Inspection Reports for Alpha Care One Assisted Living
2060 West Fifth Street Greenville, NC 27834, Greenville, NC, 27834
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
68% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 82
Capacity: 120
Deficiencies: 3
Date: Jul 30, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on July 30 and 31, 2025 to verify correction of previous deficiencies related to facility exit door alarms and environmental conditions.
Findings
The facility failed to ensure 7 of 8 exit doors were alarmed to prevent residents with cognitive impairments from exiting unnoticed, and failed to maintain environmental temperatures below 80°F in several resident rooms, posing health risks. Additionally, the facility failed to ensure referral and follow-up for a resident with significant weight loss.
Deficiencies (3)
Facility failed to ensure 7 of 8 exit doors were alarmed with an audible sounding device to prevent residents with disorientation and dementia from exiting without staff knowledge.
Facility failed to maintain environmental temperatures at or below 80°F in several rooms during the summer months, causing risk of respiratory distress and heat stroke.
Facility failed to ensure referral and follow-up to meet acute health care needs of a resident related to failure to notify primary care provider of a 12% weight loss in two months.
Report Facts
Residents present: 82
Total licensed capacity: 120
Exit doors unalarmed: 7
Resident weight loss: 12
Resident weight gain: 5
Room temperature: 92.5
Room temperature: 89.2
Room temperature: 88.3
Room temperature: 86.4
Room temperature: 86.7
Room temperature: 90.3
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 20, 2025
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey have been corrected. No further action is required.
Inspection Report
Annual Inspection
Census: 62
Capacity: 120
Deficiencies: 8
Date: Apr 7, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from 04/01/25 to 04/04/25 and 04/07/25. The complaint investigation was initiated by the Pitt County Department of Social Services on 03/05/25.
Complaint Details
The complaint investigation was initiated by the Pitt County Department of Social Services on 03/05/25. Resident #6 alleged wrongful discharge without 30 day notice related to involuntary commitment and smoking inside the facility.
Findings
The facility failed to ensure the main entrance door had a sounding device engaged to prevent disoriented residents from exiting unnoticed. The facility also failed to competency validate one staff for Licensed Health Professional Support tasks, failed to consult the Primary Care Provider prior to an emergency discharge for one resident, failed to provide supervision for three residents with aggressive behaviors resulting in altercations, failed to ensure physician notification for a resident who was involuntarily committed, failed to implement orders for daily finger stick blood sugar and blood pressure checks for three residents, failed to accurately document medication administration for three residents including application of compression stockings, and failed to implement infection control procedures for glucometers used for finger stick blood sugar readings for three residents.
Deficiencies (8)
Failed to ensure the main entrance door had a sounding device engaged to alert staff when disoriented residents exited.
Failed to ensure competency validation for one staff for Licensed Health Professional Support tasks.
Failed to consult Primary Care Provider prior to emergency discharge of a resident who was involuntarily committed.
Failed to provide supervision for three residents with aggressive behaviors resulting in resident altercations and one resident requiring emergency department visit.
Failed to ensure physician notification for a resident who was involuntarily committed.
Failed to implement orders for daily finger stick blood sugar checks and daily blood pressure checks for three residents.
Failed to ensure accurate medication administration records for three residents including medications for blood sugar, blood pressure, skin care, sleep, and psychiatric conditions, and application of compression stockings.
Failed to implement infection control procedures for glucometers used to obtain finger stick blood sugar readings for three residents, resulting in risk of cross contamination.
Report Facts
Residents with disorientation or dementia: 5
Facility licensed capacity: 120
Facility census: 62
Deficiency correction date: 2025
Deficiency correction date: 2025
Inspection Report
Capacity: 120
Deficiencies: 10
Date: Mar 7, 2024
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1978 (Revision 5) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1984 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were noted including lack of current fire and building safety inspection reports, unsafe and unclean physical plant conditions, failure to maintain fire safety equipment and emergency lighting, plumbing issues, and inadequate exhaust ventilation in specified areas.
