Inspection Report Summary
The most recent inspection on May 21, 2025, found a deficiency related to medication self-administration orders and assessments for one resident. Earlier inspections showed a pattern of issues including medication administration errors, supervision failures leading to resident-to-resident abuse, and multiple physical plant and safety code violations such as obstructed corridors, unsecured oxygen cylinders, and fire safety system problems. Complaint investigations substantiated incidents of physical and sexual abuse involving a resident, along with failures to notify authorities promptly. Enforcement actions or fines were not listed in the available reports. The facility has shown some correction of prior deficiencies, but medication management and physical plant concerns have recurred over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
115 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jul 15, 2025 | 73.75 | 13.75 | 0 | Follow-Up Inspection | |
| Apr 9, 2025 | 60 | 3.5 | 43.5 | Annual Inspection | |
| Mar 28, 2024 | 99.5 | 3.5 | 4 | Annual Inspection | |
| Jul 21, 2022 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jan 30, 2020 | 101 | 5 | 0 | Follow-Up Inspection | |
| May 9, 2019 | 96 | 5.5 | 9.5 | Annual Inspection | |
| Nov 15, 2017 | 97 | 1.25 | 0 | Follow-Up Inspection | |
| Jul 19, 2017 | 95.75 | 1.25 | 3.5 | Follow-Up Inspection | |
| Mar 21, 2017 | 98 | 3.5 | 5.5 | Annual Inspection | |
| May 29, 2013 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Jun 6, 2012 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Aug 20, 2010 | 93 | 9 | 6 | Annual Inspection | |
| Sep 14, 2009 | 95.5 | 5 | 0 | Follow-Up Inspection | |
| Sep 14, 2009 | 90.5 | 4.5 | 14 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 05/20/25 and 05/21/25 to verify correction of previous deficiencies related to medication self-administration.
Findings
The facility failed to ensure that Resident #1 had a physician's order and assessment completed to self-administer medications including cough medicine, stool softener, stomach discomfort medication, and diarrhea medication. Medications were found at the resident's bedside without proper orders or assessments, and staff interviews indicated concerns about the resident's ability to safely self-administer medications.
Deficiencies (1)
Facility failed to ensure Resident #1 had a physician's order and assessment completed to self-administer medications related to cough medicine, stool softener, stomach discomfort medication, and diarrhea medication.
Report Facts
Medication bottle fullness: 75
Medication bottle fullness: 65
Medication bottle fullness: 25
Medication tablets taken: 3
Medication bottle fullness: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide (MA) | Interviewed regarding Resident #1's medication administration and concerns about resident's ability to self-administer medications | |
| Personal Care Aide (PCA) | Interviewed about medication observations and reporting procedures | |
| Registered Nurse (RN)/Interim Administrator | Interviewed about medication administration policies and Resident #1's assessment status | |
| Representative from Resident #1's PCP's office | Telephone interview confirming Resident #1 could self-administer medications if facility staff agreed |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 24, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey with a complaint investigation from 02/18/25 to 02/21/25 and 02/24/25.
Complaint Details
Complaint investigation included resident-to-resident physical and sexual abuse incidents involving Resident #5, with failure to lock resident's door despite family requests, and failure to notify authorities timely.
Findings
The facility failed to ensure tuberculosis testing compliance, supervision according to assessed needs, physician notification for medication refusals and weight loss, proper medication administration, self-administration orders, and timely reporting of abuse incidents. Resident #4 had multiple behavioral issues and medication administration failures. Resident #5 was physically assaulted by another resident and sexually assaulted, with failure to lock the resident's door despite family requests. Resident #1 had medication administration issues including oxygen and compression socks. Resident #7 was served an incorrect diet causing distress.
Deficiencies (8)
Failure to ensure tuberculosis testing compliance for Resident #1.
Failure to provide supervision according to assessed needs for Residents #4 and #5, resulting in physical and sexual abuse incidents.
Failure to ensure physician notification for medication refusals and weight loss for Residents #1 and #4.
Failure to clarify medication orders for compression socks and an anti-depressant for Residents #4 and #6.
Failure to serve therapeutic diets as ordered for Residents #4 and #7.
Failure to ensure self-administration orders and assessments for Residents #8, #9, and #10.
Failure to immediately notify the county Department of Social Services and local law enforcement of resident-to-resident physical abuse incidents involving Resident #5.
Failure to administer medications as ordered for Residents #1, #3, #4, #5, and #6 including asthma medication, mood stabilizers, blood thinners, and blood pressure medications.
