Name of Facility

Facility/County

DFS Proposed

PRC
Approved

Explanation

Autumn Green Adult Care Home

Type B

$1,850

Type B

$1,850

According to information from the Health Care Personnel Registry, Patricia Tiller, live-in-administrator and care-giver was listed with one substantiated finding of Neglect of a Resident, entered on 4/04/03. Another finding was substantiated for misappropriation of a resident's property on or about May 22, 2003. Wake DSS determined that the violation directly affected the health, safety and welfare of the residents and issued a Type B Directed Plan of Correction directing the administrator to employ staff other than Ms. Tiller for responsibilities for carrying out the work of the family care home. The facility failed to implement any corrective measures. Instead, prior to the issuance of any negative sanctions from either DSS or DFS, Ms. Tiller filed petition for a contested case hearing and filed complaint for a restraining order against both agencies. At this time, the petitions have not been heard or dismissed. As of the last documented monitoring visit conducted on 8/24/04 by Wake DSS, Ms. Tiller continued to staff the facility.

Champions Assisted Living

New Hanover County

$3,000

$3,000

The facility failed to provide adequate supervision to prevent elopement of two of seven residents with a diagnosis of Dementia/Cognitive Decline and failed to implement the facility's elopement policy and procedures when Resident #1 and Resident #3 identified as wanderers, left the facility. One resident, with a history of elopement and living in the special care unit, was permitted to walk around the facility outside the special care unit unsupervised. The other resident was seen going outside of the facility unsupervised, but no action was taken. The facility is located where traffic is heavy and dangerous. These violations created substantial risk for serious harm or death.

Pender County

$6,350.

$6,350

The facility failed to assure that staff who administered medications successfully completed clinical skills' validation prior to administration of medications. The facility failed to ensure contact with the resident's physician or prescribing practitioner for verification or clarification of orders for medications or treatments and failed to assure that staff administered medications as ordered. The facility failed to assure that hot water temperatures at fixtures used by residents were maintained between 100 degrees F and 116 degrees F.

Pender County

$1,000

$1,000

G. Anthony Rucker Rest Home

$2,000

$2,000

The facility failed to ensure that, prior to administering medications or treatments, there was verification or clarification of physician orders. The facility also failed to document medications as administered on the medication administration record. Resident #3 was diagnosed with vascular dementia, acute delirium, major depression and psychotic features according to a current Fl-2 dated 12/15/03, On 5/15/04, facility staff administered narcotic skin patches to Resident #3 on five body areas without appropriate physician orders and without documentation that these narcotic patches were administered. Resident #3 had been assessed by the facility with decubitus ulcers to those areas and according to staff interview, the administrator had purchased Curad Telfa pads to treat the areas prior to obtaining a physician appointment. Instead Duragesic 25mcg foil packets were administered. Upon admission to the hospital, the resident was noted by emergency room staff to be "virtually unresponsive" and in an altered mental state. Resident #3 was admitted to the hospital and monitored for four days, then discharged to a skilled nursing home

Johnson County

$4,000

Resident #74, #82, #9, #83,#36 #46, #61 and #85 did not receive coordination of care between the facility,,, the contracted mental health services, and the medical physicians. The facility had 69 of 102 residents with mental illness diagnoses, including schizophrenia, bipolar disorder, physchosis disorders, mild and severe retardation, and alcohol /drug abuse. The sampled eight of the eleven residents were diagnosed with mental illness or substance abuse. These residents exhibited significant behaviors that included confrontation, threatening outbursts, hallucinations, substance abuse, drug overdose, or suicide attempts during the time period investigated. There were no staff interventions for these behaviors or coordination with health providers. These violations placed these residents at increased risk for serious physical harm or death. Residents #36 and #46 had made suicide attempts. Based on staff interviews, the administrator had physically and mentally abused residents over a period of time, with increased frequency since January 2004.

Buncombe County

$1,000

$1,000

According to an investigation by the Buncombe County DSS, the facility failed to assure that staff was in the facility at all times to provide all required duties. In addition, the facility failed to administer medications within one hour before or after the prescribed or scheduled time and to assure that each resident is served at least three nutritionally adequate meals per day at regular hours. This placed residents at risk by not receiving their scheduled evening meal and PRN medications.

The Meadows of Garner

$2,000

$5,000

According to Wake DSS during April and May, 2004 the facility failed to provide adequate supervision when Resident A was discovered to be missing from the facility between 4/19/04 and 4/20/04. Based on staff interviews conducted by the administrator and the police, staff determined that Resident A was last seen at approximately 10:45 pm on 4/19/04 but was not considered missing until approximately 8:00 am on 4/20/04. At that point a search was conducted and the police contacted. Resident A's diagnoses included schizophrenia, mental retardation, coronary artery disease, history of congestive heart failure, history of ventricular arthritis, pacemaker with chronic pain at site, and GERD. Additionally, Resident A had been adjudicated incompetent and had a general guardian appointed. The facility's failure to conduct routine supervision based on residents' needs, placed Resident A at increased substantial risk for death or serious physical harm.

Franklin County

$2,000

$2,000

Facility/County

DFS Proposed

Approved

Explanation

Alamance County

$3,725

$3,725

The facility has continually failed to assure that residents received adequate and appropriate care and services. The facility failed to comply with requirements for maintaining furniture in residents' bedrooms and for assuring competent and qualified staff in the facility. These violations directly affected the health safety or welfare of the residents. The facility had obtained no evidence that their staff met requirements for TB testing or qualifications for Health Care Registry. Criminal Records checks or personal care aide training. The facility's continued failure to provide bedroom furniture storage was considered a violation impacting resident welfare.

Orange County

$2,000

$2,000

Based on the findings of a complaint investigation the facility failed to make necessary arrangements for appropriate health care as needed. Resident #1 had physician orders for Home Health Care Agency involvement for daily dressing changes and daily subcutaneous injections of lovenox (anticoagulant) which the facility failed to assure was administered. Resident #2 was hospitalized for dehydration, and ordered to have HCTZ (diuretic/blood pressure medication ) to be discontinued but the facility continued to administer. Resident #2 did not have dietary supplements as ordered. Resident #3 on orders for Depakote and valporic acid levels, did not have these levels taken.

Bertie County

$1,0000

$1,000

Based on the findings of a complaint investigation conducted by Bertie DSS, the facility failed to assure all residents received adequate and appropriate care and services. The facility failed to notify the resident's responsible person, the appropriate law enforcement agency and the county department of social services when a resident's whereabouts were unknown. With the resident's diagnoses of Alcohol Abuse, Bi-polar Disorder, Seizure Disorder and Asthma, there was reason to be concerned for the resident's safety. During the time Resident # 1 was missing from the facility this resident was seen in two different hospitals for seizure disorder. The r3esident's Dilantin levels were documented below therapeutic levels on 4/01/04 and 4/02/04.

Cabarrus County

$1800

$1800

The facility failed to correct a type "B" violation by the specified correction date. The specified date of correction was 4-15-04 survey. The violation was in the area of Health Care. This represents 18 days past the directed correction date.