Deficiencies (10)
Facility did not have current fire and building safety inspection reports maintained in the home and available for review.
Outside grounds were not maintained in a clean and safe condition; exterior siding missing near exit by Activity Room.
Ceilings were not kept clean and in good repair; heavy dust accumulation on exhaust fan grilles; water stains and mildew spots on ceilings in various rooms.
Facility not maintained free of hazards; loose handrail brackets, improperly stored oxygen bottles, and exit doors requiring excessive force to open.
Bedrooms or adjoining bathrooms did not have a towel bar for each resident; shared bathrooms serving four residents had only two towel bars.
Failure to maintain fire safety equipment in safe operating condition; fire doors not closing or latching properly; emergency lights and exit signs not illuminating on test; missing and loose shingles on roof.
Plumbing equipment not maintained in safe and operating condition; toilets not secure to floor; water leak causing puddle; toilet not flushing with strong odor.
Failure to maintain fire safety systems; unsealed cable penetrations and holes in fire resistant ceilings and walls allowing potential spread of fire and smoke.
Hot water temperature not maintained between 100 and 116 degrees F at all fixtures used by residents; water temperature at hair washing sink was 120 degrees F.
Exhaust ventilation not maintained in specified spaces; exhaust fans not working in multiple bathrooms and shared toilets.
Report Facts
Total licensed capacity: 120
Water temperature: 120
Size of hole in smoke partition wall: 24 inches wide by 48 inches high hole above lobby.
Size of water stain: 6 inches by 12 inches brown water stain on ceiling patch.
Diameter of mildew spot: 4 inch diameter black mildew spot in ceiling stain.
Puddle size: 12
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The Adult Care Licensure Section conducted a Follow Up Survey and Complaint Investigation on 12/14/23 to 12/15/23 to assess compliance with health care regulations and follow-up on a previously cited Type B violation.
Complaint Details
This visit included a complaint investigation regarding Resident #4's safety and notification of the primary care provider. The complaint was substantiated as the facility did not notify the PCP timely about the resident's behavioral changes and safety concerns.
Findings
The facility failed to notify the primary care provider for Resident #4 who exhibited a change in behavior including agitation, reported feeling threatened, and was in possession of a sharp metal object on 10/02/23. Resident #4 was subsequently involved in a physical altercation on 10/03/23 resulting in a rib fracture. The Type B violation was unabated.
Deficiencies (1)
Failed to ensure the primary care provider was notified for Resident #4 who exhibited a change in behavior including agitation, feeling threatened, and possession of a sharp metal object.
Report Facts
Residents sampled: 5
Incident date: Oct 2, 2023
Incident date: Oct 3, 2023
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on October 11, 2023 and October 12, 2023 at Alpha Care One Assisted Living.
Complaint Details
The visit included a complaint investigation regarding failure to notify the PCP of Resident #5's change in condition and refusal of care. The violation was substantiated as a Type B Violation.
Findings
The facility failed to notify the primary care provider of a change in condition for Resident #5 related to a foot ulcer requiring hospitalization. Resident #5 refused care and wound clinic referral, and the facility did not properly document or communicate these refusals or changes in condition to the PCP, resulting in the resident being sent to the emergency department for cellulitis of the left foot. This failure was detrimental to the resident's health and constitutes a Type B Violation.
Deficiencies (1)
Facility failed to notify the primary care provider of a change in condition for Resident #5 related to a foot ulcer requiring hospitalization.
Report Facts
Dates of survey: October 11, 2023 and October 12, 2023
Correction deadline: 2023
Inspection Report
Follow-Up
Deficiencies: 6
Date: Aug 4, 2023
Visit Reason
The Adult Care Licensure Section and the Pitt County Department of Social Services conducted a follow-up survey and complaint investigation on 08/02/23 through 08/04/23. The complaint investigation was initiated on 07/19/23.
