Inspection Report
Capacity: 72
Deficiencies: 8
May 7, 2025
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes and physical plant requirements for an adult care home licensed for 72 beds.
Findings
Multiple deficiencies were noted including lack of sprinklers in the kitchen cooler and freezer, inadequate outdoor lighting on egress paths, accumulation of dust on exhaust fan grills, plumbing issues such as missing air gap on ice machine drain and a non-functioning water heater, fire doors not closing properly, fire alarm system troubles, and several exhaust fans not working.
Deficiencies (8)
| Description |
|---|
| Kitchen cooler and freezer do not have sprinklers as required by the 1996 NC State Building Code. |
| Exterior egress paths around the back of the facility are not lit as required. |
| Exhaust fan grills throughout the facility are accumulating dust and need cleaning. |
| Ice machine drain lacks the correct 2 inch air gap. |
| One of the main water heaters is not functioning. |
| Fire doors leading to the 100 and 300 hallways do not close properly, having gaps larger than the allowable 1/8 inch. |
| Fire alarm panel has trouble; a pull station and 8 smoke detectors are not reporting back to the panel. |
| Exhaust fans in the SCU laundry room, SCU bathroom, and 200 hall housekeeping closet are not working. |
Report Facts
Licensed bed capacity: 72
Number of smoke detectors not reporting: 8
Allowable fire door gap: 0.125
Inspection Report
Follow-Up
Deficiencies: 4
Oct 2, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on October 2 and 3, 2024 to verify correction of previously identified deficiencies.
Findings
The facility failed to ensure that Resident #5 had an updated FL-2 medical examination completed annually, accurate care plans signed by the assessor and primary care provider, and failed to administer medications as ordered for Resident #1, specifically a medication used to treat constipation. Medication cart audits were not consistently performed and outside medications were not properly verified against physician orders.
Deficiencies (4)
| Description |
|---|
| Failed to ensure 1 of 5 sampled residents (#5) had a FL-2 completed annually. |
| Failed to ensure 1 of 5 sampled residents (#5) had accurate care plans signed by the assessor upon completion. |
| Failed to ensure 1 of 5 sampled residents (#5) had a care plan signed by the primary care provider within 15 days of assessment. |
| Failed to administer medications as ordered for 1 of 5 sampled residents (#1) pertaining to a medication used to treat constipation. |
Report Facts
Sampled residents: 5
Deficiencies related to Resident #5: 3
Deficiencies related to Resident #1: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Coordinator | Licensed Practical Nurse (LPN) | Interviewed regarding FL-2 and care plan completion and medication administration oversight |
| Health and Wellness Director | Registered Nurse (RN) | Responsible for completing FL-2s, care plans, and medication cart audits |
| Interim Administrator | Interviewed regarding overall responsibility for FL-2s, care plans, and medication administration | |
| Special Care Unit Medication Aide | Interviewed regarding medication administration and handling of outside medications | |
| Special Care Unit Coordinator | Interviewed regarding medication administration procedures and oversight |
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 18, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on July 16-18, 2024 to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in multiple areas including failure to complete and sign Resident Registers within 72 hours of admission for 4 of 5 sampled residents, failure to serve therapeutic diets as ordered, medication administration errors affecting 3 residents, inaccurate medication administration records for 2 residents, and unsafe storage of self-administered medications for 3 residents.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident Register was not completed and signed within 72 hours of admission for 4 of 5 sampled residents (#1, #2, #3, and #4). | — |
| Failed to ensure a therapeutic diet was served as ordered for Resident #3 with a pureed diet order. | — |
| Medications were not administered as ordered to 3 residents (#2, #5, #8) including timing errors and incorrect medication administration. | Type B Violation |
| Medication administration records (MAR) were inaccurate for 2 residents (#2, #5) including discrepancies between prescribed and administered medications. | — |
| Medications were not stored in a safe and secure manner for 3 residents (#1, #9, #10) who self-administered medications, with unlocked doors and accessible medications. | — |
Report Facts
Medication error rate: 19
Residents with incomplete Resident Register: 4
Residents with unsafe medication storage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Responsible for signing Resident Registers and overseeing admission paperwork; interviewed regarding deficiencies | |
| Clinical Services Supervisor | Responsible for ensuring paperwork completion; interviewed regarding Resident Register and medication administration | |
| Health and Wellness Coordinator | Responsible for paperwork completion and entering medication orders; interviewed regarding Resident Register and medication administration | |
| Business Office Manager | Responsible for ensuring Resident Register completion before admission; interviewed regarding Resident Register | |
| Dining Services Manager | Interviewed regarding therapeutic diet preparation and adherence | |
| Medication Aide | Observed administering medications; interviewed regarding medication administration and storage | |
| Regional Clinical Service Specialist | Interviewed regarding medication administration system and education | |
| Pharmacy Technician | Interviewed regarding medication prescriptions and concerns about administration timing | |
| Pharmacist | Interviewed regarding medication administration timing and effects |
Inspection Report
Follow-Up
Capacity: 72
Deficiencies: 11
Sep 6, 2023
Visit Reason
A Construction Section Biennial Follow-Up survey was conducted to assess conformance with applicable physical plant standards and building codes for the licensed adult care home.
