Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Deficiencies: 0
Jun 3, 2025
Visit Reason
Report of a Construction Section Biennial Follow-Up Survey conducted on June 3, 2025.
Findings
All deficiencies identified in the previous inspection have been corrected. No further action is required.
Inspection Report
Annual Inspection
Deficiencies: 7
Feb 5, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 02/04/25 to 02/05/25 to assess compliance with state regulations for an adult care home.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing upon admission, incomplete physician signatures on care plans, failure to implement physician medication orders, incorrect therapeutic diet service, medication labeling errors, medication administration errors, and improper storage of discontinued medications.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure 1 of 5 residents sampled was tested upon admission for tuberculosis disease in compliance with control measures. |
| Facility failed to ensure care plans were signed by the Primary Care Provider within 15 days for 2 of 5 sampled residents. |
| Facility failed to ensure a physician order for warfarin was implemented for 1 of 5 sampled residents. |
| Facility failed to ensure therapeutic diets were served as ordered for 1 of 7 sampled residents with a diet order for a regular pureed diet. |
| Facility failed to ensure medication containers had correct labels for 2 of 6 sampled residents related to warfarin and ferrous sulfate medications. |
| Facility failed to ensure medications were administered as ordered for 1 of 5 sampled residents related to warfarin, sacubitril-valsartan, and rosuvastatin medications. |
| Facility failed to ensure discontinued medications were stored separately from actively used medications for 1 of 5 sampled residents. |
Report Facts
Residents sampled: 5
Residents sampled: 7
Residents sampled: 6
Medication counts: 3
Medication counts: 3
Medication counts: 2
Medication counts: 4
Medication tablets: 90
Medication tablets: 30
Medication tablets: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Registered Nurse (RN) | Responsible for ensuring TB tests, care plans, medication orders, and diet orders were managed and reviewed |
| Administrator | Oversaw facility compliance and was interviewed regarding responsibilities and findings | |
| Medication Aide | Responsible for entering medication orders, administering medications, and communicating with pharmacy | |
| Residential Care Coordinator | Responsible for care coordination and communication of diet orders | |
| Dietary Manager | Responsible for managing resident diet lists and meal preparation | |
| Primary Care Provider | Physician | Responsible for signing care plans and providing medication orders |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 26, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow-up survey on January 25-26, 2023 to assess compliance with regulations for the facility.
Findings
The survey identified multiple deficiencies including failure to document medication aide training for one staff member, inaccurate therapeutic diet lists for residents, and lack of physician orders and assessments for residents self-administering medications. Specifically, three residents lacked proper physician orders or assessments for self-administered medications, and therapeutic diet lists did not match physician orders for two residents.
Deficiencies (3)
| Description |
|---|
| Failure to ensure 1 of 3 Medication Aides sampled completed medication aide training hours with no documentation of successful training for Staff A. |
| Failure to maintain an accurate therapeutic diet list posted in the kitchen for 2 of 3 sampled residents with physician-ordered therapeutic diets. |
| Failure to ensure 3 of 3 sampled residents had physician orders and assessments for self-administration of medications, including missing orders for medications and oxygen, and lack of self-administration assessments. |
Report Facts
Medication Aides sampled: 3
Residents with therapeutic diets sampled: 3
Residents with self-administered medications sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in deficiency for lack of documented medication aide training |
| Health and Wellness Director | Interviewed regarding medication aide training, therapeutic diet list accuracy, and self-administration assessments | |
| Business Office Manager | Interviewed regarding personnel file audits and training documentation | |
| Administrator | Interviewed regarding personnel file audits and expectations | |
| Dietary Manager | Responsible for making therapeutic diet list | |
| Resident Care Coordinator | Responsible for providing kitchen copies of physician diet orders | |
| Executive Director | Interviewed regarding expectations for therapeutic diet list and self-administration assessments | |
| Medication Aide | Interviewed regarding awareness of resident medications and self-administration orders | |
| Personal Care Aide | Interviewed regarding resident independence and room access |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 22, 2020
Visit Reason
The Adult Care Licensure Section and the Gaston County DSS conducted an annual and follow-up survey on January 22-23, 2020 to assess compliance with regulations for therapeutic diets, medication administration, and staff training.
Findings
The facility failed to serve therapeutic diets as ordered for 2 of 3 sampled residents requiring texture modified diets, failed to administer medications as ordered for 1 of 5 sampled residents (specifically Warfarin dosing errors), and failed to ensure 1 of 3 medication aides successfully passed the required written exam within 60 days of skills validation.