Complaint Details
The complaint investigation was initiated by the Pitt County Department of Social Services on 07/19/23 related to care concerns for a resident with a Jackson Pratt drain.
Findings
The facility failed to ensure unlicensed staff were competency validated by a registered nurse to properly care for a resident's Jackson Pratt drain, resulting in improper care and substantial risk of harm. The facility also failed to meet the routine and acute health care needs of a resident with a JP drain due to missed appointments and lack of referrals, and failed to implement physician orders for flushing and documenting JP drain output. Additionally, medication administration records were inaccurate for two residents, including improper insulin administration, missed medication refills, and inaccurate documentation.
Deficiencies (6)
Failed to ensure unlicensed staff were competency validated by a registered nurse by return demonstration to flush a JP drain and measure and record output twice daily as ordered for a resident.
Failed to ensure the routine and acute health care needs of a resident with a JP drain were met, evidenced by missed appointments and lack of referral for drainage tube removal.
Failed to ensure implementation of an order to flush a JP drain and document the amount of drainage as ordered for a resident.
Failed to ensure on-site review and evaluation by a licensed professional including physical assessment and care evaluation for a resident with a JP drain.
Failed to administer medications as ordered for 2 residents including insulin, blood pressure medication, supplement, inhaler, and cholesterol medication.
Failed to maintain accurate medication administration records including documentation of medication administration, refusals, and medication availability.
Report Facts
Home Health nurse visits: 35
JP drain drainage output: 38
Missed appointments: 4
Medication refill delays: 15
Medication refill delays: 8
Medication refill delays: 5
Medication refill delays: 60
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
The Adult Care Licensure Section completed an Annual Survey and complaint investigation from 04/18/23 through 04/20/23, initiated by the Pitt County Department of Social Services on 04/05/23.
Complaint Details
Complaint investigation was initiated by the Pitt County Department of Social Services on 04/05/23 and conducted concurrently with the annual survey.
Findings
The facility failed to ensure a designated supervisor was on duty during the third shift for a census of 68 residents, and failed to administer medications as ordered for one sampled resident, including insulin and diuretic medications, placing the resident at risk for dehydration, kidney failure, and hypoglycemia.
Deficiencies (2)
Failed to ensure a designated supervisor was on duty on third shift or within 500 feet and immediately available for a facility census of 68 residents.
Failed to administer medications as ordered for Resident #5, including incorrect administration of Lantus insulin and Lasix, leading to risk of dehydration, kidney failure, and hypoglycemia.
Report Facts
Resident census: 68
Medication administration errors: 1
Correction date: 2023
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 11, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from 06/09/21 to 06/11/21 related to supervision and health care concerns at the facility.
Complaint Details
The visit was a follow-up survey and complaint investigation triggered by concerns about supervision and health care at the facility.
Findings
The facility failed to provide adequate supervision to Resident #2, who left the facility unsupervised, was struck by a vehicle, and sustained multiple serious injuries requiring hospitalization and surgery. The facility also failed to ensure timely referral and follow-up for Resident #6's bedsores, including notifying the primary care physician and obtaining wound care orders. Additionally, the facility failed to immediately notify the resident's responsible party, law enforcement, and the Department of Social Services when Resident #2 was missing.
Deficiencies (3)
Failed to provide supervision to Resident #2, resulting in the resident being hit by a car and hospitalized with serious injuries.
Failed to ensure referral and follow-up for Resident #6's bedsores, including notifying the primary care physician and obtaining wound care orders.
Failed to immediately notify the resident's responsible party, law enforcement, and the Department of Social Services when Resident #2 was missing.
Report Facts
Residents sampled: 6
Surgical procedures: 5
Resident #2 hospital intubation days: 6
Resident #2 hospital admission date: May 28, 2021
Resident #2 hospital surgery dates: May 29, 2021
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 4
Date: Apr 1, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a follow-up survey from 03/30/21 through 04/01/21 to assess compliance with regulations related to physical environment, housekeeping, health care, and other requirements.