Craven County

$2,000

$2,000

The facility failed to assist residents when necessary with personal needs that residents may be incapable of or unable to attend for themselves. The county was notified that by a neighbor that a resident was found in the street with her walker. Even though there was no injury the resident was put at risk of danger because she wandered a quarter mile down a secondary road. Residents #1,#2,#3 are documented as being disoriented or wanderers. Only resident #2 had wandering identified in the care plan but included no intervention. Although the exit doors had alarms, the front door alarm was deactivated with no plan of monitoring for the disoriented or wandering residents at that door.

Cumberland County

$2,000

$2000

The violation involved the licensee's failure to provide facility staff to perform personal care and supervision to residents during his absence. Based on the observations of DSS during an on-cite visit;, there were two residents in the facility but no facility staff. Resident #1, diagnosed with shizoaffective disorder, was being visited by a Community Based Services Worker, not employed by the facility. Resident #2, diagnosed as being constantly disoriented, was also in the facility without facility staff. The DSS determined that the violation placed the residents at substantial risk for serious harm or death.

New Hope Living Center at RTP

$2,000

$2,000

The facility failed to assure that there was an adequate supply of food to serve the planned menu, including therapeutic diets. The facility had failed to assure that medication was administered y qualified medication aides at all times. The facility failed to assure that, in the absence of the administrator, there was a qualified administer-in-charge or supervisor-in-charge in the facility or immediately available to be responsible for the total operation of the facility. DSS documented that there was only a personal care aide on duty on 5/06/04 and that medication had not been administered for 8PM on 5/05/04 or 8AM on f/06/04. Noon medications were administered approximately two hours late on 5/06/04. MAR's indicated that administrations were either not given or not documented during 5/01/04 - 5/06/04. Food supplies were inadequate to serve the planned menus and to meet needs of the therapeutic diet orders. DSS determined that these violations placed residents iat substantial risk for serious physical harm or death.

Stone Meadows Family Care Home

$3,00

$3,000

The facility failed to assure adequate staff coverage in the absence of the administrator and failed to ensure adequate access to health care. Based on staff interviews residents were left unattended on occasion. Resident #2,, after complaining for over 6 weeks of symptoms of increased fluid in legs was, chest pain and shortness of breath, was transported from church via ambulance to the hospital. The resident was diagnosed with multiple arterial blockages. Resident #5 was taken to the emergency room with rectal bleeding on 2/29/04. The resident had missed medical appointments in January and February including a hospital discharge notice instructing a three day follow up with a specialist and two appointments with the eye doctor after recent cataract surgery. The resident had also experienced falls with no medical follow up. Resident #5 was not transported to a medical specialist on at least 5 occasions to discuss treatment of a growing aneurysm. These violations directly contributed to substantial risks for serious harm or death.

Facility/County

DFS Proposed

Approved

Explanation

Pender County

$2,000

$2,000

The facility failed to assure that all residents received adequate and appropriate care and services. The facility had failed to assure aide staff provided direct personal assistance and supervision needed by all residents. Additionally, the facility failed to immediately notify residents' responsible persons, appropriate law enforcement and DSS when the whereabouts of a resident is unknown and there was reason to be concerned about the safety of a resident. On 2/1/04, Resident #1 wandering away from the facility was observed by a family member and returned to the facility. Resident #1 had a diagnosis of Alzheimer's Disease. When Resident #1 had exited the facility, the facility staff had silenced the required door alarm without checking for wandering residents. The resident had no adverse effects from the experience although the temperature was 40 degrees on that day. On 3/1/04, Resident #2 left the facility, having signed out to go to the grocery store. The facility did not contact the responsible person until the next day. They did not contact local law enforcement but contacted DSS on 3/3/04. DSS recommended that the facility contact law enforcement. This was done and they located the resident on 3/4/04. Resident #2, with a diagnosis of Schizoaffective disorder -- depressed type as well as bronchial asthma, had no adverse effects from the elopement although going without medications for 4 days. Residents #1 and #2 were both placed at substantial risk for death or serious physical harm.

Alamance County

$1500

Dismissed

The facility failed to assure that adequate and appropriate care and services were provided to all residents. The facility failed to assure that occasional or incidental medical care was provided to all residents on an individual basis and to attend to personal needs that the residents are unable to attend for themselves. Resident #1 was admitted to the emergency room on 3/20/04 with "multiple decubitus ulcers on over 25 areas on heels, buttocks and legs" which were red, broken, blistered and/or infected and included Stage III-IV and necrotic areas. Lab results showed a white blood cell count of 28,000. Resident #1 required assistance with incontinence care, ambulation, bathing, dressing, grooming and transferring. According to the administrator, this resident was only diaper changed twice daily and remained in a wheelchair throughout the whole day due to weight. Based on the physician's statement, the resident's nutritional status likely contributed to the skin breakdown, citing an albumin level of 1.6. Alamance DSS determined that the facility's failure to provide personal care assistance to Resident #1 resulted in serious physical harm to the resident "in form of painful, multiple, and life-threatening decubitus ulcers (bedsores)."

Buncombe County

$900

$900

The facility failed to correct a Type "B" penalty violation within a specified time period. This violation was in the area of nutrition and food service. The facility failed to assure that there was at least a 3-day supply of perishable food and a 5-day supply of non-perishable food in the facility based on the menu, for both regular and therapeutic diets. The violation extended 9 days past the specified correction date.

New Hanover County

$1000

$1000

The facility failed to provide adequate and appropriate care and services to all residents. The facility failed to assure aide staff provided direct personal assistance and supervision needed by all residents. Resident #1 was admitted to the facility of 10/31/03 with a diagnosis of dementia and an order to self-administer medications. One ordered medication for the resident was Aricept for memory impairment. At the time of placement, Resident #1 had experienced being unable to find the way home and had been assisted by police several times. Since admission staff had observed times that the resident was confused or forgetful. The facility did not assess or reassess the resident's need level or capability to self-administer. The facility failed to assure that Resident #1's marked confusion was supervised adequately and failed to assure that medication such as Aricept were administered as needed. On 3/5/04 Resident #1 left the facility unknown to the staff and became confused at a bank and unable to remember. Resident #1 was at risk for wandering, which placed the resident at substantial risk for death or serious physical harm.

Transylvania County

$2000

Dismissed

The facility failed to make arrangements for appropriate health care as needed to enable the resident to be in the best possible health condition. Based on the report, staff of the Parc at Brevard found the resident unresponsive and informed EMS personnel that the resident had not voided for 3 days prior. ER staff at Transylvania Community Hospital was informed of this also according to hospital records. In a letter to the Transylvania County Department of Social Services during the investigation, the attending physician states that it had not been reported to him that the resident had not voided for 3 days, but that was borne out by the fact that ER personnel got 1700 cc's of urine when she was catheterized. According to the Department of Social Services, the delay in seeking medical intervention for the resident caused the resident suffering and harm and violated her right to appropriate health care. Note: General Statute 131D-34 (b)(3) requires the Department to impose a civil penalty which is treble the amount which is assessed when a facility, under the same management and ownership has received a citation and paid a penalty for violating the same specific provision of a statute or regulation for which it received a citation during the previous 12 months. Therefore, if assessed, the proposed penalty amount would have been a total of $2000 x 3 = $6000.

Mecklenburg County

$1650

$1650

The facility failed to correct a Type B penalty violation by the specified time period. This violation was in the area of medication. According to the information provided, the facility failed to assure that staff administered medications and/or treatments according to physician's orders which are maintained in the resident's record. This violation had a direct relationship to the health, safety, and welfare of the residents affected, but posed no substantial risk of death or serious physical harm.