Report Facts
Weight loss: 35
Medication refusals: 16
Falls: 16
Medication doses: 234
Medication doses: 63
Medication doses: 18
Medication doses: 8
Medication doses: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Resident Care Director | Resident Care Director | Named in multiple interviews related to supervision failures, medication administration, and abuse incident management. |
| Unnamed Special Care Coordinator | Special Care Coordinator | Named in interviews related to supervision, medication administration, and abuse incident management. |
| Unnamed Administrator | Administrator | Named in interviews related to overall facility management, incident reporting, and medication administration oversight. |
| Unnamed Licensed Practical Nurse | Licensed Practical Nurse | Named in interviews related to medication administration and resident care. |
| Unnamed Medication Aide | Medication Aide | Named in interviews related to medication administration and documentation. |
| Unnamed Personal Care Aide | Personal Care Aide | Named in interviews related to resident supervision and medication observations. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
Follow up construction survey conducted by documentation review to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected based on documentation received, and no further action is required at this time.
Inspection Report
Census: 115
Deficiencies: 11
Date: Nov 7, 2024
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for Licensing Adult Care Homes and the 1996 NC State Building Code.
Findings
Multiple deficiencies were cited related to physical plant issues including improper use of bathrooms for storage, lack of handrails on steps, missing wanderer alarms, poor housekeeping and maintenance, unsafe storage of oxygen bottles, fire safety system failures, unsafe electrical and plumbing conditions, inadequate supervision of ovens, hot water temperature issues, insufficient lighting, and lack of exhaust ventilation in several areas.
Deficiencies (11)
Bathroom used for storage of wheelchairs in SCU Spa.
Exterior steps outside Stair 2 lack handrails; riser height greater than 7 3/4".
Exit doors not equipped with wanderer alarms despite presence of disoriented residents.
Walls, ceilings, and floors not kept clean and in good repair; multiple stained and damaged ceiling tiles and walls throughout facility.
Facility not maintained free from hazards; unsecured oxygen bottles in resident rooms.
Means of egress obstructed or hazardous; loose door latching device and tripping hazards from cords.
Failure to maintain fire safety systems; holes in fire rated ceilings, use of non-fire resistant materials, plumbing issues, emergency lighting failures, doors not closing/latching properly, missing electrical cover plates, and unapproved door hold-open devices.
Ovens in activity areas not locked or supervised, posing risk of injury.
Hot water temperature below required minimum at resident fixtures.
Insufficient general lighting in stairwells; burned out lights.
Lack of exhaust ventilation in janitor's closet, staff bathrooms, housekeeping areas, and several resident bathrooms.
Report Facts
Resident census: 115
Water temperature: 96
Steps without handrails: 3
Oxygen bottles unsecured: 8
Ceiling tiles with water stains: 9
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 2
Date: Feb 28, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 02/27/24 and 02/28/24 to assess compliance with nutrition and food service regulations in the Special Care Unit (SCU).
Findings
The facility failed to ensure that each resident in the SCU was served 8 ounces of milk three times daily and water was served in addition to other beverages at each meal. Staff offered milk and water but did not pour a glass for every resident at every meal, and no tracking was done to ensure compliance.
Deficiencies (2)
Facility failed to ensure 8 ounces of milk was served three times daily to residents in the Special Care Unit (SCU).
Facility failed to ensure water was served in addition to other beverages to each resident in the Special Care Unit (SCU).
Report Facts
Residents present during lunch meal service: 17
Residents present during breakfast meal service: 18
Unopened gallons of milk: 6
Gallon of milk available in SCU kitchenette: 1
Residents poured a glass of milk at lunch: 4
Residents poured a glass of milk at breakfast: 12
Residents poured a glass of water at lunch: 7
Residents poured a glass of water at breakfast: 10
Cartons of nectar-thickened water: 6
Inspection Report
Deficiencies: 3
Date: Jan 10, 2020
Visit Reason
Report of a Construction Section Biennial Survey conducted on January 10, 2020.
Findings
Multiple deficiencies were cited including unsafe outside premises with tripping hazards, electrical outlets in wet locations lacking ground fault interrupters, and building equipment such as smoke tight corridor doors not maintained in a safe and operating condition.
Deficiencies (3)
Outside grounds are not maintained in a clean and safe condition; two 4-inch black corrugated pipes cross the sidewalk creating a tripping hazard.
Electrical outlets in wet locations at sinks lack ground fault interrupters; one receptacle near the sink has reversed hot/neutral wiring and is not ground fault protected.