Deficiencies (3)
| Description |
|---|
| Failed to assure therapeutic diets were served as ordered for 2 of 3 sampled residents with texture modified diet orders. |
| Failed to administer Warfarin medication as ordered for Resident #3, resulting in incorrect dosing on multiple occasions. |
| Failed to assure 1 of 3 Medication Aides successfully passed the written medication aide exam within 60 days of skills validation. |
Report Facts
Residents sampled with therapeutic diet orders: 3
Residents sampled for medication administration: 5
Medication Aides sampled: 3
Warfarin doses administered incorrectly: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Failed to pass the required written medication aide exam within 60 days of skills validation |
| Dining Services Coordinator | Responsible for therapeutic diet list and meal service | |
| Health and Wellness Director | Responsible for diet orders and medication order entry | |
| Administrator | Oversight of facility compliance with diet and medication orders | |
| Resident #3's Primary Care Physician | Provided Warfarin orders and expectations for therapeutic diets |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 19, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to the condition of walls and doors in resident rooms.
Findings
The facility failed to assure walls and doors in resident rooms #37 and #40 were in good repair, with multiple scratches, gouges, black scuff marks, and broken door components observed. Maintenance records showed no recent repairs for these rooms, and staff and residents reported ongoing damage caused by wheelchairs and lack of timely repairs by maintenance staff.
Deficiencies (1)
| Description |
|---|
| Walls and doors in resident rooms #37 and #40 had scratches revealing bare wood, black scuff marks, gouges, and broken door components. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Responsible for repairs; reported to have not repaired rooms #37 and #40 adequately. |
| Administrator | Administrator | Interviewed regarding maintenance responsibilities and expectations. |
| Resident Care Coordinator | Resident Care Coordinator | Received reports of needed repairs and complaints from staff. |
Inspection Report
Capacity: 86
Deficiencies: 9
Jan 9, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety standards for the facility.
Findings
Multiple deficiencies were cited related to building safety and maintenance, including issues with delayed egress locking systems, missing hand grips in bathrooms, unsafe outside premises, poor housekeeping and furnishings, inadequate fire safety rehearsals documentation, malfunctioning emergency equipment, fire safety hazards such as unsealed penetrations and fire door failures, obstructed sprinkler heads, and lack of spare fire sprinkler heads.
Deficiencies (9)
| Description |
|---|
| Delayed egress locking system doors did not release properly when force applied and instructional signs were faded or falling off. |
| Bathrooms lacked required hand grips at commodes accessible to residents. |
| Outside grounds were not maintained in a clean and safe condition due to broken landscape lights. |
| Building components were broken or missing parts, including a missing panic device end cover exposing sharp edges. |
| Fire safety rehearsals were not properly documented with staff response, duration, or description. |
| Emergency exit sign at front entrance did not illuminate on backup power. |
| Fire safety hazards included unsealed holes in smoke tight walls and ceilings, fire rated doors not latching properly, and gaps around fire-resistance-rated assemblies. |
| Fire sprinkler heads were obstructed by stored items and some sprinkler heads had missing or incomplete escutcheon plates allowing smoke and heat spread. |
| No spare fire sprinkler heads of the required type were available in the sprinkler head storage box. |
Report Facts
Total licensed capacity: 86
Force applied to delayed egress door: 15
Date of inspection: Jan 9, 2019
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 11, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 10/09/18-10/11/18 to assess compliance with regulations related to housekeeping, furnishings, and health care.
Findings
The facility was found out of compliance with housekeeping standards due to stained carpets and damaged walls and doors in multiple resident rooms and corridors. Additionally, the facility failed to notify the physician and properly monitor blood pressure and pulse for one resident (Resident #5), resulting in a Type B violation related to health care and medication administration.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Walls and floors in 5 resident rooms and main corridors were not clean and in good repair, with stained carpets and damaged walls and doors. | — |
| Failure to notify the physician for Resident #5 regarding blood pressure readings outside ordered parameters. | Type B Violation |
| Failure to implement physician's orders for Resident #5 related to monitoring blood pressure and pulse prior to medication administration. | — |
| Failure to assure residents received care and services that are adequate and appropriate, specifically related to health care and medication administration for Resident #5. | — |
Report Facts
Resident rooms with housekeeping deficiencies: 5
Blood pressure readings outside parameters: 9
Hospitalization days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for carpet cleaning, wall repairs, and maintenance issues. | |
| Administrator | Provided information about carpet cleaning contracts and maintenance responsibilities. | |
| Medication Aide | MA | Responsible for notifying physician of blood pressure issues and administering medications. |
| Resident Care Coordinator | RCC | Responsible for auditing eMARs and resident records and entering new orders. |
| Health and Wellness Director | HWD | Responsible for processing new physician orders and auditing eMARs. |
Inspection Report
Follow-Up
Deficiencies: 3
Dec 6, 2017
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services conducted a follow-up survey on December 5 and 6, 2017 to verify correction of previous deficiencies.
