COMPLAINT INVESTIGATION SUMMARY Facility Name: HOMINY VALLEY RETIREMENT CENTER Facility Address: 2189 SMOKY PARK HWY CANDLER, NC 28715 License Number: HAL011329 County: Buncombe Date Complaint Received. 06/07i2016 Date of Visit(s): 06/13l2016, 06/20l2016 l. Complaint intake Number: ll. Participants: Lisa Catron, Beth Boone, Facility Staff and residents Ill. Facility Census: 28 lV. Sample Size: "15 V. Allegations: Allegation #1 The facility failed to assure that: The hot water system shall be of such size to provide an adequate supply of hot water to the kitchen, bathrooms laundry, housekeeping closets and soil utility room. The hot water temperature at all ?xtures used by residents shall be maintained at a minimum of 100 degrees (38 degrees C) and shall not exceed 116 degrees (46 7 degrees C). Allegation #2 The facility failed to assure that: Food Requirements In Adult Care Homes: (1) Each resident shall be served a minimum of three nutritionally adequate, palatable meals a day at regular'hours with at least 10 hours between the breakfast and evening meals. (2) Foods and beverages that are appropriate to residents' diets shall be offered or made available to all residents as snacks between each meal for a total of three snacks per day and shown on the menu as snacks. (3) Daily menus for regular diets shaii include the following: (A) Homogenized whole milk, low fat milk, skim milk or buttermilk: One cup (8 ounces) of pasteurized milk at least twice a day. Reconstituted dry milk or diluted evaporated milk may be used in cooking only and not for drinking purposes due to risk of bacterial contamination during mixing and the lower nutritional value of the product if too much water is used. (B) Fruit: Two servings of fruit (one serving equals 6 ounces of juice; 1/2 cup of raw, canned or cooked fruit; 1 medium?size whole fruit; or 1/3 cup dried fruit). One serving shall be a citrus fruit or a single strength juice in which there is 100% of the recommended dietary aliowance of vitamin in each six ounces of juice. The second fruit serving shall be of another variety of fresh, dried or canned fruit. (C) Vegetables: Three servings of vegetables (one serving equals 1/2 cup of cooked or canned vegetable; 8 ounces of vegetable' Juice; or 1 cup of raw vegetable). One of these shall be a dark green leafy or deep yellow three times a week. (D) Eggs: One whole egg or substitute g. 2 egg whites or cup of pasteurized egg product) at least three times a week at breakfast. (E) Protein: Two to three ounces of pure cooked meat at least two times a day for a minimum of 4 ounces. A substitute 4 tablespoons of peanut butter, 1 cup of cooked dried peas or beans or 2 ounces of pure cheese) may be served three times a week but not more than once a day, unless requested by the resident. Note: Bacon is considered to be fat and not meet for the purposes of this Rule. (F) - Cereals and Breads: At least six servings of whole grain or enriched cereal and bread or grain products a day. Examples of one serving are as follows: 1 slice of bread; 1/2 of a bagel, English muf?n or hamburger bun; one 1 ?ounce muf?n, 1- ounce roll, 2- -ounce biscuit or 2 ounce piece of cornbread; 1/2 cup cooked rice or cereal g. oatmeal or grits); cup ready to- eat cereal; or one waffle, pancake or tortiila that' [3 six inches' In diameter Cereals and breads offered as snacks may be included' in meeting this requirement. (G) Fats. include butter, oii, margarine or items consisting primarily of one of these (e icing or gravy). (H) Water and Other Beverages. Water shall be served to each resident at each meal, in addition to other vbeverages. Allegation #3 The facility failed to assure that: An adult care home shall provide care and services in accordance with the resident?s care plan. DHSRIAC 4654 NC nuns Page 1 of 3 Allegation #4 The facility failed to assure that: An adult care home shall assure that the rights of all residents guaranteed under 6. S. f31 D- 21 Declaration of Residents? Rights, are maintained and may be exercised without hindrance. I Allegation #5 The facility failed to assure that: To document a resident?s receipt of the State- County Special Assistance personal needs allowance after payment of the cost of care, a statement shall be signed by the resident or marked by the resident with two witnesses' signatures The statement shall be maintained In the home. - Upon the written authorization of the resident or his legal representative or payee an administrator or the administrator's