Smoke tight corridor doors are not maintained in a safe and operating condition; manual flush bolts on inactive leaves circumvent positive latching requirements on multiple floors and electromagnetic hold open device is not secured to the wall.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 11, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey on March 6 - 8, 2019 and on March 11, 2019 to assess compliance with state regulations for adult care homes.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing compliance for staff, failure to verify staff qualifications via the Health Care Personnel Registry, inadequate kitchen cleanliness and food safety practices, medication order clarifications and administration errors, and failure to provide required special care unit staff training. Additionally, the facility failed to respond timely to resident call bells.
Deficiencies (7)
Facility failed to assure 3 of 6 sampled staff were tested for tuberculosis disease with the two-step skin test in compliance with control measures.
Facility failed to access the North Carolina Health Care Personnel Registry to assure 2 of 6 staff had no substantiated findings listed.
Facility failed to assure hair nets were worn in the special care unit kitchen while food was being served and failed to keep kitchen and food storage areas clean and free of contamination.
Facility failed to ensure contact with prescribing physician for clarification of medication orders for 2 of 7 sampled residents regarding antibiotics and other medications.
Facility failed to ensure medications were administered as ordered for 3 of 5 sampled residents related to medication discontinuation, holding Coumadin for high INR, and antibiotic administration errors.
Facility failed to assure 1 of 3 sampled staff who rotated as a Medication Aide in the Special Care Unit had completed 20 hours of training within the first six months.
Facility failed to respond to resident call bells requesting assistance in a timely manner for 2 residents.
Report Facts
Staff tuberculosis testing noncompliance: 3
Staff HCPR check missing: 2
Hours of SCU training missing: 14
Medication doses administered after discontinuation: 12
Medication doses administered after order change: 12
Fosfomycin doses administered twice weekly: 2
Coumadin INR: 4.99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in tuberculosis testing deficiency |
| Staff D | Medication Aide | Named in tuberculosis testing, HCPR check, and SCU training deficiencies |
| Staff F | Cook | Named in tuberculosis testing and HCPR check deficiencies |
| Business Office Manager | Responsible for personnel records; interviewed regarding TB testing and HCPR check deficiencies | |
| Executive Director | Interviewed regarding multiple deficiencies including TB testing, HCPR, kitchen cleanliness, medication administration, and call bell response | |
| Resident Care Director | Interviewed regarding medication order clarifications and record reviews | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and food safety deficiencies | |
| Medication Aide | Interviewed regarding medication administration deficiencies | |
| Wellness Nurse | Interviewed regarding medication order clarifications and administration | |
| Pharmacist | Interviewed regarding medication order clarifications and pharmacy records | |
| Physician Assistant | Interviewed regarding medication orders for residents | |
| Personal Care Aide | Interviewed regarding call bell response deficiencies | |
| Assisted Living Coordinator | Interviewed regarding call bell response system and logs | |
| Maintenance Director | Interviewed regarding call bell system maintenance |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jan 25, 2018
Visit Reason
This is a biennial follow-up construction survey to verify correction of previously cited deficiencies related to building and physical plant compliance.
Findings
Many deficiencies from prior inspections were not corrected, including issues with special locking system doors, obstructed electrical panels, corridor obstructions, improper storage of medical oxygen cylinders, fire sprinkler clearance violations, and fire alarm system trouble conditions.
Deficiencies (7)
Facility failed to have all required components for doors with Special Locking System; no wiring diagram or systems components location map posted under glass at the fire alarm panel.
Obstructed access to electric panels due to storage of a clean linen cart blocking 4 electrical panels.
Corridors obstructed with chairs, maintenance carts, and other items reducing clear width below code requirements, including storage of a lift in stairway reducing width to about 30 inches.
Improper handling and storage of portable medical oxygen cylinders without racks or containers, including two cylinders stored in janitor's closet.
Storage too close to fire sprinkler heads, with boxes stacked within 4 inches of ceiling in janitor's closet, potentially negating sprinkler effectiveness.
Many corridor fire-rated doors prevented from closing and latching properly, including doors tied open, planed edges creating gaps, propped open doors, and missing latchset strikes.
Fire alarm system showing a 'Trouble = 2' condition, indicating potential failure to operate properly when needed.
Report Facts
Electrical panels blocked: 4
Chairs stored in corridor: 4
Clear corridor width: 4
Clear corridor width: 0.67
Clear stairway width: 30
Oxygen cylinders improperly stored: 2
Distance from ceiling to stacked boxes: 4
Gap between fire-rated doors: 0.375
Inspection Report
Follow-Up
Deficiencies: 10
Date: Nov 21, 2017
Visit Reason
This is a biennial follow-up construction survey to verify correction of previously cited deficiencies related to physical plant and safety code compliance at Brighton Gardens of Winston Salem.