Findings
The facility failed to ensure 8 of 9 exit doors accessible to residents with dementia were equipped with functioning sounding devices, failed to properly secure oxygen cylinders in storage, failed to maintain hot water temperatures within the required range, and failed to ensure coordination of health care for a resident with documented self-harm behavior.
Deficiencies (4)
Failed to ensure 8 of 9 exit doors accessible to 18 residents with dementia were equipped with a sounding device that activated when the door was opened.
Failed to ensure 2 of 40 oxygen cylinders were stored without being properly secured, creating a hazard.
Failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit; observed temperatures were as high as 128 degrees and as low as 92 degrees at various fixtures.
Failed to ensure coordination of health care for a resident who attempted to harm himself by wrapping a tube around his neck, including failure to notify mental health provider and implement safety interventions.
Report Facts
Residents with dementia: 18
Oxygen cylinders: 40
Unsecured oxygen cylinders: 2
Residents: 66
Exit doors: 9
Exit doors without functioning alarms: 8
Hot water temperature: 128
Hot water temperature: 92
Hot water temperature: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for checking and maintaining exit door alarms and water temperatures; interviewed multiple times regarding alarm issues and water temperature. | |
| Administrator | Interviewed regarding alarm issues, water temperature, and coordination of care. | |
| Resident Care Coordinator (RCC) | Responsible for monitoring residents and coordinating care; interviewed regarding notification of resident self-harm incident. | |
| Medication Aide (MA) | Documented resident incident of self-harm; interviewed regarding notification and reporting responsibilities. | |
| Executive Director | Interviewed regarding incident reporting and facility policies. | |
| Mental Health Provider | Provided psychiatric care to resident #2; interviewed regarding notification of self-harm incident. | |
| Hospice Nurse | Interviewed regarding resident care and awareness of self-harm incident. |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Oct 6, 2020
Visit Reason
The Adult Care Licensure Section conducted a COVID-19 focused Infection Control survey with an onsite visit from 10/05/20 to 10/06/20, a desk review from 10/07/20 to 10/08/20, and a telephone exit on 10/08/20 to assess compliance with CDC, NC DHHS, and Local Health Department guidelines related to COVID-19 infection control.
Findings
The facility failed to ensure staff appropriately wore personal protective equipment (PPE) when providing care to residents who tested positive for COVID-19, failed to post required airborne precaution signage on isolation rooms, and residents did not maintain social distancing of 6 feet in common areas such as smoking and TV rooms. These failures were detrimental to resident health and safety and constituted a Type B Violation.
Deficiencies (3)
Failure to ensure staff appropriately wore PPE when providing care to COVID-19 positive residents.
Failure to post isolation signage on rooms of residents who tested positive for COVID-19.
Failure to ensure residents maintained social distancing of 6 feet in common areas.
Report Facts
Residents diagnosed with COVID-19: 9
Residents tested positive for COVID-19 on 09/10/20: 16
Residents allowed in smoking area at one time: 2
Residents observed in smoking area: 4
Residents allowed in TV room at one time: 4
Residents observed in TV room: 6
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 18, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 04/16/19 through 04/18/19 to assess correction of previous deficiencies related to health care referral and follow-up, resident rights, and abuse/neglect allegations.
Findings
The facility failed to assure referral and follow-up for routine and acute health care needs for 4 of 5 sampled residents, including failure to report oral pain and schedule necessary medical appointments. The facility also failed to protect residents from sexual abuse and exploitation, and neglected to provide pain relief medication for a resident with severe oral pain. Additionally, the facility failed to treat a resident with respect and dignity, and did not ensure adequate care and services in compliance with regulations.
Deficiencies (3)
Failed to assure referral and follow-up for routine and acute health care needs for 4 of 5 sampled residents, including oral pain, podiatry consult, eye exam, and swallowing evaluation.
Failed to assure residents were free of sexual abuse, exploitation and neglect, including allegations of sexual contact between a staff and a resident and neglect of pain relief medication.