Findings
Multiple deficiencies were cited related to physical plant maintenance including failure to maintain emergency exit doors with a master override switch, worn flooring, lack of GFCI protection on electrical outlets near water sources, deteriorated fire safety components, unsealed holes compromising fire safety, malfunctioning fire alarm control of emergency exits, and inoperable exhaust fans in specified areas.
Deficiencies (11)
| Description |
|---|
| The master override switch in the Special Care Unit does not release the emergency exit doors. |
| The floor in the main nurses station is worn beyond repair. |
| Electrical outlets surrounding the laundry room washer machines are not GFCI protected. |
| Exterior sprinkler escutcheons are rusted/pitting with evidence of holes. |
| Multiple holes in walls/ceiling at exit doors where old key pads were removed are not sealed with proper fire rated material. |
| Large hole in boiler room above hot water tank. |
| Stain on ceiling around recessed light in dining room diminishing fire rating. |
| Fire door leaf closest to main nurses station drags on floor preventing proper closure. |
| Fire alarm system does not control emergency exit doors; doors do not release when alarm tested. |
| Emergency egress exit doors are not tied into fire alarm system and cannot be opened with one-handed motion. |
| Exhaust fans in the 100 and 300 hall do not work. |
Report Facts
Licensed bed capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Meyer | Conducted the Construction Section Biennial Follow-Up survey |
Inspection Report
Annual Inspection
Deficiencies: 5
Apr 21, 2022
Visit Reason
The Adult Care Licensure Section and the Carteret County Department of Social Services conducted an annual survey on April 20-21, 2022.
Findings
The facility failed to have matching therapeutic diet menus for residents with physician-ordered therapeutic diets, failed to administer medications as ordered for one resident related to pain and anxiety medications, failed to maintain accurate medication administration records, failed to implement infection control measures during medication administration, and failed to ensure self-administered medications were stored in a safe and secure manner.
Deficiencies (5)
| Description |
|---|
| Facility failed to have matching therapeutic diet menus for 3 of 6 sampled residents with physician-ordered therapeutic diets. |
| Facility failed to administer medications as ordered for 1 of 5 residents sampled related to pain and anxiety medications. |
| Facility failed to ensure electronic medication administration records were accurate for 1 of 5 sampled residents including documentation of pain and anti-anxiety medication administration. |
| Facility failed to ensure infection control measures during medication administration when medication dropped on the floor was given to resident without replacement. |
| Facility failed to ensure self-administered medications were stored in a safe and secure manner for 1 resident who kept medications unlocked in his room. |
Report Facts
Residents with therapeutic diet orders lacking matching menus: 3
Doses of Xanax not administered: 6
Doses of Oxycodone not documented on eMAR: 13
Doses of Oxycodone not documented on eMAR: 13
Doses of Oxycodone not documented on eMAR: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Named in medication administration and documentation deficiencies related to pain and anxiety medications. |
| Resident #2 | Resident | Named in therapeutic diet and medication storage deficiencies. |
| Resident #3 | Resident | Named in therapeutic diet deficiency. |
| Resident #6 | Resident | Named in therapeutic diet deficiency. |
| Resident #7 | Resident | Named in infection control deficiency related to medication administration. |
| Health and Wellness Coordinator | Interviewed regarding therapeutic diet menus, medication administration, and medication storage. | |
| Administrator | Interviewed regarding therapeutic diet menus, medication administration, infection control, and medication storage. | |
| Medication Aide | Observed and interviewed regarding medication administration and infection control. |
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 11, 2019
Visit Reason
The Adult Care Licensure Section and Carteret County Department of Social Services conducted an annual survey on April 9-11, 2019 to assess compliance with medication administration regulations.
Findings
The facility failed to administer medications as ordered for 1 of 6 sampled residents (#2), including errors with medications used for pain, to thin mucus, to thin the blood, a vitamin supplement, and a laxative. Multiple missed doses were documented due to awaiting pharmacy delivery, and medication availability issues were noted from February 5 through February 11, 2019.
Deficiencies (1)
| Description |
|---|
| Failed to administer medications as ordered for Resident #2, including Aspirin EC, Acetaminophen, Mucinex ER, Vitamin D3, Senexon-S, and Celebrex, with documented missed doses due to awaiting pharmacy. |
Report Facts
Tablets dispensed: 23
Tablets dispensed: 69
Tablets dispensed: 46
Tablets dispensed: 23
Tablets dispensed: 46
Tablets dispensed: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding medication administration and medication cart audits | |
| Lead Medication Aide | Interviewed regarding medication cart audits and medication availability | |
| Executive Director | Interviewed regarding medication order processes and expectations on admission | |
| Pharmacist | Interviewed regarding pharmacy delivery and medication orders |
Inspection Report
Follow-Up
Deficiencies: 3
Jun 15, 2018
Visit Reason
This was a biennial follow-up construction survey to verify correction of previously identified deficiencies related to building code compliance and physical plant requirements.