Findings
The facility failed to correct many deficiencies including issues with special locking system doors, obstructed corridors, improper storage of oxygen cylinders, malfunctioning emergency lights, compromised fire-rated doors and walls, incorrect exit signage, and non-functioning exhaust ventilation in the Special Care soiled linen room.
Deficiencies (10)
Facility failed to meet NC State Building Code for doors/gates with Special Locking System; emergency release switch requires a key not carried by staff.
No wiring diagram or system components location map posted under glass at the fire alarm panel.
Corridors were obstructed with items including med carts, chairs, and equipment reducing clear width to less than 4 feet.
Portable medical oxygen cylinder stored unsecured in room 320.
Storage stacked too close to fire sprinkler head, negating fire sprinkler effectiveness.
Battery powered emergency lights would not work when tested, including in men's employee bathroom.
Exit sign on employee entrance corridor removed, leaving hole in ceiling; previous sign pointed toward dead end.
Multiple corridor fire-rated doors prevented from closing and latching properly, some propped open or with missing latchset strikes.
One-hour fire rated walls and ceilings compromised with holes and penetrations unsealed in multiple locations.
Exhaust fan not working in Special Care soiled linen room; mechanical ventilation required but not provided.
Report Facts
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Harrell | Surveyor who conducted the biennial follow-up construction survey. | |
| Maintenance Director | Assisted staff with gate operation and provided information about exhaust ventilation. |
Inspection Report
Census: 115
Capacity: 115
Deficiencies: 17
Date: Sep 20, 2017
Visit Reason
Biennial construction section survey to assess compliance with physical plant, building, fire safety, and housekeeping regulations.
Findings
The facility failed to meet multiple NC State Building Code and licensing requirements including issues with special locking systems on doors, obstructed corridors, improper storage of medical oxygen cylinders, fire safety equipment malfunctions, improper storage near sprinkler heads, and inadequate exhaust ventilation.
Deficiencies (17)
Facility failed to have all required components for doors/gates with Special Locking System, including emergency release switch key access.
Corridors were obstructed with equipment and items reducing clear width, potentially delaying evacuation.
Improper handling and storage of portable medical oxygen cylinders without racks or containers.
Storage stacked too close to fire sprinkler heads, negating fire suppression ability.
Presence of hasp and padlock on walk-in cooler door, risking entrapment.
Dry waste trap in soiled linen/biohazard room allowing odors and bacteria to enter facility.
Barrel bolt latch installed on exit door from Special Care delaying evacuation (corrected during survey).
Fire plan rehearsals records lacked sufficient description of activities.
Fire alarm system showing 'System Trouble' condition, risking failure to operate properly.
Large quantities of combustible storage in non-storage rooms, including bedroom used for storage.
Battery powered emergency lights failed to work in multiple locations.
Exit sign directing exit toward dead end at elevator, potentially delaying evacuation.
Multiple corridor doors failed to close and latch properly, compromising fire and smoke barriers.
One-hour fire rated walls and ceilings compromised by unsealed holes and penetrations.
Exit signs hanging loose from ceiling in employee entrance corridor.
Broken magnetic hold open bracket on door to 2nd floor bistro.
Exhaust ventilation failed in Special Care soiled linen room and was dirty in 2nd floor soiled linen/biohazard room.
Report Facts
Residents served: 115
Special Care Unit residents: 26
Mattresses stored in bedroom 226: 3
Wood chests of drawers stored in bedroom 226: 5
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 31, 2017
Visit Reason
The Adult Care Licensure Section and Forsyth County Department of Social Services conducted a follow-up survey on May 30-31, 2017 to verify correction of a previous Type B medication administration violation.
Findings
The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 1 of 7 sampled residents (Resident #5). Specifically, metoprolol succinate 25mg ER was not administered as ordered, and metoprolol tartrate 25mg was administered instead without checking blood pressure as required. This medication error was detrimental to the resident's health and safety and constituted an unabated Type B violation.
Deficiencies (1)
Failure to administer metoprolol succinate 25mg ER as ordered and substitution with metoprolol tartrate 25mg without checking blood pressure as required.
Report Facts
Sampled residents: 7
Medication tablets remaining: 8
Blood pressure reading: 122.68
Correction date deadline: Jun 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Responsible for comparing eMARs to paper MARs and entering orders; unaware of medication substitution and lack of BP checks |
| Medication Aide | Administered medications; unaware that metoprolol succinate ER and metoprolol tartrate were different medications | |
| Physician's Assistant | Interviewed and stated metoprolol tartrate should not be administered without BP check and that the two medications are not interchangeable | |
| Executive Director | Stated MAs were supposed to check BP prior to administering metoprolol tartrate and compare medication names on eMAR and bingo cards |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 2, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 02/28/17 through 03/02/17 to assess compliance with healthcare regulations and medication administration standards.