Cumberland County

$4675

$4675

The facility failed to assure that residents received adequate and appropriate care and services. DFS documented that the facility failed to assure that the staff administer medications according to the licensed prescribing practitioner's orders or that arrangements were made as needed to enable the residents to remain in the best possible health condition. DFS determined that these violations directly affected health, safety, and welfare of residents and issued Type B Directed Plan of Corrections. The facility was directed to make necessary corrections no later than 3/20/04. Based on the findings of a follow-up survey conducted on 4/13-14/04, DFS determined that the facility had failed to comply with the directed plan of corrections. The facility then set a date to be in compliance for 5/15/04. Upon follow-up survey on 6/16-18/04, the violations remained uncorrected. The violation for failure to administer medications as orders continued as an uncorrected Type B as of the submittla of the penalty recommendation. The violation for failure to coordinate for residents' best health conditions was stopped as a Type B and re-issued as a Type A based on the increased significance of the findings that posed a potential risk for death or serious physical harm. Therefore, the Type B for Health Care is stopped as of 5/15/04. Additionally, DFS has issued a Notice on Intent to Revoke the license for Wade Assisted Living, Inc. This decision was based on the facility's continuing substantial failure to correct significant violations and the consideration that there was not a reasonable probability that the licensee could remedy the deficiencies within a reasonable period of time.

Facility/County

DFS Proposed

PRC
Approved

Explanation

Jones County

$2,000

$2,000

Facility failed to provide incidental medical care or to make arrangements for appropriate health care to enable a resident to be in the best possible health condition. Resident #1 was blind and wheelchair bound, incontinent of bowel and bladder, and was observed to be slumped over and to have a cough during the monitoring visit. This resident had not been seen by the attending physician since April 2003 and had actually missed scheduled appointments on 7/27/03 and 11/04/03. These appointments were not cancelled; the facility staff failed to take the resident to see the physician for them. Under APS, Jones DSS made arrangements for the resident to be examined by the physician. On 12/03/03, the physician examination documented that Resident #1 had fluid in lower back, ear, nose and throat; teeth in poor condition; a developing stage 1 decubiti on the sacral area; lungs with scattered rhonchi. It was determined that the level of care for Resident #1 was an upgrade to ICF level. These failures created a substantial risk for serious physical harm or death as the resident remained without physician attention as health condition deteriorated. Separate from the submittal of this penalty proposal to DFS, additional licensure actions taken by DFS against the licensee have included: (1) Type A penalty imposed 3/18/03 in the areas of medicine administration and controlled substances. (2) Continuing Type A penalty imposed on 5/09/03 for continuing failures to correct areas noted above in item #1. (3) Suspension of Admissions for new residents based on violations in the areas of residents' rights, including failure to assure appropriate care and services, pharmaceutical services, management and other staff, and refunds. The provider violated the Suspension by the admission of new residents during February 2004 and was directed to relocate the new residents. (4) DFS took the license of the facility under non-renewal authority on 4/23/04 and closed the facility based on the facility's failure to pay the penalties as noted in items #1 and #2 above. The DSS is currently conducting an investigation of the provider for operating without a license and providing direct care in an unlicensed facility based on an APS investigation. Residents found at that time were relocated from this unlicensed home.

Durham County

$2,000

$2,000

Facility failed to assure that residents received adequate and appropriate care and services. Durham DSS determined that the facility failed to make arrangements for appropriate health care as needed to enable resident to be in the best possible health condition, failed to document physician contacts, and failed to respond immediately and report as required any accident or incident resulting in injury. Resident A was not seen by a physician until two days after falling and receiving a blow to the eye. The resident after being seen was immediately referred to the emergency room and diagnosed with a right elbow fracture and right maxillary sinus fracture with blood in sinus. Resident B experienced almost daily vomiting for 3-1/2 weeks with no indication of coordination for this resident's health care needs to be met. Based on these violations, there was substantial risk for serious physical harm.

Sampson County

$1,900

$1,000 Training

Facility failed to assure that medication orders from prescribing practitioners were clarified as necessary and documented and maintained in resident records. The facility failed to correct violations in medication orders and medication administration which were originally cited on 6/24-25/03. DSS identified the continuing deficiencies as Type B and implemented a Directed Plan of Correction, delivered to the facility on 10/30/03. The facility was directed to make necessary corrections no later than 11/13/03. Follow up conducted on 1/14 and 1/20/04 documented that the facility remained non-compliant. The facility agreed that corrections would be made by 1/28/04. Compliance was documented during a2/11/04 follow-up monitoring visit from the DSS. The continuing failure to assure medications were administered correctly directly affected these residents' health, safety and welfare and placed all residents at risk.

New Hanover County

$2,000

$2,000

Facility failed to assure that residents received adequate and appropriate care and services. The facility failed to assure that aide responsibilities were met to provide direct personal assistance and supervision as needed by the residents. On 2/01/04 and again on 2/09/04, Resident #1 eloped from the facility. Resident #1 was diagnosed with Dementia and had been assessed by the facility to be in need of supervision for wandering/elopement behaviors. The resident was evaluated and found to have not been harmed in both episodes. However, the potential risk for serious physical harm or death to occur was very great. The facility environment includes an unfenced retention pond, a wooded area with no sidewalks, and a busy, primary four-lane highway. During the 2/01/04 incident, Resident #1 wandered away between 7:00 and 8"45 p.m. and located by EMS, walking in a median of this highway. The temperatures at that time had dropped below freezing. On 2/09/04, between 8:00 and 8:30 a.m., Resident #1 wandered away from the facility and was discovered by off-duty staff, walking down the road and crossing in traffic.

$1,000

$1,000

Facility failed to assure all residents received adequate and appropriate care and services. It was determined that the administrator failed to assure that at no time was any resident left alone in the home without a staff member. During an unannounced visit to the facility on 3/01/04, with the DFS Consultant accompanying, upon arrival at 11:43 a.m., the AHS was informed that the administrator was not in the facility having left around 9:00 a.m. Further inquiry confirmed upon entering the facility that there was no staff with the residents. The AHS then contacted the administrator by cell phone and the administrator arrived at the facility at 11:58. During a walk-through of the facility, it was observed that in addition to Resident #1, Resident #3 was sitting in the facility and Resident #4 was still asleep in the facility. Diagnoses for these residents include mild retardation and schizoaffective disorder. Failure to provide direct supervision to three of the four residents placed these residents at substantial risk of death or serious physical harm. The AHS has documented a history of not being able to conduct routine monitoring visits in the facility due to lack of response to her arrival. On at least one prior occasion the AHS had been informed at the door that there was no staff in the facility and did not gain entry to the facility at that time.

