Deficiencies (last 2 years)
Deficiencies (over 2 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jun 24, 2025 | 105.5 | 5.5 | 0 | Annual Inspection | |
| May 9, 2024 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Dec 21, 2022 | 90.5 | 5 | 0 | Follow-Up Inspection | |
| Oct 10, 2022 | 85.5 | 2.5 | 17 | Annual Inspection | |
| Apr 16, 2021 | 96 | 0 | 4 | Re-Issued |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 19, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on August 18-19, 2022 to assess compliance with health care, medication administration, infection control, and resident rights regulations.
Findings
The facility failed to notify the primary care provider of new wounds and ensure home health wound care referral implementation for Resident #3, and failed to implement orders for daily circulation checks for Resident #2. Resident #1's blood pressure medication was administered outside ordered parameters multiple times. Additionally, staff failed to wear masks as required by infection control guidance.
Deficiencies (5)
Failed to notify Resident #3's primary care provider of new wounds and ensure home health wound care referral was implemented, placing the resident at risk of infection, sepsis, loss of function, or death.
Failed to implement orders for daily circulation checks on Resident #2's injured extremity and wound care every other day for Resident #3 until home health wound care was initiated.
Failed to administer Resident #1's blood pressure medication Coreg according to ordered vital sign parameters, administering medication when diastolic blood pressure was below ordered limits.
Failed to provide wound care with Xeroform gauze and wound cleanser, Betadine, and gauze as ordered for Resident #3, resulting in missed wound care opportunities and risk of infection and delayed healing.
Failed to ensure staff wore masks as personal protective equipment (PPE) in accordance with CDC and NC DHHS guidance to prevent COVID-19 transmission.
Report Facts
Medication administration errors: 10
Missed wound care opportunities: 20
Missed wound care opportunities: 5
Missed wound care opportunities: 20
Missed circulation checks: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operations Manager | Named as responsible for following up on wound care and circulation check orders and ensuring accuracy of medication orders on eMAR. | |
| Clinical Operations Director | Named as responsible for oversight of wound care and infection control practices. | |
| Administrator | Named as responsible for overall facility compliance and unaware of failures in wound care and medication administration. | |
| Resident #3's PCP | Primary Care Provider | Interviewed regarding wound care orders and lack of notification of new wounds. |
| Resident #3's Podiatrist | Provided wound care orders and antibiotic prescriptions for Resident #3. | |
| Pharmacist | Contracted pharmacy pharmacist interviewed regarding medication order entry and errors on eMAR. | |
| Medication Aide / Personal Care Aide | Multiple staff interviewed regarding wound care and medication administration practices. |
Inspection Report
Original Licensing
Deficiencies: 3
Date: Feb 15, 2021
Visit Reason
The Adult Care Licensure Section conducted an initial survey with an onsite visit on February 15, 2021.
Findings
The facility failed to ensure exit doors had operational alarms for residents who were intermittently or constantly disoriented, failed to protect food storage areas from contamination due to expired foods and beverages, and failed to ensure proper implementation of COVID-19 screening procedures for staff.
Deficiencies (3)
Facility failed to ensure 3 of 3 exit doors had an alarm activated and sounding when opened to alert staff for 2 residents who were intermittently or constantly disoriented.
Facility failed to ensure food storage areas were protected from contamination as evidenced by expired foods and beverages noted in refrigerators.
Facility failed to ensure implementation and maintenance of COVID-19 screening procedures for staff, with multiple staff not signing the COVID-19 Screening Log consistently at shift start.
Report Facts
Expired food items: 3
Staff shifts with incomplete COVID-19 screening logs: 10
Residents sampled with disorientation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide/Supervisor-in-Charge (MA/SIC) | Interviewed regarding resident conditions, alarm system status, refrigerator cleaning, and COVID-19 screening procedures. | |
| Communications Relations Director | Interviewed regarding resident wandering assessments, alarm system status, and COVID-19 screening log procedures. | |
| Community Relations Director | Interviewed regarding food expiration monitoring and COVID-19 screening log procedures. |
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