Inspection Report
Capacity: 60
Deficiencies: 12
May 9, 2024
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety regulations applicable to the facility.
Findings
Multiple deficiencies were cited including failure of delayed egress locks to release within required time, lack of current building safety inspection reports, corridor obstructions, unsafe and unmaintained fire safety and electrical equipment, missing sprinkler escutcheon rings, holes in fire-resistant ceilings, broken plumbing fixtures, non-functioning emergency lighting, and inadequate exhaust ventilation.
Deficiencies (12)
| Description |
|---|
| Delayed egress locks did not release within 15 seconds when force was applied to the front entry door and Exit #3 door. |
| Facility did not have current building safety inspection reports available for review. |
| Corridors were obstructed by equipment such as a wheelchair diminishing corridor width and obstructing egress. |
| Outside grounds were not maintained in a clean and safe condition; missing escutcheon ring on sprinkler head near Service Hall Mechanical Room. |
| Failure to maintain emergency fire alarm system devices and equipment in safe operating condition, including trouble on Fire Alarm Control Panel and missing heat detector end cap. |
| Fire safety equipment not maintained in operating condition; dry pipe sprinkler system turned off for repairs, holes and gaps in fire-resistant ceilings, missing sprinkler escutcheon rings, unsealed cable penetrations, and open junction boxes. |
| Plumbing equipment not maintained in safe operating condition; broken hot water knob on floor sink. |
| Fire safety doors in smoke compartments did not close and latch properly. |
| Missing sprinkler head on Gallery Porch leaving a 2 inch diameter hole. |
| Electrical emergency/safety lighting equipment not maintained in safe operating condition; multiple emergency lights failed to illuminate on test. |
| Electrical equipment not maintained safely; open junction box in Riser Room. |
| Exhaust ventilation not maintained in specified spaces; kitchen housekeeping closet exhaust fan not working. |
Report Facts
Total licensed capacity: 60
Inspection Report
Follow-Up
Deficiencies: 2
Dec 19, 2018
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
Some deficiencies were not corrected. The building was not maintained safely due to improper handling of portable medical oxygen cylinders, and fire safety rehearsal records lacked sufficient description of the rehearsals.
Deficiencies (2)
| Description |
|---|
| One portable medical oxygen cylinder was stored in an unapproved plastic crate in room 710, posing a safety hazard. |
| Records of fire safety rehearsals lacked adequate description of what the rehearsals involved. |
Inspection Report
Capacity: 60
Deficiencies: 11
Oct 24, 2018
Visit Reason
This is a biennial construction section survey conducted to ensure the facility meets the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 Edition of the North Carolina State Building Code.
Findings
The facility was found deficient in several areas including lack of current sanitation and fire safety inspection reports, unsafe handling and storage of portable medical oxygen cylinders, improper use of extension cords, contamination risk from ice machine drain line, irregular fire safety rehearsals, malfunctioning emergency lights, compromised fire rated walls and ceilings, and corridor doors that do not close and latch properly.
Deficiencies (11)
| Description |
|---|
| Required annual fire alarm system inspection report could not be located. |
| Most recent Fire Marshal building safety inspection report could not be located. |
| Portable medical oxygen cylinders stored in an unapproved plastic crate in room 710. |
| Extension cord used in place of permanent wiring in maintenance office, penetrating ceiling. |
| Ice machine drain line extended into floor drain, risking contamination. |
| Fire drill rehearsals not conducted regularly with at least one per shift each quarter; records lacked descriptions. |
| Battery powered emergency lights would not work when tested in multiple locations. |
| Smoke barrier door near laundry did not close and latch when activated by fire alarm system. |
| One-hour fire rated walls and ceilings compromised by holes and penetrations not sealed properly. |
| Improperly fitting sprinkler escutcheons in spa and kitchen compromising fire rated ceilings. |
| Corridor doors to bedrooms 102 and 103 were wedged or propped open, preventing proper closing and latching. |
Report Facts
Licensed bed capacity: 60
Number of portable oxygen cylinders improperly stored: 7
Inspection Report
Follow-Up
Deficiencies: 3
Feb 16, 2017
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies related to building equipment and fire safety.
Findings
Several emergency lights on exterior porches failed to illuminate on backup power, and building fire safety was not maintained due to gaps in firestopping and missing or improperly attached vinyl siding. Some deficiencies from prior inspections were not corrected, requiring further action.
Deficiencies (3)
| Description |
|---|
| Emergency lights on exterior porches did not illuminate on backup power when tested. |
| Gap around a cable not firestopped as it penetrates the fire-resistance-rated ceiling assembly in the Business Office Coordinator Office. |
| Several pieces of vinyl siding were missing or improperly attached. |
Inspection Report
Capacity: 60
Deficiencies: 10
Nov 29, 2016
Visit Reason
This was a Construction Section Biennial Survey conducted to ensure compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including failure to maintain current sanitation and fire safety inspection reports, corridors obstructed by equipment, unsafe plumbing and building equipment, inadequate fire safety rehearsal documentation, electrical hazards, lack of maintenance and documentation for the kitchen hood fire suppression system, malfunctioning emergency lighting, and inadequate exhaust ventilation.
Deficiencies (10)
| Description |
|---|
| Facility failed to maintain current annual sanitation and fire safety inspection reports. |
| Corridors were obstructed by boxed Christmas decorations restricting width to less than seventy-two inches. |
| Building plumbing equipment was not maintained safely; commode connection to floor was loose in staff toilet room. |
| Fire plan rehearsals lacked sufficient documentation of what the rehearsals involved. |
| Emergency lighting did not illuminate on backup power at multiple corridor and exterior porch locations. |
| Gaps around cables in Business Office Coordinator and Executive Director offices were not firestopped. |
| Ground-fault circuit-interrupter (GFCI) electrical receptacle near kitchen serving window was burned. |
| Commercial kitchen hood fire suppression system lacked required monthly inspection documentation since March 2016. |
| Bedroom 205 corridor door did not latch into its frame when closed. |
| Exhaust ventilation system in staff toilet room on service corridor near kitchen did not work, allowing odor buildup. |
Report Facts
Total licensed beds: 60
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