Robeson County

$3,000

$3,000

Facility failed to assure adequate and appropriate care and services and failed to assure that all residents were treated with respect, consideration, dignity, and full recognition of his or her individuality and right to privacy. According to these findings the facility failed to assist residents to attend to any personal needs the residents may be incapable of or unable to attend for themselves. Robeson DSS determined that Resident #2 did not receive adequate supervision based on licensed health professional recommendations to the facility due to history of falls with injury and being a wanderer and injurious to self. Emergency Medical Technicians found Resident #2 in fetal position on floor, with blood all over the floor in the room in small amounts. They also observed resident to have numerous open wounds to both arms and hematoma to hip and eye. This failure resulted in a hospital admission with diagnoses of hypothermia (likely secondary to environmental reasons) and dehydration. It was noted that Resident #2 also was observed by hospital staff to have bruises all over the body as well as skin tears. These violations created substantial risk for serious physical harm or death. Harm did occur to Resident #2.

Henderson County

$3,000

$3,000

Facility left the residents alone without supervision on 3/9/04. Because there were no staff members in the facility providing supervision to residents for a period of time, staff could no respond immediately to an accident involving Resident #1 and make a report of her wandering away and sustaining a fractured hip. Leaving the facility without supervision also placed the other residents at a risk for harm.

Facility/County

DFS Proposed

Approved

Explanation

Durham County

$1,575

$1,500

Facility failed to assure that qualified staff were employed in the facility to assure appropriate care and services were provided to the residents in the absence of the administrator. Durham DSS determined that these violations directly affected all residents' health, safety and welfare and implemented a Type B Directed Plan of Correction to assure that staff in the absence of the administrator met all required qualifications. Employed staff also were not validated competent to administer medications and had not received necessary personal care training. Any staff that met those qualifications were not available to the facility at the time of the DSS monitoring visits. The facility achieved compliance by submittal of Medication Administration Clinical Skills checklists to DSS on 2/9/04. Note: In the Administrative Penalty Proposal, Durham DSS writes that the uncorrected days for this penalty ran from 12/10/03 through 2/8/04 for a total of 60 days. However, based on the 12/21/03 Directed Plan of Correction as written, the established correction date was 12/7/03. Therefore, this penalty amount was determined based on 63 days.

Pender County

$2,000

$2,000

Facility failed to assure all residents received adequate and appropriate care and services. The facility had failed to assure that aides on duty provided needed supervision to residents. Resident #1, with a diagnosis of Alzheimer's Disease, wandered away from the facility without supervision. According to the findings, Resident #1 left the building from the front door of the facility. The door, when exited, sounded the alarm but staff silenced the alarm without checking to see who had left the building. Based on interview, it was determined that Resident #1 happened to be sighted by Staff Member #1, an employee of the facility who was on their way to work and returned to the facility without harm. When discovered by Staff Member #1, Resident #1 was dressed in nightgown and was barefoot. It is noted that this investigation began prior to and was concluded after a change of ownership that occurred on 1/1/04. The DSS concluded and substantiated the violations prepared an investigation report and penalty recommendation addressed to the owner of the license on 11/8/03. A Correction Action Report was not issued when the investigation was concluded, as the owner responsible for the violation was no longer responsible for corrective actions at this facility.

Durham County

$1,350

$1,350

Facility failed to assure that residents received a minimum of three nutritionally adequate meals each day. Also, the facility failed to assure adequate, clean bed linens and towels and failed to adequately staff the facility to attend to residents and carry out food service duties. Durham DSS determined that based on the scope of the violations that impacted all residents, the violations directly affected the health, safety, and welfare of all the residents and implemented a Type B Directed Plan of Correction. Corrective measures were to be taken by the facility no later than 2/10/04. A follow up monitoring visited conducted on 2/13/04 documented that the facility remained out of compliance in these rule areas. At the time of the penalty proposal submittal the facility had failed to achieve necessary compliance.

Durham County

$1,150

$1,150

Facility failed to maintain an approved sanitation score of 85 or above at all times. The facility had received a score of 80.5. Durham DSS determined that based on the scope of the violations, all the residents' health, safety and welfare were affected and implemented a Type B Directed Plan of Correction. Corrective measures were to be taken by the facility to obtain a reinspection for an approved score no later than 2/20/04. Confirmed via a phone call from Durham DSS to the Durham County Health Department on 3/1/04, the facility failed to call for a reinspection. The facility called for a reinspection on 3/15/04. An approved score of 85.0 was obtained the violation was determined to be abated.

$1,300

$1,300

Facility failed to correct a "B" level violation by the specified correction date. The violation was in the area of housekeeping and furnishings. Based on the Penalty Proposal, the violation continued for a period of 13 days past the agreed upon correction date.

Northampton County

$4,500

$4,500

Facility failed to assure adequate and appropriate care and services were provided to all residents according to rules and regulations in the rule areas of Medications and Health Care. The facility had failed to assure that medications were administered to residents according to orders by the licensed practitioner. DSS determined the violation to be a Type B and issued a Directed Plan of Correction to achieve compliance no later than 11/30/03. Also, the facility had failed to make arrangements for appropriate health care to enable the residents to be in the best possible health condition. An additional Type B Directed Plan of Correction was issued to the facility to achieve compliance in this rule area no later than 11/30/03. Follow up monitoring conducted by Northampton DSS during January 2004 confirmed that compliance had not been achieved as directed. Medications for eight of fourteen residents were not administered correctly. Coordination of health care was not provided for five of eleven residents. Additional follow up on 2/18-19/04 documented that the violations continued. The facility set a new compliance date as 3/10/04, which was later extended to 3/19/04. A visit to the facility on 4/14/04 confirmed corrections were made. These continuing Type B violations directly affected the health, safety and welfare of the affected residents.

Mecklenburg County

$2,000

$3,000

Facility failed to administer medications to a resident according to physician orders. Subsequent to this failure, the resident was hospitalized for a resulting injury. The investigation showed that the resident did not receive care and services which were adequate, appropriate, and in compliance with relevant federal and state laws and rules and regulations. The penalty proposal involves one violation where serious physical harm has occurred.

Facility/County

DFS Proposed

PRC Approved

Explanation

Wake County

$2,000

$2,000

Facility failed to assure that residents received adequate and appropriate care and services in compliance with rules and regulations. The facility failed to assure that the licensed Special Care Unity for Alzheimer's and Related Disorders implemented policies and procedures to keep wandering residents safe. And to assure that responsible staff assisted residents on an individual basis to attend to any personal needs the residents may be incapable of or unable to attend for themselves. Residents #1 is identified on the FL-2 as a wanderer and intermittently disoriented. Although staff had identified Resident #1 as at significant risk for wandering, the assessments and care plan completed on this resident did not address wandering. On the evening of 1/10/04, Resident #1 had been agitated and wandered from the facility after setting off door alarms. The staff of the facility did not implement the facility's policy and procedure in their manner for responding to the door alarm and also failed to follow the facility's procedure to walk outside and survey the property and surrounding area to locate residents who may have exited undetected. Staff, in interviews, were inconsistent as to how the alarm system worked and records indicated that the facility's policy for monthly elopement drills had not been followed. These violations created substantial risk for death or serious physical harm. Resident #1, in a wheelchair, was found that evening alongside the road by a passing motorist and returned to the facility without harm.

