Facility at fault in 4 NC assisted living deaths, committee says | Raleigh News & Observer

At least four people died in North Carolina assisted living centers this year in cases where the facility was found to have violated state regulations, according to a state oversight committee.

In addition, state and county inspectors reported five centers to have been negligent in allowing residents to wander away unsupervised and five others to have violated rules on dispensing glucose to diabetics.

Other cases heard by the N.C. Penalty Review Committee included that of a Wake County family care home, for six or fewer people, that had its state license revoked in part because one resident had been observed restrained by a leash.

“Based on interviews, the home failed to assure each resident was free from physical restraints without a physician’s order as evidenced by one resident being restrained by a metal dog leash,” a state report found in an investigation of On Track Residential.

Staff of the home also acted in ways that were threatening, demeaning and intimidating to residents, state investigators found. The phone for On Track Residential has been disconnected and efforts to reach a representative were unsuccessful Friday.

State records from 2014 list cases in which residents died in situations where a facility took action, or failed to take action, in a way that contributed to the death:

• At Magnolia Gardens in Warrenton, a report said, “one demented, wandering resident in a wheelchair” left the building when an alarm signal was not activated, “resulting in a fall and sustained injuries that led to the resident's death.” The center was fined $12,000.

• At Angel House in Buncombe County, the facility failed to provide adequate supervision to meet the needs of “one resident with wandering and exit-seeking behaviors related to dementia who exited the facility without supervision.” The resident died. The center was fined $8,000.

• At Westchester Harbour in Guilford County, the facility “failed to increase supervision for two residents with multiple falls, resulting in injuries with one resident sustaining a head injury.” The resident died, state records show. Westchester Harbour appealed the fine of $16,000 in September.

• Pinecrest Gardens in Harnett County has appealed a $16,000 fine based on a report that it failed to provide “personal care and supervision for a resident who choked during meal time and died.”

Diabetes care, wandering

After five people died in a Wayne County assisted living facility in 2009, state public officials and legislators beefed up requirements and training on administering glucose and performing pinpricks for people with diabetes.

This year state inspectors found that residents received faulty or negligent diabetes care at Oak Hill Living Center in Harnett County, Nana’s Assisted Living in Buncombe County, Primrose Villa Retirement III in Harnett, Woodhaven Rest Home #2 in Halifax and Highland Gardens in Northhampton.

Many people with dementia at least occasionally wander off from facilities, sometimes because they think they are needed at home or at work. Cited in 2014 for allowing residents to wander off were Pinewood Manor in Hertford County, Ashewood Estates Early Retirement Center in Lee County, Seven Lakes Assisted Living in Moore, China Grove Retirement Center in Rowan and Forest Trail Retirement Center in Sampson.