Inspection Report
Annual Inspection
Deficiencies: 5
Jul 10, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 07/08/25 through 07/10/25 to assess compliance with state regulations for the adult care home.
Findings
The facility was found deficient in multiple areas including tuberculosis testing compliance for new admissions, failure to follow up on elevated blood pressure for a resident, medication administration errors for three residents, failure to observe medication ingestion for one resident, and non-compliance with self-administration medication policy for one resident.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 5 sampled residents completed a tuberculosis skin test prior to admission as required. | — |
| Facility failed to ensure health care referral and follow-up was completed for 1 of 5 sampled residents related to not following up with the primary care provider when systolic blood pressure was elevated. | — |
| Facility failed to ensure medications were administered as ordered for 3 of 4 residents observed during medication passes, including insulin administration error, missed diuretic doses, and missed blood pressure medication. | Type B Violation |
| Medication aide failed to observe 1 of 1 sampled resident take medications; resident was ambulating with loose medications on walker seat during administration. | — |
| Facility failed to ensure 1 of 5 sampled residents was in compliance with self-administration medication policy; resident stored medication bottles offsite and family filled pill organizer. | — |
Report Facts
Medication error rate: 13
Resident blood pressure readings: 220
Medication doses missed: 7
Medication doses remaining: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding TB testing responsibilities and medication administration oversight |
| Administrator | Administrator and Health and Wellness Director (HWD) | Interviewed regarding TB testing, medication administration errors, and self-administration concerns |
| Medication Aide | Medication Aide (MA) | Observed and interviewed regarding medication administration errors and failure to observe medication ingestion |
| Pharmacist | Contracted Pharmacy Pharmacist | Interviewed regarding medication supply and refill issues |
| Corporate RN | Corporate Registered Nurse | Interviewed regarding self-administration medication evaluation |
| Primary Care Provider | Primary Care Provider (PCP) | Interviewed regarding elevated blood pressure follow-up and medication administration concerns |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 18, 2025
Visit Reason
Report of a Biennial Construction Follow Up Survey conducted to verify correction of previous deficiencies.
Findings
Deficiencies have been corrected. No further action is needed.
Inspection Report
Capacity: 82
Deficiencies: 5
Dec 10, 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 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure of the emergency override switch at the nurses station to release electromagnetic locked doors, lack of documentation for routine fire extinguisher inspections, unsafe electrical equipment such as a non-operable outlet showing signs of burning, missing smoke detectors in several locations, and non-operable inside door releasing device on the walk-in freezer.
Deficiencies (5)
| Description |
|---|
| Emergency override switch at nurses station did not operate to release electromagnetic locked doors. |
| Portable fire extinguishers lacked required monthly inspection documentation. |
| Electrical equipment not maintained in safe operating condition; range lacks staff-controlled locking feature and electrical outlet below window A/C unit shows signs of burning and is not operable. |
| Missing smoke detectors in dining room, hall near room 21, and laundry clean linen area. |
| Walk-in freezer inside door releasing device was not operable, potentially trapping occupants. |
Report Facts
Licensed capacity: 82
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 21, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 07/20/22 and 07/21/22 to assess compliance with health care and licensed health professional support regulations.
Findings
The facility failed to ensure proper referral and follow-up for health care needs related to weekly INR monitoring for one resident, and failed to ensure Licensed Health Professional Support (LHPS) evaluations were reviewed and completed by an appropriate licensed health professional for all five sampled residents. Documentation and communication deficiencies were noted regarding medication administration and LHPS reviews.