Failed to assure a resident was treated with respect, consideration and dignity; staff spoke harshly and used beverages and snacks as leverage.
Report Facts
Number of sampled residents with failed referral and follow-up: 4
Number of sampled residents with sexual abuse and neglect issues: 2
Number of sampled residents treated with disrespect: 1
Number of sexual encounters reported between staff and resident: 3
Number of doses of Acetaminophen administered to Resident #5 in March 2019: 4
Inspection Report
Follow-Up
Deficiencies: 10
Date: Dec 7, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies identified in a prior Biennial Construction Survey.
Findings
The facility had multiple deficiencies related to housekeeping, building maintenance, fire safety, plumbing, electrical systems, and firestopping. Issues included pest presence, loose plumbing fixtures, fire doors not latching, emergency exit signs and lights not functioning properly, gaps in fire-resistance-rated assemblies, missing hardware on fire doors, and unsafe electrical panels and outlets.
Deficiencies (10)
Facility has not kept the facility clean and orderly by allowing pests in the facility to go unmanaged; one live roach observed in pantry.
Building plumbing equipment not maintained in a clean and orderly manner free of hazards; loose toilet in Bedroom 115 with missing bolt.
Fire rated doors in a firewall did not close completely and latch to contain smoke/fire; doors near Bedrooms 109 and 128 not latching.
Exit signs near Bedrooms 126, 307, and Dining Room Right Exit did not illuminate on backup power.
Emergency light near Bedroom 341 making buzzing sound, low light output, and did not illuminate on test.
Gaps and unsealed penetrations in fire-resistance-rated ceiling assemblies in multiple locations including Bathroom 108, Business Office 212, Dining Room wall near Kitchen, Kitchen, Kitchen Office, Records Room.
Smoke tight corridor doors not maintained in safe and operating condition; Bathroom 330 door has gaps.
Building components failed to function as intended or are missing; panic hardware covers missing on firewall doors near Bedrooms 226 and 308.
Electrical system not maintained in safe and operating condition; open slots in electrical panel in Laundry, GFCI outlet in Bedroom 120 Restroom did not trip and would not reset.
Electrical receptacle missing cover plate in Records Room.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 6, 2018
Visit Reason
The Adult Care Licensure Section and the Pitt County Department of Social Services conducted a follow-up survey and a complaint investigation on December 6-7, 2018. The complaint investigation was initiated by the Pitt County Department of Social Services on October 25, 2018.
Complaint Details
Complaint investigation was initiated by the Pitt County Department of Social Services on October 25, 2018. Based on survey findings, the complaint allegation was not substantiated.
Findings
The facility failed to schedule follow-up orthopedic care for one of seven sampled residents (#2) who had fallen and obtained a fractured humerus. The previous unabated Type B Violation was not abated. The facility also failed to ensure care and services related to health care referral and follow-up needs, constituting a continuing unabated Type B Violation.
Deficiencies (2)
Failed to schedule follow-up orthopedic care for Resident #2 who had a fractured humerus after a fall.
Failed to ensure care and services related to health care referral and follow-up needs.
Report Facts
Sampled residents: 7
Resident #2 fall date: Nov 25, 2018
Follow-up survey date: Dec 6, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Olson | RN, BSN, M.Ed., Nurse Consultant | Signed the revisit report and letter dated December 19, 2018 |
| Paula Meekins | Administrator | Named as facility administrator in the report |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 6, 2018
Visit Reason
The Adult Care Licensure Section and the Pitt County Department of Social Services conducted a follow-up survey and a complaint investigation on December 6-7, 2018, initiated by a complaint from October 25, 2018.
Complaint Details
Complaint investigation initiated by Pitt County Department of Social Services on October 25, 2018, regarding failure to provide appropriate follow-up care after a fall.
Findings
The facility failed to schedule follow-up orthopedic care for Resident #2 who had fallen and sustained a fractured humerus. Despite orders and discharge instructions from the emergency department, the resident had not been seen by an orthopedic specialist, placing him at risk for serious complications. This failure was deemed a continuing unabated Type B Violation.