designee may handle the personal money for a resident, provided an accurate accounting of monies received and disbursed and the balance on hand' Is available upon request of the resident or his legal representative or payee. A record of each transaction involving the use of the resident's personal funds according to Paragraph of this Rule shall be signed by the resident, legal representative or payee _or marked by the resident, if not adjudicated incompetent, with two witnesses' signatures at least verifying the accuracy of the disbursement of personal funds. The record shall be maintained in the home. A resident's personal funds shall not be commingled with facility funds. The facility shall not commingle the personal funds of residents' In an interest?bearing account. All or any portion of a resident's personal funds shall be available to the resident or his legal representative or payee upon request during regular of?ce hours, except as provided' In Rule. 1105 of this Subchapter. The resident's personal needs allowance shail be credited to the resident" account within 24 hours of the check being deposited following endorsement Allegation #6 The facility failed to assure that: Adult care homes shall: (6) have a supply of bath soap, clean towels, washcloths, sheets, pillow cases, blankets, and additional coverings adequate for resident use on hand at all times; Allegation #7 The facility failed to assure that:- Covers all 13F.1000 sections. Allegation #8 The facility failed to assure that: Air conditioning or at least one fan per resident bedroom and living and dining areas shall be provided when the temperature in the main center corridor exceeds 80 degrees (26.7 degrees C). Allegation #9 The facility failed to assure that: An adult 'care home shall assure that staff Who provide ?or- directly supervise Staff Who provide personal care. _to residents successfully complete an 80- hour.- personal "care training and competency evaluation program established .by the Department Directly supervise means being on duty' In the facility to oversee or direct the performance of staff duties. Copies of the 80-hour training and competency evaluation program are available at the cost of printing and mailing by contacting the Division of Health Service Regulation, Adult Care Licensure Section, 2708 Mail Service Center, Raleigh, NC 27699 2708. The facility shall assure that training specified In Paragraph of this Rule is successfully completed within six months after hiring for staff hired after September 1, 2003 Documentation of the successful completion of the 80- hour training and competency evaluation program shall be maintained in the facility and available for review. The Department shall exempt staff from the 80-hour training and competency evaluation program who are: (1) licensed health professionals; (2) listed on the Nurse Aide Registry; or (3) documented as having successfully completed a 40-45 hour or 75-80 hour training program ?or competency evaluation-program approved by the Department since January 1, 1996 according to Rule .0502 of this Section. The facility shall assure that staff who perform or directly supervise staff who perform personal care receive on~the?job training and supervision as necessary for the performance of individual job'assignments prior to meeting the training and competency requirements of this Rule. Documentation of the on-the?iob training shall be maintained in the facility and available for review. Vi. Method of investigation: An unannounced visit(s) were made to the facility on the dates listed above. The investigation included the following: Observations,lnterviews.Record Reviews 4654 NC DHHS Page 2 or 3 Vii. Findings (Allegation Substantiated or Unsubstantiated): Finding #1 10A NCAC 13F.0311(d) OTHER REQUIREMENTS UNSUBSTANTIATED Finding #2 10A NCAC 13F.0904(d) NUTRITION AND FOOD SERVICE UNSUBSTANTIATED Finding #3 10A NCAC 13F.0902(a) HEALTH CARE UNSUBSTANTEATED Finding #4 10A NCAC 13F.0909 RESIDENT RIGHTS UNSUBSTANTIATED Finding #5 10A NCAC ACCOUNTING FOR PERSONAL FUNDS UNSUBSTANTIATED Finding #6 10A NCAC HOUSEKEEPING AND FURNISHINGS UNSUBSTANTIATED Finding #7 NCAC 13F.1000 MEDICATEONS UNSUBSTANTIATED Finding #8 10A NCAC OTHER REQUIREMENTS UNSUBSTANTEATED Finding-#9 10A NCAC TRAINING AND Action Plan: The AHS will continue to monitor the facility for compliance with rules. USA D. CATRON I 06/30/2016 AHS Signature Date: CATHIE J. BEATTY 06/30/2016 Adult Services Supervisor Signature Date: 4654 NC DHHS Page 3 0f 3