Findings
The facility failed to implement a physician's order for weekly blood pressure checks for one resident and failed to administer medications as ordered for three residents, including warfarin, aspirin, and respiratory treatments. These failures posed risks of serious health complications. The facility provided a plan of correction to audit medication administration and improve compliance.
Deficiencies (2)
Failed to implement an order for weekly blood pressure checks for Resident #4.
Failed to ensure medications were administered as ordered for 3 of 7 sampled residents regarding aspirin 81 mg, warfarin, and Mucinex and DuoNebs.
Report Facts
Medication administration opportunities missed: 8
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Interviewed regarding medication administration issues and audit responsibilities. |
| Nurse Practitioner | Nurse Practitioner (NP) | Provided physician order for weekly blood pressure checks and described order transmission. |
| Medication Aide | Medication Aide (MA) | Interviewed about medication administration and eMAR system use. |
| Physician | Physician | Interviewed regarding warfarin dosing and aspirin medication issues. |
| Physician Assistant | Physician Assistant (PA) | Interviewed regarding Resident #6 medication orders and concerns. |
| Wellness Nurse | Wellness Nurse | Interviewed about medication order processing and eMAR conversion. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 29, 2016
Visit Reason
This report is of a Follow-up Survey conducted to verify correction of previously identified deficiencies at Brighton Gardens of Winston Salem.
Findings
The follow-up survey revealed that not all deficiencies have been corrected. Specifically, the facility did not meet the 1996 NC State Building Code requirements related to special (magnetic) locking, including the absence of an emergency release switch within 3 feet of the exit gate and lack of a wiring diagram and system component map adjacent to the fire alarm panel.
Deficiencies (2)
No emergency release switch within 3 feet of the exit gate as required by Section 1012.6.1. 4.E. of the 1996 NC State Building Code.
No wiring diagram or system component map provided under glass adjacent to the fire alarm panel as required by Section 1012.6.1. 4.C.
Inspection Report
Follow-Up
Census: 115
Deficiencies: 4
Date: Dec 11, 2015
Visit Reason
Follow-up survey conducted to assess outstanding deficiencies related to compliance with the 1996 NC State Building Code and licensing rules for adult care homes.
Findings
The facility did not meet requirements related to special (magnetic) locking, including staff not carrying emergency release keys, lack of emergency release switch at a locked gate, absence of wiring diagram at the fire alarm panel, and uncertainty if locked doors unlock upon fire alarm activation.
Deficiencies (4)
Most staff in the Special Care Unit did not carry emergency release switch keys.
No emergency release switch provided at the electronically locked gate located off the main dining room.
No wiring diagram or system component location map located at the fire alarm panel.
It was not determined if the electronically locked gate located off the main dining room unlocked on fire alarm activation.
Report Facts
Residents served: 115
Special Care Unit residents: 26
Inspection Report
Census: 115
Deficiencies: 16
Date: Aug 18, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 NC State Building Code and applicable adult care home licensing rules.
Findings
Multiple deficiencies were identified including lack of central emergency release switches for magnetic locks, missing emergency release keys among staff, obstructions to electrical panels, missing sanitation inspection report, unpleasant odors in bathrooms, fire safety issues with corridor doors, improper storage of medical oxygen cylinders, compromised fire rated walls, non-functioning GFCI receptacle, and non-working exhaust ventilation in the soiled linen room.
Deficiencies (16)
No central emergency release switch for magnetically locked doors and gates.
Most staff in Special Care Unit did not carry emergency release switch keys; multiple keys required for magnetic locks.
No emergency release switch within 3 feet of each locked door/gate.
No wiring diagram or system component map at fire alarm panel.
Uncertain if electronically locked gate off main dining room unlocks on fire alarm activation.
Clothes dryer obstructing electrical panel in Special Care laundry.
Missing annual sanitation inspection report.
Significant unpleasant odor in bathroom off room 235.
Dry waste trap in 'Associate Lockers' area allowing odors to enter facility.
Battery powered emergency light near vending machines not working.
Multiple corridor doors prevented from closing and latching properly, held open by wedges or missing latches.
Exterior exit door at stairwell #4 propped open with disabled wanderer alarm.
Improper storage of portable medical oxygen cylinders in unapproved containers or unsecured.
Compromised one-hour fire rated walls and ceilings with unsealed conduit sleeve and improperly attached fire collar.
GFCI receptacle in bathroom off room 259 would not trip when tested.
Exhaust system not working in main soiled linen room.
Report Facts
Residents served: 115
Special Care Unit residents: 26
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