Deficiencies (2)
Failed to schedule follow-up orthopedic care for Resident #2 with a fractured humerus after a fall.
Failed to ensure care and services related to health care referral and follow-up needs for Resident #2.
Report Facts
Sampled residents: 7
Days without follow-up care: 11
Medication dosage: 500
Inspection Report
Routine
Capacity: 120
Deficiencies: 19
Date: Aug 29, 2018
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant conditions including corridor obstructions, housekeeping issues, building equipment safety, fire safety, electrical system safety, plumbing safety, and ventilation system failures. Several deficiencies were corrected before surveyors departed the site.
Deficiencies (19)
Corridors are not free of obstructions, including hospital beds and furniture reducing corridor width and extension cords creating tripping hazards.
Building mechanical systems not kept clean and in good repair, including excessive dust/lint accumulation and missing PTAC unit cover exposing sharp edges.
Ceilings stained from past leaks and walls damaged or marred in resident rooms and common areas.
Rodent infestation observed with live and dead roaches in multiple areas.
Chronic unpleasant odors present in resident restrooms.
Portable medical oxygen cylinders not secured properly, posing projectile hazard.
Plumbing equipment not maintained, including loose commode connections.
Building egress impeded by locked gates, painted shut doors, and furniture restricting exit width.
Fire rated doors in firewall did not close and latch properly, compromising smoke/fire containment.
Emergency exit signs and emergency lighting not functioning properly on normal or backup power.
Fire alarm system heat detector dangling from ceiling by wires.
Numerous penetrations in fire-resistance-rated ceiling and wall assemblies not properly firestopped, including gaps around cables, pipes, conduits, and holes.
Smoke tight corridor doors not maintained in safe and operating condition with gaps, doors hitting floors, missing latches, and hardware issues.
Doors requiring more than allowed opening force.
Building components missing or failed to function as intended, including missing panic hardware covers and malfunctioning panic bars on firewall doors.
Electrical system unsafe with open panel slots, missing switch and receptacle covers, non-functioning GFCI receptacle, blocked electrical panels, and unauthorized multiple plug adaptors.
Corridor doors held open by objects preventing rapid closure and latching, compromising fire safety.
Plumbing equipment unsafe with missing pressure relief valve pipe extensions and use of non-approved PVC piping for valve extensions.
Exhaust ventilation systems in multiple areas not functioning, causing odor issues.
Report Facts
Total licensed capacity: 120
Door gap measurements: 0.5
Door gap measurements: 0.375
Door opening force: 15
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 23, 2018
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from August 14, 2018 to August 23, 2018 to verify correction of previous deficiencies.
Findings
The facility failed to assure tuberculosis testing compliance for one resident, failed to provide adequate supervision for a confused resident who left the facility multiple times, failed to notify the cardiology provider of significant weight changes for a resident with heart failure, and failed to treat a resident with dignity and respect by staff members.
Deficiencies (4)
Failed to assure 1 of 8 sampled residents was tested upon admission for Tuberculosis disease with a two-step TB skin test.
Failed to provide supervision for 1 of 8 sampled residents resulting in an unsupervised, confused and disoriented resident leaving the facility multiple times.
Failed to notify the cardiology provider for 1 of 8 sampled residents with daily weight fluctuations as ordered.
Failed to assure 1 of 8 residents was treated with dignity and respect by staff members who called the resident lazy and nasty.