Deficiencies (2)
| Description |
|---|
| Failure to ensure referral and follow-up to meet health care needs for 1 of 5 sampled residents (#3) with weekly INR orders. |
| Failure to ensure Licensed Health Professional Support (LHPS) evaluation was reviewed and completed by an appropriate licensed health professional for 5 of 5 sampled residents (#1, #2, #3, #4, #5). |
Report Facts
INR values: 14
Sampled residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding INR monitoring and medication administration for Resident #3. | |
| Resident Care Coordinator (RCC) | Interviewed regarding LHPS reviews and communication with PCP and medication orders. | |
| Primary Care Provider (PCP) for Resident #3 | Interviewed regarding verbal orders and INR monitoring procedures. | |
| Executive Director/Administrator | Interviewed regarding facility policies on documentation and LHPS reviews. |
Inspection Report
Annual Inspection
Deficiencies: 5
Jan 17, 2020
Visit Reason
The Adult Care Licensure Section and the Rockingham County Department of Social Services conducted an annual survey from 01/15/20 through 01/17/20.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing and Health Care Personnel Registry checks were completed upon hire for staff, failure to clarify medication orders for a resident, failure to implement proper infection control procedures for glucometer use resulting in sharing between residents, and failure to ensure medication aides completed required training prior to administering medications.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to assure 1 of 3 sampled staff was tested for tuberculosis disease upon hire. | — |
| Facility failed to assure 1 of 3 sampled staff had no substantiated findings listed on the North Carolina Health Care Personnel Registry upon hire. | — |
| Facility failed to ensure medication orders were clarified with the prescribing practitioner for 1 of 6 sampled residents related to fingerstick blood sugar and parameters for holding a long-acting insulin. | — |
| Facility failed to implement a written infection control policy consistent with CDC guidelines to assure proper infection control procedures for the use of glucometers for 3 of 7 sampled residents, resulting in sharing glucometers between residents. | Type B Violation |
| Facility failed to assure 1 of 3 sampled staff who administered medications had completed the required medication administration course prior to administering medication. | — |
Report Facts
Number of sampled staff failing TB test upon hire: 1
Number of sampled staff failing HCPR check upon hire: 1
Number of sampled residents with medication order clarification issues: 1
Number of sampled residents with glucometer sharing issues: 3
Number of days medication aide administered medication before completing training: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to have TB test upon hire, failed to have HCPR check upon hire, administered medication before completing required training |
| Administrator | Interviewed regarding staff TB testing, HCPR checks, medication order clarifications, and medication aide training | |
| Health and Wellness Director | Responsible for training Staff C and auditing medication orders | |
| Business Office Manager | Responsible for keeping track of TB skin tests and pre-employment paperwork | |
| Resident Care Coordinator | Responsible for medication administration and clarifying medication orders | |
| Resident Care Director | Responsible for ensuring glucometers were not shared between residents |
Inspection Report
Capacity: 82
Deficiencies: 13
Oct 10, 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 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant conditions including housekeeping and furnishings, plumbing system repair, mechanical system hazards, fire safety evacuation plan and rehearsals, building equipment maintenance, fire alarm system, electrical system, fire safety, sprinkler system maintenance, and corridor door safety.
Deficiencies (13)
| Description |
|---|
| Building walls are not kept clean and in good repair; hole in bathroom door in Bedroom 29. |
| Ice machine drain line in kitchen lacks minimum 2 inch air gap allowing potential backflow contamination. |
| Mechanical systems have hazards including sealed combustion air inlets on gas furnaces, tied open radiation damper, and inaccessible duct smoke detector sampling tubes. |
| Evacuation diagrams improperly posted, many are upside down or sideways. |
| Fire safety rehearsals not performed regularly on each shift quarterly; multiple shifts missed rehearsals in last 12 months. |
| Emergency equipment not maintained safely; no emergency lighting in paths of egress; unsecured exit sign/emergency light in Sun Room. |
| Building not kept in good repair; smoke barrier doors missing panic hardware rods and end covers exposing sharp edges. |
| Fire alarm system not maintained; manual fire pull stations blocked by kitchen cart. |
| Electrical system unsafe; exterior electrical disconnect devices lack covers; GFCI receptacle does not trip when tested. |
| Fire safety compromised by unsealed holes in fire-resistance-rated assemblies and gaps around conduits allowing smoke and heat spread. |
| Smoke tight corridor doors not maintained; gaps and doors requiring excessive force to close. |
| Fire sprinkler heads obstructed by stored items; escutcheon plates do not cover holes allowing smoke and heat spread. |
| Corridor doors blocked open or held open by unapproved devices, limiting ability to contain smoke and fire. |
Report Facts
Total licensed capacity: 82
Inspection Report
Capacity: 82
Deficiencies: 7
Sep 20, 2017
Visit Reason
This 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 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant conditions including failure to maintain instructional signage on emergency exit doors, excessive particulate buildup in HVAC vents, mildew accumulation in mechanical closets, loose door hinges preventing proper latching, incomplete fire protection for electrical ceiling penetrations, plumbing without required air-gap, and failure of mechanical exhaust fans to properly ventilate several rooms.