Carteret County

$10,000

$10,000

Facility failed to assure that residents received adequate and appropriate care and services. The facility failed to provide adequate supervision to prevent elopement, failed to implement the facility policy and procedure for "Wandering and/or Disoriented Residents", and failed to implement the facility policy and procedure for "Missing Residents." Patient information on the FL-2 for Resident #1 identified the resident as being intermittently disoriented and ambulatory. The resident record also contained a nursing note entry that documented that on "12/17/03, Resident #1 appears confused, talking to himself, not oriented X 3. Needs to be watched closely." This observation was completed by a psychiatric nurse consultant hired by the facility. On the evening of 12/17/03, Resident #1 was taking outside the facility to drink coffee and smoke cigarettes without supervision, in direct conflict to the nurse's instructions. Staff report that they later noticed Resident #1 was missing from the facility porch and also report that interior and exterior searches of the facility were conducted. It was noted, as reported, that the staff did not follow the facility policy to call 911 after an interior search failed to locate a missing resident. Resident #1 was hit by an automobile approximately 0.25 miles from the facility on Highway 70 East at approximately 9:14. The accident was fatal for Resident #1. The facility's failures resulted in a significant risk for death or serious physical harm and death did occur. As noted by Carteret DSS, the facility received an imposed penalty from the 9/11/03 PRC Meeting for another Type A which was cited in a different rule area, Personal Services, 42D.1701. Therefore, a treble penalty does not apply, according to G.S131D-34(b)(3).

Nash County

$1,050

$1,050

Facility failed to assure that staff administer medications according to orders by a licensed prescribing practitioner and to have at least quarterly pharmaceutical care, including required on-site reviews. Facility failed to assure that medications were available in the facility and that medications were administered as ordered. Facility documentation identified violations that included failures to obtain order clarifications, medications not being in the facility, indications of "not given" with no reasons indicated, resident out to medical appointments during med passes, medications omitted. Based on these findings 17 of 54 residents failed to receive medications as ordered. 14 of 54 residents did not have their medication available in the facility. 54 of 54 residents did not receive Pharmaceutical Care services as required. The continuing areas of non-compliance directly affected health, safety, and welfare of the residents indicated above.

Guilford County

$5,500

$2,750

Facility failed to assure that residents received adequate and appropriate care and services. The facility failed to assure that all therapeutic diets were served to residents as ordered by the physician and failed to assure that non- and semi-ambulatory residents were assisted with dressing, toileting and ambulating, including failures to provide a functional call ell system. DFS determined that these Type B violations directly affected health, safety, welfare of the affected residents, three of six with physician ordered diets and five of five residents needing assistance for personal care. A directed Plan of Correction was issued for compliance to be achieved no later than 12/19/03 for diet orders and 12/27/03 for assistance with personal care. DFS and Guilford DSS conducted a deficiency follow up survey on 1/20-21/04 and determined that the facility had failed to correct these Type B violations within the specified time frames. On February 3, 2004 the facility advised that corrections would be complete by February 17, 2004, which was confirmed by survey on 3/9-10/04. Based on interventions by DFS and Guilford DSS, the facility had had compliance issues from the Change of Ownership Survey of 7/17-18/03,including Type B violations which had been directed for corrections. On the surveys of 9/10 and 9/25/03 corrections to those earlier citations were confirmed and those violations were abated.

$6,000

$6,000

Facility violated Resident's rights by admitting a resident requiring professional nursing care, failed to contact the physician to clarify orders, services, medications and treatments, and failed to assure that medications and treatments were administered as ordered. Despite an FL-2 specifying skilled nursing facility, the facility admitted a resident without obtaining and administering prescribed medications and treatments. The resident was subsequently transferred to the hospital ER the day following admission to the adult care home.

Wake County

$10,000

$10,000

Facility failed to assure that residents received adequate and appropriate care and services in compliance with rules and regulations. The facility failed to assure that housekeeping duties performed by aides between the hours of 9 pm and 7 am, did not hinder the care of supervision of the residents or any immediate response necessary and did not take the aides out of view of where the residents were. Resident A's current diagnoses included Alzheimer's/dementia and this resident was known to the facility staff to be a wanderer. A bell was kept on the bedroom door of Resident A to alert others when he left the room at night. The aide assigned to the 100 hall where Resident A resided arrived at work at 11:00 pm, assisted one resident that requested help, and went straight to work in the laundry room without checking the other residents on 100 hall. The laundry room is located on another hall and not in view of this hall. According to the shift supervisor, at 11:15 pm an exit door alarm sounded in activity room. This supervisor stated she checked the room and looked out the door that had sounded but did not call for an immediate search of the facility and property to check for known wanderers. Resident A, during this time period, wandered undetected from the facility and into traffic near the facility, was struck and killed by a car. These violations created substantial risk for death or serious physical harm for residents known to the facility to be wanderers. For Resident A death did occur.

Transylvania County

$2,000

$2,000

Facility failed to make arrangements for appropriate health care as needed to enable the resident to be in the best possible health condition. The DSS report indicates that although the resident requested medical intervention and the staff on duty recommended that the resident be transported to the emergency room at the hospital, the management did not approve that request until after the resident collapsed and could not be revived. Written facility policy and procedure was not followed. During the time that the resident requested medical help, the resident's physician was not contacted for guidance or orders. In addition, the report shows that the facility failed on the date of the violation to administer medications to the resident in accordance with physician's orders. Although the evidence does not indicate that these violations were the cause of the resident's death, they present a substantial risk of serious physical harm or death, and therefore are a serious violation of residents' rights.

Facility/County

DFS Proposed

PRC Approved

Explanation

Franklin County

$400

$400

Facility failed to correct a type "B" penalty violation by the specified correction date. This violation was in the area of Building Service Equipment (hot water temperature). According to the proposal, the facility did not assure that the hot water temperature at resident use faucets remained in the licensure permitted range of between 100 degrees F. and 116 degrees F. This violation continued for 4 days past the specified date of correction.

Mecklenburg County

$1,750

$1,750

Facility failed to correct type "B" violations by the specified correction date. These violations were in the areas of medication administration competency for medication aide staff and competency validation for staff performing licensed health professional support tasks identified in rule 13F. 0903. The correction of these violations was not made by the facility until 12-5-03 as verified by the county DSS. This represents a total of 35 days beyond the specified correction date.

Buncombe County

$1,000

$1,000

Facility left the residents alone without supervision on 9-24-03. The facility is located within a cluster of homes and each is in close proximity to one another. However, according to the investigation, residents living in the home are diagnosed with schizophrenia, type 11 diabetes, HTN, bipolar disorder, and traumatic brain injury among others. Because of the varying medical and mental health problems of the residents, being left unsupervised created an environment of substantial risk for serious physical harm and/or death.

Buncombe County

$1,000

$1,000

Facility left the residents alone without supervision on 9-24-03. The facility is located within a cluster of homes and each is in close proximity to one another. However, according to the investigation, residents living in the home are diagnosed with schizophrenia, diabetes, visual impairment, seizure disorder, and COPD among others. Because of the varying medical and mental health problems of the residents, being left unsupervised created an environment of substantial risk for serious physical harm and/or death.

$250

(Dis-missed)

Based on the findings of routine monitoring conducted by the Chatham DSS during September and October, 2003, the facility had failed to supervise on an individual basis residents who smoke and need supervision and to follow the home's written policy on smoking. Chatham DSS determined that this was a Type B violation and issued a Directed Plan of Correction for measures to be taken to closely supervise certain smokers to include room checks, to review and enforce the home's policy with these residents. Supervision plans were to be in place on 10/10/03 and the review completed by 10/14/03. Of additional concern was that unsupervised smokers were smoking in the immediate vicinity of oxygen tanks in use by other residents within the facility, with knowledge and without regard for the safeness of others. Based on the DSS follow up monitoring of 10/17/03 and 10/21/03, compliance with these measures to safeguard the facility were not achieved until 10/20/03. The continuation of the violations created a serious, daily direct relationship to all residents' health, safety, and welfare.