Report Facts
Sampled residents: 8
Resident #6 admission date: Sep 25, 2017
Resident #2 admission date: Mar 10, 2008
Resident #5 admission date: Mar 27, 2017
Weight gain: 4.2
Weight gain: 3.2
Weight gain: 3.7
Weight gain: 4.3
Weight gain: 5.2
Weight gain: 4.7
Weight gain: 3.5
Weight gain: 4.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named by Resident #8 as calling resident lazy | |
| Staff B | Personal Care Aide | Named by Resident #8 as calling resident lazy and involved in inappropriate behavior |
| Staff C | Named by Resident #8 as calling resident lazy and suspended pending investigation | |
| Resident Care Coordinator | RCC | Responsible for tracking TB skin tests and resident supervision |
| Administrator | Responsible for facility oversight and communication with PCP | |
| Medication Aide | MA | Documented weight and contacted providers regarding Resident #5's weight |
| Primary Care Provider | PCP | Ordered supervision for Resident #2 and was contacted regarding Resident #5's weight |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 16, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from March 14, 2018 to March 16, 2018.
Findings
The facility was found deficient in multiple areas including housekeeping and furnishings with unclean floors and walls in resident rooms and bathrooms; failure to assure 4 of 7 sampled residents were tested for tuberculosis with a two-step TB skin test upon admission; failure to notify medical providers of non-compliance with CPAP use and refusal of emergent medical evaluation for high blood pressure; failure to keep kitchen equipment clean and repair broken shelves; and failure to ensure medication aides completed annual infection control training.
Deficiencies (5)
Floors, walls, and ceilings were not clean and in good repair in 4 resident rooms, 6 shared bathrooms, and the community bathroom on the Men's Hall.
Facility failed to assure 4 of 7 sampled residents were tested upon admission for Tuberculosis disease with a two-step TB skin test.
Facility failed to notify medical providers for 2 of 7 sampled residents for non-compliance with CPAP use and refusal of emergent medical evaluation for high blood pressure.
Facility failed to keep 1 microwave clean and free from contamination and failed to repair 1 shelf in the refrigerator and 1 shelf in the freezer.
Facility failed to assure 1 of 3 Medication Aides sampled completed the state mandated infection control training annually.
Report Facts
Residents sampled for TB testing: 7
Residents non-compliant with CPAP or medical evaluation: 2
Blood pressure reading: 212
Blood pressure reading: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to complete state mandated infection control training annually. |
| Resident Care Coordinator | Responsible for ensuring TB testing and infection control training compliance; interviewed multiple times regarding deficiencies. | |
| Administrator | Interviewed regarding multiple deficiencies including TB testing, CPAP non-compliance, kitchen equipment, and infection control training. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 9, 2016
Visit Reason
Follow Up Survey conducted to verify correction of deficiencies identified during the 08/17/2016 Biennial Survey.
Findings
Deficiencies from the prior biennial survey remain uncorrected, including issues with electrical emergency equipment, fire safety equipment, plumbing, and exhaust ventilation.
Deficiencies (4)
Electrical emergency/safety related equipment not maintained in operating condition; heat detector in Room #230 detached and hanging by wiring.
Fire safety equipment not maintained; door in Room 330 Shower/Bath does not close and latch properly.
Plumbing equipment not maintained in safe condition; ice machine condensate drain in kitchen not a minimum of 2 inches above floor drain.
Exhaust ventilation not provided or not operating in required spaces; resident bathroom exhaust fan in Room #214 not working and Maintenance Room #331 lacks exhaust fan.
Inspection Report
Routine
Capacity: 120
Deficiencies: 8
Date: Aug 17, 2016
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure.
Findings
The survey identified multiple deficiencies related to physical plant maintenance including walls and floors not kept in good repair, hazards such as unsecured oxygen bottles, electrical emergency equipment not functioning, unsafe electrical equipment use, fire safety components not maintained properly, plumbing not installed per code, and inadequate exhaust ventilation in specified areas.
Deficiencies (8)
Facility walls not kept in good repair with holes and missing strike plates on door frames.
Facility floors not kept in good repair with missing floor tiles and water collecting in depressions.
Oxygen bottles not stored in racks or restrained, posing hazard.
Electrical emergency/safety equipment not maintained in operating condition; emergency exit lights failed battery test.
Electrical equipment used unsafely with multi-plug adapters and power strips used as extension cords; broken outlet cover plate.
