Inspection Report Summary
The most recent inspection on October 16, 2024, found that previously identified deficiencies had been corrected and no further action was necessary. Earlier inspections noted issues primarily related to medication administration training, storage and safety of self-administered medications, therapeutic diet compliance, building maintenance, fire safety features, and ventilation systems. Complaint investigations were not listed in the available reports, and no fines, immediate jeopardy findings, or license actions were reported. Prior deficiencies included medication aide training gaps and building code violations such as fire-rated wall penetrations and non-functioning emergency lighting. The correction of all prior deficiencies by the latest inspection suggests an improving trend in compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previous deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is necessary.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 6, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 6-7, 2022 with an exit conference via telephone on April 8, 2022.
Findings
The facility failed to serve therapeutic diets as ordered by the physician for 1 of 5 sampled residents with a reduced concentrated sweets (RCS) diet. Additionally, the facility failed to ensure that residents' self-administered medications were stored in a safe and secure manner for 3 of 3 sampled residents. The facility also failed to assure that 3 of 3 medication aides completed the required state-approved medication administration training and competency evaluation prior to administering medications.
Deficiencies (3)
Failed to serve therapeutic diets as ordered by the physician for 1 of 5 sampled residents with a reduced concentrated sweets (RCS) diet.
Failed to ensure residents' self-administered medications were stored in a safe and secure manner for 3 of 3 sampled residents.
Failed to assure 3 of 3 medication aides completed the required state-approved medication administration training and competency evaluation prior to administering medications.
Report Facts
Sampled residents with diet deficiency: 1
Sampled residents with medication storage deficiency: 3
Sampled medication aides without required training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to provide documentation of 15-hour state approved medication administration training and clinical skills checklist |
| Staff B | Medication Aide | Failed to provide documentation of 15-hour state approved medication administration training and clinical skills checklist |
| Staff C | Medication Aide | Failed to provide documentation of 15-hour state approved medication administration training and clinical skills checklist |
| Resident Service Director | Registered Nurse | Responsible for ensuring medication aides had completed required training and competency |
| Executive Director | Held Resident Service Director responsible for communication and training regarding therapeutic diets |
Inspection Report
Capacity: 20
Deficiencies: 6
Date: Oct 8, 2019
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 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified including non-compliance with building exit requirements, dirty plumbing systems, corridor doors that do not close and latch properly, compromised one-hour fire rated walls and ceilings with unsealed penetrations, improperly fitted sprinkler escutcheons, and a non-functioning combination exit sign/emergency light.
Deficiencies (6)
Facility exits are not in accordance with the NC State Building Code; exit through kitchen is not permitted.
Building plumbing systems are not kept clean and in good repair; hopper was extremely dirty.
Many corridor doors do not close quickly and latch to resist fire and smoke passage; specific doors to rooms 6106, 6115, 6116, 6120 will not latch; mechanical kick-downs present on some doors.
Required one-hour fire rated walls and ceilings compromised by unsealed holes and penetrations in multiple locations including mechanical room and FACP room.
Required one-hour fire rated ceilings compromised by improperly fitting or missing sprinkler escutcheons in Resident Laundry, FACP room, and small closet in room 6132.
Combination exit sign/battery powered emergency light near room 6100 did not work on normal or battery power.
Report Facts
Licensed beds: 20
Number of doors not latching: 4
Size of hole in FACP room ceiling: 120
Number of water heater flues without fire collar: 4
Number of unsealed penetrations in FACP room ceiling: 3
Number of locations with improperly fitted sprinkler escutcheons: 3
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 25, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual and a follow-up survey on 04/25/19.
Findings
The facility failed to ensure that one of two medication aides sampled (Staff C) completed the required 15-hour state approved medication administration training course or had verification of previous employment as a medication aide within the last 24 months prior to administering medications to residents.
Deficiencies (1)
Facility failed to assure Staff C completed the 5, 10 or 15-hour state approved medication administration training course or had verification of previous employment prior to administering medications.
Report Facts
Dates Staff C administered medications: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in medication administration training deficiency. |
| Resident Service Director | Resident Service Director | Responsible for ensuring medication aides complete required training. |
| Administrator | Administrator | Interviewed regarding knowledge of medication aide training requirements. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 19, 2017
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to building exhaust ventilation systems.
Findings
The facility failed to provide required exhaust ventilation in mechanically exhausted rooms. Specifically, the exhaust fan over the toilet in the spa adjacent to the maintenance room was not working, and an exhaust fan was not installed in the assisted living main laundry.
Deficiencies (2)
Exhaust fan over the toilet in the spa adjacent to the maintenance room not working.
Exhaust fan not installed in the assisted living main laundry.
Inspection Report
Capacity: 20
Deficiencies: 4
Date: Oct 27, 2017
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 the 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
The survey identified multiple deficiencies including bathrooms being used for storage, failure to maintain electrical emergency and safety lighting equipment in safe operating condition, missing fire sprinkler head escutcheon creating holes in fire resistant ceilings, and failure to provide required exhaust ventilation in several rooms.
Deficiencies (4)
Bathroom being used as storage space with wheelchairs and other items stored in the spa adjacent to the maintenance room.
Electrical emergency/safety lighting equipment not maintained in safe operating condition; emergency light above door to assisted living screened porch and exit sign at cross corridor doors did not illuminate on battery power.
Missing fire sprinkler head escutcheon in foyer creating a hole in the fire resistant rated ceiling.
Failure to provide exhaust ventilation in rooms required to be mechanically exhausted including spa adjacent to maintenance room, assisted living main laundry, and utility room adjacent to room 6129.
Report Facts
Licensed capacity: 20
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 4, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on November 4, 2016.
Findings
The facility failed to ensure that 1 of 3 medication aide staff completed the required annual state infection control training. Staff C had last completed the training on 7/15/2015 and did not attend the scheduled training on 9/16/2016. No corrective action was taken to ensure completion.
Deficiencies (1)
Facility failed to assure 1 of 3 staff completed an annual state infection control training.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in deficiency for not completing annual infection control training. |
| Resident Care Director | Resident Care Director | Interviewed regarding staff infection control training and audit. |
| Administrator | Administrator | Interviewed regarding awareness of staff infection control training status. |
Inspection Report
Capacity: 20
Deficiencies: 6
Date: Jan 15, 2016
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 2005 Minimum and Desired Standards and the 2009 North Carolina State Building Code Section 407, Type I-2 for a facility licensed for 20 beds.
Findings
The facility was found to have multiple deficiencies including failure to maintain the building free of hazards such as unsecured oxygen containers and loose handrails, failure to maintain fire resistance of building components including malfunctioning smoke door magnets and gaps around sprinkler pipes, and failure to maintain plumbing in a safe and operating condition as evidenced by a loose commode.
Deficiencies (6)
Oxygen containers were not stored securely, with an unsupported bottle found in Resident Room 6116.
Hand rails were not secured tightly to the wall, specifically outside Resident Room 6120.
Cross corridor smoke door magnets did not release upon detection of smoke.
Sprinkler pipe in Maintenance Office dropped below ceiling level with a large gap exposed.
Sprinkler head escutcheons in Charting Room and Back Mechanical Rooms dropped below ceiling, revealing large gaps.
Commode in Women's Bathroom was loose at the connection to the floor.
Report Facts
Licensed bed capacity: 20
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