Wake County

$2,600

$2,600

Facility failed to assure residents received adequate, appropriate care and services or to make necessary arrangements to enable residents to be in the best possible health condition. The findings documented that the facility had failed to coordinate significant health care needs for a sampled six of eight residents with such needs as medical consults, laboratory service, and wound care. These failures directly affect resident health, safety, and welfare. DFS determined these to be Type B violations and issued a Directed Plan of Correction for measure to be taken no later than 9/26/03 to achieve compliance in Health Care. During a follow up survey conducted on 10/28/03, the violations were documented to remain uncorrected and the facility established a new correction date of 11/17/03. Compliance was documented during a return follow up survey conducted on 12/16-17/03.

Facility/County

DFS Proposed

Approved

Explanation

Cabarrus County

$3,000

$3,000

Facility failed to assure proper identification of a resident prior to administering medications. The facility administered the wrong medication to a resident prescribed to another resident and sent the wrong resident file to the hospital with EMS personnel after the resident became very ill. The facility did not discover the mistake until after the resident was admitted to the hospital. The resident recovered after receiving emergency treatment from the first responders and hospital personnel.

Buncombe County

$2,500

$2,500

Facility failed to correct a type B penalty violation by the specified time period. The facility failed to administer medications as ordered by the physician. Also, the facility failed to contact the physician for clarification of orders for medications and treatments. The specified correction date was 8-30-03. The violation was not abated as of 9-25-03 as verified by the Department of Social Services and the violation ongoing as of the date of the proposal submittal. This represented a failure to correct the violation for 25 days past the specified correction date.

Nash County

$3,150

$3,150

Facility failed to assure that staff administers medications according to orders by a licensed prescribing practitioner and to have at least quarterly pharmaceutical care, including required on-site reviews. Facility failed to assure that medications were available in the facility and that medications were administered as ordered. Facility documentation identified violations that included failures to obtain order clarifications medications not being in the facility, indications of "not given" with no reasons indicated, resident out to medical appointments during med passes, medications omitted. Based on these findings, 17 of 54 residents failed to receive medications as ordered. 14 of 54 residents did not have their medication available in the facility. 54 of 54 residents did not receive Pharmaceutical Care services as required. The continuing areas of non-compliance directly affected health safety, welfare of the residents indicated above.

Buncombe County

$1,000

$1,000

Facility failed to protect a resident's right to be free of mental and physical abuse. A resident was threatened and assaulted by another resident, resulting in physical harm and emotional distress, even though the facility staff had knowledge of the threats several days prior to the actual attach. According to the investigation report, the lack of immediate intervention by the facility placed the victim and other residents in a position of risk for further harm.

$10,000

$10,000

Facility failed to assure adequate staffing to meet the needs of the residents, to assure that staff responded immediately to incidents involving residents, or to assure that residents received adequate and appropriate services and were free of mental and physical abuse. On March 27, 2003, Resident #1 and #2, after leaving the facility and becoming drunk, returned to the facility and became assaultive and abusive. During this episode, Resident #2 stabbed Resident #1 with a knife in the abdomen and chest. Resident #1 died a week later in the hospital. The cause of death was given by the Office of the Chief Medical Examiner as stab wound to the chest and abdomen. The facility had failed to provide minimal staff coverage at the time of the incident, had failed to be aware that Resident #1 and #2 were missing from the facility prior to the incident, and failed to notify the proper law enforcement authorities during the incident. Both residents had been known to have substance abuse diagnoses and to continue to drink and be abusive, through medical history and to the facility's staff's own knowledge. Also, after stabbing incident of March 27^th, the facility returned Resident #2 to the facility where he remained, a potential threat to others, until he was arrested for the homicide of Resident #1. These violations contributed to a very significant risk of death or serious physical harm to every resident in the facility. Resident #1 died as a result of this risk.

$3,000

$3,000

Review of the nurses notes dated 11/08/02 at 10 PM revealed while a resident was sitting on the front porch, the resident walked down the road and was seen by a community resident that notified the facility about the resident's whereabouts. A nurse's note entry on 11/10/02 indicated the resident had a wanderguard on the right leg. A nurse's note entry dated 1/7/03 indicated the resident complained about the wanderguard and wanted it to be removed. The resident promised not tot he elope and the wanderguard was removed. A nurse's note dated 2/20/03 at 12?05 AM revealed the resident was smoking outside the building unsupervised when she eloped. The police called the facility and informed the staff that the resident was found near a highway in a ditch on her knees. The resident told staff she was going to Michigan.

Facility/County

DFS Proposed

Approved

Explanation

Buncombe County

$500

$500

Facility failed to correct a violation by the specified time period. Facility failed to assure that a week's supply of food was available per review of menus, resident records and facility food storage.

Orange County

$3,000

$3,000

Facility failed to assure that residents received adequate and appropriate care and services by failing to assure that staff administered medications according to orders of a licensed prescribing practitioner. 8 out of 23 reviewed residents experienced medication administration problems. During a follow-up survey, facility failed to make necessary corrections as previously directed and the error rate had increased to 28% and later, to 37%, an increase that was potentially much more harmful.

Rowan County

$3,000

$3,000

Facility failed to assure that residents received adequate and appropriate care and services by failing to provide incidental medical care or to assure appropriate health care. Facility also failed to assure that reassessments were completed for residents with significant changes and required licensed health professional support reviews were conducted. Two residents experienced significant changes in skin condition without the facility assuring needed wound care, reassessing care planning or assuring a health professional support review. Both residents died after hospital admission.

Buncombe County

$1,000

$1,000

Facility failed to correct violation by the specified date. Facility filed to administer medications as ordered by the physician and also failed to contact the physician for clarification of orders for medications and treatments.

Robeson County

$3,000

Abated

Facility failed to assure that Resident #1 received adequate and appropriate care and services and to assure that staff were able to apply emergency procedures for the protection of the resident. During the resident's bath, staff left the resident alone after she had started slipping. EMS arrived at the facility, started oxygen on the resident and transported to the hospital with a diagnosis of near drowning. The penalty was abated after it was decided that the resident had not been left alone.

Buncombe County

$1,000

$1,000

Facility failed to provide residents with appropriate supervision in the home. A resident was left alone in the home for approximately 2-3 hours. This presented a threat of serious physical harm or death as hazardous cleaning supplies were stored in an unlocked laundry room and one of the residents is diagnosed with serious physical and mental disorders.

Facility/County

DFS Proposed

Approved

Explanation

Craven County

$2,000

$2,000

Facility staff failed to assure that arrangements were made for appropriate health care by failing to follow facility's emergency procedures for accidents. Resident suffered a fall in the facility and was found by facility staff lying on the bathroom floor. Staff observed Resident's right foot to be turned outward and the resident complained of pain on her right side hip and leg area. The facility emergency procedure for accidents stated for staff to assess the inured area and take appropriate measures and call the rescue squad if medication attention was necessary. Although the staff, were aware that the position of the resident's foot might indicate hip fracture, the resident was stood up and moved into a sitting position in a wheelchair. Resident was diagnosed at the hospital with an acute displaced fracture of right hip and displaced fracture of the base of neck of femur.

