine Tree Villa

Wake County

Type A

$2,000

Type A

$2,000

Staff looked for a resident known to be disoriented with multiple diagnoses at the beginning of the 3:00 shift on 4/23/05 and as of 3:45 could not locate the resident.  There was no information available that an organized search was initiated by staff.  A passerby found the resident about a half-mile from the facility at approximately 6-6:30 and it was nearly 7:00 before the resident returned to the facility.  The resident was placed at substantial risk of death or serious physical harm.

Salem Terrace

Forsyth County

Type B

$4,350

Type B

$4,350

The facility failed to assure that staff administered medications according to orders by a licensed prescribing practitioner.  DFS and Forsyth County DSS determined in March, 2005, that the violations directly related to the health, safety and welfare of the residents and issued a Type B Directed Plan of Correction requiring corrective measures by 4/15.  During a follow-up survey in May, it was determined that the facility had not made the required corrections.  The facility stated they could comply by 6/10.  More than a month later, it was documented again that the facility was not in compliance.

The Braxton Home II

Alamance County

Type A

$1,000

Type A

$1,000

The facility failed to assure that necessary transportation for residents was provided in an appropriate and safe manner.  On 4/19/05 in lieu of other facility staff the staff in charge of the facility instructed Resident #2 to transport another resident to a scheduled medical appointment.  Resident #2 had a driving record that included several infractions including speeding, felony possession of cocaine several times and having an open container after consuming alcohol.  Resident #2’s car insurance was terminated 1/31/05 and the car plates revoked on 3/30/05 .

Facility/County

DFS Proposed

PRC

Approved

Explanation

Bethamy Retirement Center

Rowan County

Type A

$2,000

Abated

On 1/18/05 , a resident was transported via ambulance to Rowan Regional Center for an MRI of the left shoulder.  When the procedure was completed, the resident was transported back to the facility in the facility van.  After considering the findings of a complaint investigation initiated by Rowan DSS on 1/25/05 and concluded on 5/04/05 , a motion to abate the proposed penalty was approved on a 5-1 vote.

Chatham Creek Rest Home

Wake County

Type A

$2,000

Type A

$2,000

The facility failed to assure residents received adequate and appropriate care and services and to assure residents were free from neglect.  A resident that had been documented as being at risk for wandering on 8/09/04 did elope from the facility on 4/07/05 .  The facility had previously failed to identify this resident in their “Wandering Resident Policy” and still had not done so on 4/12/05 .  These violations placed the resident and potentially other unidentified wanderers as substantial risk for death or serious physical harm.

Eno Point Assisted Living

Durham County

Type A

$3,000

$1,000

Training

Residents of the facility were at risk for not receiving medications as ordered as well as not being in the highest practicable level of physical, emotional and social well-being due to the facility’s failure to make arrangements for appropriate health care.  A resident was placed at substantial risk for death or serious physical harm because the facility failed to administer insulin as ordered and failed to ensure coordination of health care services in relation to the resident’s blood sugar readings.  The committee reduced the recommended penalty to $1,000 to be used for medication administration training.

Long Acres Family Care Home #2

Wake County

Type B

$3,025

Type B

$3,025

The facility failed to assure staff who administered medications or who supervised medication staff successfully completed the required clinical skills validation of the competency evaluation.  The facility also failed to assure that staff administered medications according to the orders by a licensed prescribing practitioner.  Violations continued after the dates mandated in a Type B Directed Plan of Correction issued by DFS.

Thompson’s Family Care Home

Vance County

Type B

$5,150

Type B

$5,150

The facility failed to assure that each staff person had no substantiated findings listed on the N.C. Health Care Personnel Registry; failed to assure that staff performing licensed health professional tasks were validated competent to perform the tasks; failed to assure that at least one staff person on the premises at all times had completed the required CPR course; and failed to assure that staff who administer medications were competency validated to do so.  Violations continued after the dates mandated in a Type B Directed Plan of Correction issued by Vance DSS.

Facility/County

DFS Proposed

PRC

Approved

Explanation

A Place to Call Home #1

Alamance County

Type B

$2,100

Type B

$2,100

The facility failed to assure residents received adequate and appropriate care and services.  The facility failed to assure that each staff person had a criminal background check and also failed to assure that personal care aide training and competency validation were completed as required for all staff employed to perform personal care or those who directly supervise personal care aides.  These violations were determined to present a direct relationship to the health, safety and welfare of all residents, and these violations were documented as continuing Type B violations.

A Place to Call Home #2

Alamance County

Type A

$1,000

Type A

$1,000

The facility failed to assure that residents received adequate and appropriate care and services.  The facility failed to assure that responsible staff was in the facility at all times and to assure that at no time was a resident left alone in the home without a staff member.  Three residents had been left unattended.  These violations created significant risk that death or serious physical harm may have occurred.

A Place to Call Home #2

Alamance County

Type B

$2,100

Type B

$2,100

(Explanation is the same as that reported above for A Place to Call Home #1.)

Pinebrook Residential Center #1 Proposal #1

Yadkin County

Type A

$2,000

Type A

$2,000

The facility failed to provide residents the appropriate care, safety, and services necessary to enable them to attain and maintain their highest level of physical, emotional, and social well-being.  Residents were placed at risk of an exacerbation of either existing physical or mental health and/or physical harm.

Pinebrook Residential Center #1 Proposal #2

Yadkin County

Type A

$2,000

Type A

$1,000

The facility failed to administer a medication to a resident as ordered by the prescribing physician.  This failure placed the resident at risk of serious physical harm.

Pinebrook Residential

Center #1 Proposal #3

Continued

Yadkin County

Type A

$1,600

Type A

$1,000

The facility was cited with a Type A violation with a Directed Plan correction date.  A follow-up survey showed that the violation previously cited had not been corrected.  This represented a failure to correct the Type A violation for a period of 16 days.  This failure placed the resident at substantial risk of physical harm.

Pinebrook Residential Center #2 Proposal #1

Yadkin County

Type A

$2,000

Type A

$2,000

The facility failed to administer medications to residents as ordered by the prescribing physician.  This failure placed residents at risk of serious physical harm or death.

Pinebrook Residential Center #2 Proposal #2

Type A

$2,000

Type A

$2,000

The facility failed to provide residents the appropriate care, safety, and services necessary to enable them to attain and maintain their highest level of physical, emotional, and social well-being.  Residents were placed at risk of an exacerbation of either existing physical or mental health and/or physical harm.

Lenoir Park

Caldwell County

Type A

$1,000

$1,000

for Training

A motion was passed in lieu of the penalty, to have the $1,000 go towards education regarding medication monitoring and anticoagulation therapy.

Facility/County

DFS Proposed

PRC

Approved

Explanation