Fire safety components not maintained; unapproved door hold open devices present; doors not latching properly; gaps in fire resistant ceilings.
Plumbing equipment not maintained in safe condition; ice machine condensate drain improperly installed.
Exhaust ventilation not provided or not operating in required spaces such as resident bathroom and maintenance room.
Report Facts
Total licensed capacity: 120
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 28, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 27-28, 2016 at Southern Living Assisted Care.
Findings
The facility failed to provide wheelchair-bound residents with community outings every other month, failed to provide call bells for residents who requested them, and failed to ensure medication aides completed required infection control and medication administration training.
Deficiencies (4)
Facility failed to provide wheelchair-bound residents with the opportunity to participate in at least one outing every other month.
Facility failed to provide call bells for 2 residents who had previously requested them for assistance.
Facility failed to assure 2 of 2 sampled medication aides had completed the annual state mandated infection control course.
Facility failed to assure 2 of 2 sampled medication aides had successfully completed the required 15-hour medication administration training prior to administering medications.
Report Facts
Number of wheelchair residents interviewed: 5
Number of call bells in supply closet: 10
Number of medication aides sampled: 2
Staff A hire date: May 20, 2015
Staff D hire date: Mar 17, 2014
Inspection Report
Follow-Up
Deficiencies: 6
Date: Oct 21, 2015
Visit Reason
This report is of a Followup Survey conducted to verify if previously identified deficiencies have been corrected at Southern Living Assisted Care.
Findings
The followup survey revealed that the facility failed to maintain floors, walls, and baseboards clean and in good repair; sanitation scores were below the required 85 with a score of 70.5; resident rooms were cluttered; roaches were observed; and HVAC ventilation grilles and dampers had excessive dust accumulation.
Deficiencies (6)
Facility failed to maintain floors clean and in good repair with excessive wax and dirt build-up and missed stains.
Facility failed to maintain walls and baseboards clean and in good repair, including damage from moisture behind commodes.
Facility failed to maintain sanitation scores of 85 or above, with a documented score of 70.5 during re-inspection.
Resident rooms were cluttered with residents' clothes and belongings, failing to remain uncluttered.
Facility allowed dead and alive roaches to remain unmanaged in the front section of the 100 Hall.
Facility failed to maintain HVAC/ventilation grilles and associated dampers, which had excessive dust and lint accumulation.
Report Facts
Sanitation score: 70.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob Getchell | Conducted the followup survey on October 21, 2015. |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 9
Date: Aug 20, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of poor environmental conditions at the facility.
Complaint Details
The complaint alleged poor environmental conditions at the facility and was substantiated by the inspection findings.
Findings
The complaint was substantiated with multiple deficiencies cited including poor housekeeping with dirty floors and walls, sanitation score below required standards, cluttered resident rooms, pest infestation, HVAC and plumbing maintenance issues, and breaches in fire-resistance-rated construction compromising safety.
Deficiencies (9)
Facility failed to maintain floors clean and in good repair with excessive wax and dirt build-up, stains, and damaged vinyl floor tiles.
Facility failed to maintain walls and baseboards clean and in good repair, including water damage behind commodes.
Facility failed to maintain sanitation score of 85 or above; documented score was 70.5 on re-inspection.
Resident rooms were cluttered with clothes and belongings, creating hazards and pest harborage.
Dead and live roaches observed in the front section of the 100 Hall despite pest exterminator presence.
HVAC and ventilation grilles and dampers had excessive dust and lint accumulation, risking fire containment.
Several hand sinks in group bathrooms were loose and propped up with wet wooden supports, creating cleaning difficulties and safety concerns.
Fire-resistance-rated corridor walls in Residents' Toilet Rooms had holes compromising fire safety.
Exit door near dining on 100 Hall had a compromised top hinge causing difficulty in operation and allowing insect, vermin, and weather access.
Report Facts
Licensed capacity: 120
Sanitation score: 70.5
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