Bertie County

$1,400

$1,400

Facility failed to assure that staff who administered medications were competency validated prior to administering medications. Failure to comply increased risk for potential for harm to all six residents.

Wilson County

$10,000

$10,000

Facility failed to assure that residents received adequate and appropriate care and services and failed to assure that residents were free of abuse, neglect or exploitation. Resident was not assessed for significant change for deterioration of behavior or mood and referred to the physician or an appropriate licensed health professional. Facility failed to adequately supervise, monitor or intervene with 3 or 4 residents during episodes of abusive, aggressive encounters. The failure of the facility to provide adequate supervision contributed to the death of the Resident.

New Hanover County

$3,000

$3,000

Facility failed to assure that adequate and appropriate care and services were received by all residents. The facility failed to ensure clarification of orders for medications by the prescribing practitioner. Staff failed to clarify multiple hospital admission forms and failed to follow up after a clarification request was submitted to the physician. Resident suffered serious physical harm and substantial risks that death could have occurred as a result of an overdose.

Wake County

$1,150

$1,000 for Training

Facility failed to assure that residents receive adequate and appropriate care and services by failing to provide incidental medical care. Facility failed to provide modified diets as ordered by physician for 6 or 9 residents.

Wake County

$2,000

$2,000

Facility failed to assure that residents receive adequate and appropriate care and services by failing to make arrangements to enable the residents to be in the best possible health condition and to ensure medications were administered as ordered by a licensed prescribing practitioner. Violations created a substantial risk for serious physical harm or death.

Davie County

$1,000

$1,000

Facility failed to assure that residents receive adequate and appropriate care or to be free of neglect. Administrator repeatedly left the residents without staff supervision.

New Hanover County

$6,000

$6,000

Facility failed to assure that residents receive adequate and appropriate care and to be free of neglect. Facility staff failed to immediately notify the appropriate law enforcement agency or DSS when there was reason to be concerned about a resident's safety. Resident #1 had returned alone and stated to staff that Resident #2 was drunk and passed out at a friend's house. Resident #2 was taking medications that are contraindicated with consumption of alcohol and diagnoses of Schizoaffective disorder and sleep apnea with an order for autopap oxygen overnight. The facility's failure to immediately respond created a significant risk for serious physical harm or death. The resident was found deceased the following morning according to the police report.

Stokes County

$1,000

$1,000

Facility failed to assure that residents received adequate and appropriate care and were free from neglect. The administrator failed to assure that residents were not let alone at any time without a staff member. There had been a on going pattern of leaving the residents unattended.

Rockingham County

$3,000

$3,000

Facility failed to assure that residents received adequate and appropriate care. Facility failed to maintain required door alarms on exit doors for residents known to be wanderers. Resident wandered from the facility at night, fell at the bottom of the steps where he remained until the next morning. Resident was transported to a local hospital where surgery was conducted for a hip fracture. The resident died. The certificate of death noted that this hip fracture was another significant condition contributing to the death but not resulting in the underlying cause.

Facility/County

DFS Proposed

Approved

Explanation

Buncombe County

$450

$450

Facility failed to correct violation by the specified correction date. The facility had failed to assure that at least one staff person is on the premises at all times who has successfully completed within 24 months a course on CPR and Heimlich maneuver.

Cumberland County

$3,000

$3,000

Facility failed to assure that residents were treated with respect, consideration and dignity, that residents received adequate and appropriate care and services, and that they were free from mental and physical abuse. A resident was seriously injured, resulting in a coma, after no precautions were taken to ensure the resident's safety. Resident had been addressed in a derogatory racial manner prior to this incident. During the course of this investigation, another resident did not have privacy protection and was questioned by the administrator regarding an interview by the DSS.

Buncombe County

$600

$600

Facility failed to correct penalty violation by the specified time period. Facility failed to regulate hot water temperature. Facility no longer in existence.

Guilford County

$2,700

$2,700

Facility failed to assure that medication aides were qualified to administer medications, that the medication policies and procedures were implemented as required, or that personal care staff were trained and knowledgeable in the care of residents with diabetes. Violations created substantial risk for serious physical harm or death.

Proposal #1

$10,395

$10,395

Facility failed to assure adequate and appropriate care and services including the rule areas of medication aide qualifications, medication administration, and providing therapeutic diets. Violations of medication aide qualifications and medication administrations were found to remain uncorrected upon three follow up surveys. The violations for therapeutic diets were documented as corrected upon follow up.

Proposal #2

$3,000

$3,000

Facility failed to assure that the residents receive adequate and appropriate care and services. Resident diagnosed with insulin-dependent diabetes did not receive prompt medical attention for a wound to his right foot. Resident had previously had a below knee amputation on his left foot and his Care Plan noted to watch for ulceration of the right foot. Facility failed to assure that prompt medical attention was sought resulting in amputation of the foot.

Harnett County

$3,000

$3,000

Facility failed to reassess a care plan for a significant skin change for Resident or to assure that medications and treatments were administered as ordered by the prescribing practitioner. These violations resulted in substantial risk for serious physical harm.

Facility/County

DFS Proposed

Approved

Explanation

New Hanover County

$3,000

$3,000

On January 25, 2003 Resident was admitted to the facility with diagnoses of Alzheimer's and hypothyroidism. The resident was ambulatory without assistance but required total care. Resident was discharged from the facility on February 3, 2003 and was observed to have great difficulty walking, with dirty hair and fingernails and exhibited a "pitiful and bewildered" demeanor. Physician described the resident as "a shadow of his former self" and diagnosed a pressure decubitus. Staff of the facility informed DSS that they had no knowledge of the skin breakdown or of the change in ambulation.

Carteret County

$2,000

$2,000

Facility failed to provide adequate care and services. Facility also failed to immediately notify a resident's responsible person, appropriate law enforcement, or the DSS when resident's whereabouts were unknown. Resident who had been diagnosed with Mild Mental Retardation and adjudicated incompetent, with an assigned guardian, signed self out of facility with no known destination or person accompanying. Resident reported to the facility that another resident had raped her and that she had been arrested for shoplifting while away from the facility.

Cumberland County

$3,000

Abated

Facility failed to assure that at least one staff person on the premises was certified in CPR and choking management. Resident was choking and was given CPR by two male residents. Staff attempted "the method to get him to release food". Resident was admitted to the hospital due to cardiac arrest secondary to choking. Resident died due to choking episode. Facility stated that five staff were CPR qualified, but the certification was not in the file at the time. Penalty was abated.

Buncombe County

$1,000

$1,000

Facility failed to notify the appropriate law enforcement agency and DSS when it was discovered that a resident had left the facility without notice and was unaccounted for. The resident is mentally ill and is known to endanger herself when outside of the home. The resident's whereabouts were unknown until the following day. Resident was at a convenience store 9 miles away.

Iredell County

$1,000

$1,000

Facility failed to assure that staff administerd medication and treatments according to orders by a licensed prescribing practitioner for two residents.