Deficiencies (7)
| Description |
|---|
| Failed to maintain instructional signage on Main Kitchen exterior exit door with 15 second delay magnetic locking system. |
| Failed to maintain service and cleaning of HVAC air-distribution vents with excessive particulate buildup in resident bathrooms, corridor return-air grilles, and spa bathrooms. |
| Failed to prevent mildew accumulation in interior mechanical closets adjacent to Rooms 18 and 26 due to unsealed and uninsulated HVAC duct condensation. |
| Med Room entry door has a loose bottom door hinge preventing adequate latching. |
| Failed to maintain fire protection for electrical ceiling penetrations with incomplete fire-caulking in Front Mechanical Room. |
| Ice-machine condensate line to floor drain in Main Kitchen lacks required air-gap. |
| Mechanical exhaust fans not exhausting interior air in Room 27, Room 32, Mop Closet/Main Kitchen, and Men's/Women's Bathroom adjacent to Dining Hall. |
Report Facts
Licensed capacity: 82
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 6, 2016
Visit Reason
The Adult Care Licensure Section and the Rockingham County Department of Social Services conducted an annual survey on 10/5 and 10/06, 2016 to assess compliance with medication administration regulations.
Findings
The facility failed to assure medications were administered as ordered by a physician related to Coumadin for 2 of 2 sampled residents. Specifically, multiple physician orders for one-time dose adjustments of Coumadin were not administered or documented, and the pharmacy was not informed of these orders. The facility staff responsible for order review and medication administration were unaware of these omissions.
Deficiencies (2)
| Description |
|---|
| Failure to administer Coumadin as ordered by the physician for Resident #3, including missed one-time doses on 8/11/16, 8/30/16, and 8/31/16. |
| Failure to administer Coumadin as ordered by the physician for Resident #5, with discrepancies in dosing and documentation. |
Report Facts
INR lab results: 2.5
INR lab results: 1.8
INR lab results: 1.2
INR lab results: 1.4
INR lab results: 2.8
INR lab results: 3
INR lab results: 1.3
INR lab results: 1.6
INR lab results: 1.7
INR lab results: 2
INR lab results: 2.2
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding oversight of medication administration and training |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for reviewing new orders and placing them in resident records; interviewed about order tracking |
| Medication Aide | Medication Aide | Interviewed about medication order processing and faxing to pharmacy |
| Prescribing Physician's Nurse | Nurse | Interviewed regarding physician orders and awareness of missed medication doses |
| Facility Nurse | Nurse | Interviewed about medication administration and order review responsibilities |
Inspection Report
Biennial Survey
Capacity: 82
Deficiencies: 10
Nov 5, 2015
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 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a biennial survey.
Findings
Multiple deficiencies were found related to housekeeping, maintenance, fire safety, mechanical systems, plumbing safety devices, and exhaust ventilation. Issues included heavy dust accumulation on HVAC components, mildew and mold in mechanical rooms, blocked exit doors, gaps in fire resistant ceilings, non-functioning emergency exit signs, doors that do not latch properly, HVAC leaks, missing plumbing safety devices, and non-working exhaust fans.
Deficiencies (10)
| Description |
|---|
| Failure to keep HVAC components clean and in good repair due to heavy accumulation of dust and dirt on ductwork components. |
| Failure to keep wall components clean and in good repair; areas in need of painting with scratched and marred door surfaces and door frames. |
| Facility not maintained free from hazards; heavy mildew and mold accumulating on ceilings in mechanical rooms. |
| Facility not maintained free from obstructions; kitchen exit door blocked by food cart and trash can (corrected on site). |
| Failure to maintain fire safety systems; gaps and open penetrations in fire resistant rated ceilings. |
| Failure to maintain electrical emergency/safety equipment; exit signs did not work on battery power. |
| Failure to maintain fire safety equipment; doors do not completely close and latch, limiting smoke and fire containment. |
| Failure to maintain mechanical system; HVAC unit leak with standing water on closet floor. |
| Failure to install and maintain required plumbing safety devices; missing vacuum breakers/anti-siphon device for sink rinse wand. |
| Failure to provide mechanical exhaust ventilation in required rooms; exhaust fans in unisex and employee restrooms not working. |
Report Facts
Total licensed capacity: 82
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