A list of the most recent deficiencies for Alamance Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-11-29 | 2024-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-29 | 2024-02-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-29 | 2024-02-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-29 | 2024-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-29 | 2024-02-10 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-11-02 | 2023-11-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-02 | 2023-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-02 | 2023-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-02 | 2023-11-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-02 | 2023-11-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-02 | 2023-09-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-27 | 2023-09-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-27 | 2023-09-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-27 | 2023-09-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-06 | 2023-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-08-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-06 | 2023-08-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-06 | 2023-08-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-06 | 2023-08-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-23 | 2023-07-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-27 | 2023-07-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-27 | 2023-07-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-27 | 2023-07-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-27 | 2023-07-06 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-27 | 2023-05-19 | N |
| Post nurse staffing information every day. | Health | 2023-04-27 | 2023-04-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-17 | 2023-02-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-17 | 2023-02-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-17 | 2023-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-17 | 2023-02-06 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-17 | 2023-02-06 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-09 | 2023-01-16 | Y |
| Install proper backup exit lighting. | Fire Safety | 2022-11-03 | 2022-12-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-03 | 2022-12-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-12-18 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-12-18 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-11-22 | 2022-12-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-19 | 2022-11-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-19 | 2022-11-22 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-09-19 | 2022-11-22 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-19 | 2022-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-19 | 2022-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-19 | 2022-11-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-19 | 2022-11-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-19 | 2022-11-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-19 | 2022-11-22 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-19 | 2022-11-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-19 | 2022-11-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-19 | 2022-11-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-19 | 2022-11-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-19 | 2022-11-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2022-11-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-19 | 2022-11-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-31 | 2022-04-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-31 | 2022-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-31 | 2022-04-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-31 | 2022-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-31 | 2022-04-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-31 | 2022-04-26 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-13 | 2022-02-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-13 | 2022-02-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-13 | 2022-01-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-13 | 2022-01-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-13 | 2022-01-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-13 | 2022-01-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-13 | 2022-01-13 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-13 | 2022-01-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-13 | 2022-01-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-13 | 2022-01-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-11 | 2022-01-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-06 | 2021-05-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-06 | 2021-05-27 | Y |