Harnett County

$3,000

$3,000

Facility failed to assure that adequate water was provided to all residents according to requirements and failed to assure that incidental medical care was provided as ordered by physicians for hydration of four out of four residents with medical histories of dehydration. Each of the four residents experienced multiple visits to the emergency room due to dehydration.

McDowell County

$1,275

$1,275

Facility filed to correct violation in the area of Health Care within the specified date.

Hertford County

$3,000

$2,000

Facility failed to assure appropriate health care. Resident had spilled coffee on self during breakfast. Burns were observed by staff and reported to the supervisor. No incident report or follow-up documentation was made. Although staff continued to observe significant changes to Resident's skin condition, no immediate medical intervention was sought. Resident was eventually admitted to the hospital with third degree burns.

Buncombe County

$250

$250

Facility failed to correct violation within the specified time frame for failure to maintain appropriate hot water temperature.

Facility/County

DFS Proposed

Approved

Explanation

Alleghany County

$1,000

$1,000

Facility failed to contact the physician in response to a medication review by the pharmacist. The mental health agency was not notified that the resident refused medications for an extended period. Once the mental health agency was notified, the resident was involuntarily admitted to the mental health hospital.

Alleghany County

$6,000

$6,000

Facility failed to arrange for medical care in a timely manner after a resident complained of chest pains and appeared to be in distress. Only after the resident was found to be unresponsive did the staff call 911. The resident was pronounced dead on arrival at the hospital. Facility's license was revoked- no longer in operation.

Lincoln County

$8,000

$8,000

Facility failed to respond in accordance with adult care home rules and their own emergency policy after a resident wandered from the facility in sub-freezing weather. The facility failed to contact EMS in a timely manner after finding the resident lying on the ground, bleeding from the head. Resident died of hypothermia.

Orange County

$4,350

$1,740

Facility failed to provide provision of therapeutic diets as ordered by physicians, directly affecting residents' health and safety. Facility failed to make required corrections by specified date. During a follow-up survey, 5 of 10 sampled residents were not provided their diets as ordered by physician. Residents included ones with Type II Diabetes, chronic and acute renal insufficiency, and resident requiring mechanically soft prepared foods.

Rowan County

$700

$700

Facility failed to assure that diet orders were clarified with physicians, that menus were planned and reviewed by registered dietician as needed, and served accordingly.

Sampson County

$4,600

$4,600

Facility failed to administer medications as ordered by prescribing practitioner. Some residents did not receive medications as ordered due to those medications not being available in the facility. The facility failed to make necessary corrections by date specified.

Wake County

$2,250

$1,125

Facility failed to maintain the hot water temperatures at all fixtures at appropriate levels. Water temperatures were found to be as high as 154 degrees. While the facility had made efforts to meet the directed plan, the temperatures remained higher than 120 degrees, which has been determined to have the potential to result in severe scalding and create serious risk for older people and people with compromised health.

Caldwell County

$2,500

$2,500

Facility failed to assure that the Adult Care Home Bill of Rights was upheld. Facility failed to assure that residents received care and services which were in compliance with rules and regulations.

Cleveland County

$1,000

$2,500

Facility failed to contact EMS or the resident's physician following a fall in the facility. The facility further violated the resident's rights by allowing him to remain on the facility floor for over two hours until the next staff shift reported to work, claiming an inability to lift the resident to a bed or chair. Per a DSS recommendation, training was assessed in lieu of a monetary penalty.

Beaufort County

$3,000

$3,000

Facility failed to assure that residents were supervised while they while they were raking and burning leaves on the property. One of four residents sustained serious burns from the fire. This resident was diagnosed with mental retardation. According to hospital records, the resident had suffered surface burns to approximately 9% of his body. During the incident, the other residents intervened to save this resident. Without their intervention, the resulting harm would have been more significant.

Facility/County

DFS Proposed

Approved

Explanation

Cleveland County

$10,000

$10,000

Facility failed to provide appropriate supervision and neglected a resident during bathing. Facility staff left a resident, who required assistance, unattended for an undetermined length of time, resulting in the resident sustaining third degree burns over a large percentage of the body. There was a delay of approximately 36 minutes before calling 911 once the staff became aware of the resident's distress. The resident later died of scalding injuries.

Mecklenburg County

$3,200

$3,200

Facility failed to correct a violation in the area of Health Care by the specified date. The facility failed to notify the resident's appropriate health care provider and make arrangements to assure residents receive care as needed for best possible health.

Mecklenburg County

$2,150

$2,150

Facility failed to correct a violation in the area of Management of Medications by the specified date. Facility failed to assure that medications were administered according to physician's orders.

Wake County

$5,000

$5,000

Facility failed to assure that all arrangements were made to enable Resident to remain in the best possible health condition. Resident's physician documented significant weight loss with order for nutritional supplements and a return visit on a specified date. Facility failed to administer nutritional supplements as ordered. A return visit to the physician was never made. Resident was transported to local hospital with the complaint that resident had not eaten or walked for four days. Additionally, facility had no heat in the residents' area with the thermostat set on 54 degrees when the outside temperature was 25 degrees. Resident died at the hospital due to complications from pneumonia/ hypothermia.

Cleveland County

$2,400

$2,400

Facility failed to correct penalty violation in the area of Medication Management/ Controlled Substances. Facility failed to assure a readily retrievable record of controlled substances by documenting receipt, administration, and disposition of controlled substances.

Cleveland County

$1,600

$1,600

Facility failed to correct penalty violation for Qualifications for Medication Staff. Facility failed to assure that staff who are administering medications are qualified in accordance with rules.

Buncombe County

$1,550

$1,550

Facility failed to correct a penalty violation by the specified time period. Facility failed to arrange for a physician follow-up appointment as instructed by the physician.

Wake County

$5,200

$5,200

Facility failed to provide appropriate care and services, including the provision of modified diets as ordered by physicians. Facility failed to make necessary corrections as directed by the specified date. Facility continued in the violation for an extended time before taking appropriate actions. The facility's continued failure to provide therapeutic diets had a direct relationship to the health and safety of 45 of the 67 residents.

Durham County

$2,000

$2,000

Facility failed to provide appropriate care and services to the residents of their licensed Special Care Unit for Alzheimer's and Related Disorders. The facility failed to assure that required policies were implemented, that admission criteria were met, that special care unit staff were adequately trained or that the staff were in adequate numbers to provide necessary care.

Buncombe County

$3,000

$3,000

Facility failed to assure that staff was present in the home to provide appropriate supervision and services, receive morning medications, and receive breakfast. Lack of staff supervision, meal service and medication as ordered placed the residents at risk for serious physical harm.

Facility/County

DFS Proposed

PRC
Approved

Explanation

Alleghany County

$1,900

$1,900

Facility failed to correct B penalty violations by the specified correction date. These violations were in the areas of Health Care (restraints), Admission Policies, Management of Medications and Medication Administration.

Ashe County

$400

$400

Facility failed to correct B penalty violations within the specified correction date. This violation was in the area of Licensed Health Professional Support. It should be noted that the facility, shile under licensee revocation action by DFS, voluntarily removed all residents and closed the facility on 1/4/03.

Craven County

$850

$850

Facility failed to make necessary corrective measures as directed to assure that staff administered medications according to physician orders.. Facility was found to have made corrections upon 2^nd compliance date.

Alamance County

$3,950

$3,950