Findings
The survey found that some deficiencies were not corrected, including doors in smoke barrier walls lacking the required fire rating, missing signage on delayed egress exit doors, and corridor doors that do not close and latch properly, which could compromise fire safety.
Deficiencies (3)
| Description |
|---|
| Doors in smoke barrier walls did not have the required minimum 20 minute fire rating, including a pair of 15 pane French type doors in the Special Care Unit. |
| Exit doors lacked required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.' on delayed egress exits near room 403 and the Activity Parlor. |
| Many corridor doors were prevented from closing quickly and latching, including one pair of doors to the Dining room that does not latch when closed. |
Inspection Report
Capacity: 72
Deficiencies: 19
Feb 7, 2018
Visit Reason
Report of Construction Section Biennial Survey conducted on 2-7-2018 to assess compliance with applicable building codes and adult care home regulations.
Findings
Multiple deficiencies were cited including failure to meet NC State Building Code fire rating requirements for smoke barrier doors, missing signage on delayed egress exits, lack of current correction documentation for sprinkler inspection deficiencies, absence of hand grips in bathrooms, corridor obstructions, housekeeping and maintenance issues, fire safety rehearsal record deficiencies, compromised fire rated walls and ceilings, malfunctioning emergency lights and fire alarm silence feature, and inadequate exhaust ventilation in certain areas.
Deficiencies (19)
| Description |
|---|
| Smoke barrier wall doors in Special Care Unit lack required 20 minute fire rating. |
| Delayed Egress exit doors missing required signage near room 403 and Activity Parlor. |
| Sprinkler inspection report dated 01-22-2018 listed 4 deficiencies with no documentation of correction. |
| No hand grips provided at tub in Clarebridge and shower in the Spa. |
| Corridors obstructed by medical carts, chairs, and game table reducing clear width below required 6 feet. |
| Ceiling HVAC penetrations not kept clean; radiation damper in Clarebridge laundry exhaust very dirty. |
| Improper handling and storage of portable medical oxygen cylinders and storage too close to fire sprinkler head. |
| No documentation of January monthly inspection on range hood fire suppression system tag. |
| Missing globe on outdoor light fixture near room 409. |
| Fire safety rehearsal records lack sufficient description of activities involved. |
| One-hour fire rated walls and ceilings compromised by holes, unsealed penetrations, missing or fallen fire collars in multiple locations including Control Room and Training Room. |
| Sprinkler escutcheons missing or improperly mounted in multiple locations compromising fire rated ceilings. |
| Corridor doors prevented from closing and latching properly, including laundry door held open with magnet and doors to Dining room and various offices with holes or not latching. |
| Many corridor doors do not fit openings properly to resist passage of smoke in multiple resident rooms and offices. |
| Battery powered emergency lights in corridor at room 207 and Clarebridge laundry would not work when tested. |
| Broken switch plate and missing junction box cover in control room exposing energized wires. |
| GFCI electrical outlet in 300 Hall Parlor would not trip when tested, posing electrocution hazard. |
| Fire alarm silence feature not working; horns and strobes continued to sound in 100 and 200 halls when system silenced. |
| Exhaust ventilation not working in janitor closet by kitchen and laundry in Clarebridge. |
Report Facts
Licensed bed capacity: 72
Sprinkler inspection deficiencies: 4
Portable medical oxygen cylinders improperly stored: 7
Clear corridor width required: 6
Clearance below sprinkler head: 18
Storage clearance observed: 4
Inspection Report
Annual Inspection
Capacity: 72
Deficiencies: 7
Feb 3, 2016
Visit Reason
This is a Report of a Biennial Construction Survey conducted on February 3, 2016, to assess compliance with physical plant and safety regulations for the facility.
Findings
The facility was found to have multiple deficiencies related to physical plant safety, including fire safety issues, housekeeping hazards, delayed egress signage, and electrical system maintenance. Corrective actions were planned and scheduled for monthly inspections to ensure compliance.
Deficiencies (7)
| Description |
|---|
| The facility failed to ensure the building is safe by not maintaining fire resistance of building components, including smoke doors that do not close properly and doors propped open. |
| Oxygen bottles in storage rooms and patient rooms were not properly supported, posing a hazard. |
| The facility failed to maintain the EXIT door so that it easily opens in an emergency. |
| Housekeeping and furnishings were not clean or in good repair, including vinyl flooring damage and accumulation of dust and dirt in HVAC grills. |
| Delayed egress EXIT doors lacked proper signage, potentially confusing occupants during emergencies. |
| Corridors were narrowed by furniture and equipment, reducing clearance below required widths. |
| Electrical system deficiencies included non-working light fixtures in EXIT vestibules and exterior areas, creating dark and unsafe conditions. |
Report Facts
Total licensed beds: 72
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