Findings
The facility failed to maintain walls, ceilings, and floors in good repair in multiple resident rooms, and failed to assure medications were administered as ordered for sampled residents, with multiple discrepancies found in medication administration records and medication availability. The facility also failed to maintain accurate medication administration records for two sampled residents.
Deficiencies (3)
| Description |
|---|
| Facility failed to assure walls and floors in 4 resident rooms (#13, #27, #37, and #40) were clean and in good repair, with multiple scuff marks, gouges, and worn carpets observed. |
| Facility failed to assure medications were administered as ordered for 1 of 5 sampled residents (Resident #2), including incorrect dosages, missing medications, and failure to update medication administration records. |
| Facility failed to assure accuracy of medication administration records (MARs) for 2 of 5 sampled residents (Resident #1 and Resident #2), including missing documentation of medication administration and failure to discontinue medications as ordered. |
Report Facts
Resident rooms with wall/floor issues: 4
Sampled residents with medication issues: 2
Dates of follow-up survey: December 5 and 6, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff | Reported on repairs and maintenance of walls and carpets | |
| Executive Director | Interviewed regarding maintenance and medication issues | |
| Medication Aides | Interviewed regarding medication administration and documentation errors | |
| Resident Care Coordinator | Responsible for reviewing medication orders and eMARs, interviewed about medication administration procedures | |
| Health and Wellness Director | Involved in reviewing medication orders and planning staff training |
Inspection Report
Follow-Up
Deficiencies: 5
Aug 1, 2017
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services conducted a follow-up survey on August 1 and 2, 2017 with a telephone exit on August 3, 2017.
Findings
The facility failed to maintain walls and floors in good repair and clean condition in multiple resident rooms and common areas. The facility also failed to implement physician orders for thromboembolic deterrent stockings (TED hose) for Resident #2, and failed to ensure licensed health professional support evaluations were completed timely for Residents #2 and #5. Additionally, medication administration errors were found for Residents #1, #3, #5, and #6, including incorrect dosages and inaccurate medication administration records.
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to assure walls and floors were clean and in good repair in 10 Resident Bedrooms, 1 Resident Bathroom, and all Hallways throughout the facility. | — |
| Facility failed to order and apply compression stockings as ordered by the primary care provider for Resident #2. | Type B Violation |
| Facility failed to ensure Licensed Health Professional Support evaluations were completed within required timeframes for Residents #2 and #5. | — |
| Facility failed to assure medications were administered as ordered for Residents #1, #3, #5, and #6, including incorrect clonazepam dosage and administration of wrong acetaminophen strength. | — |
| Medication Administration Records (MARs) were inaccurate for Residents #1 and #5 regarding Xanax and clonazepam administration. | — |
Report Facts
Resident rooms with deficiencies: 10
Resident bathrooms with deficiencies: 1
Medication administration documentation: 30
Medication administration documentation: 15
Medication administration documentation: 26
Medication administration documentation: 30
Medication administration documentation: 31
Inspection Report
Annual Inspection
Deficiencies: 8
Mar 31, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on March 29, 30, and 31, 2017 to assess compliance with state regulations.
Findings
The survey identified multiple deficiencies including housekeeping issues with cleanliness and repair of walls and floors, hot water temperatures exceeding regulatory limits in resident bathrooms, incomplete tuberculosis testing upon admission for one resident, failure to complete quarterly Licensed Health Professional Support evaluations for two residents, failure to serve a resident's therapeutic diet as ordered, and medication administration errors involving three residents.
Severity Breakdown
Type B Violation: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to assure walls and floors were clean and in good repair in 9 resident bedrooms/bathrooms and common areas. | — |
| Hot water temperatures exceeded the maximum allowed 116 degrees F in 8 resident bathroom sinks. | — |
| Facility failed to assure tuberculosis testing was completed upon admission for 1 of 5 sampled residents. | — |
| Licensed Health Professional Support evaluations were not completed quarterly for 2 of 5 sampled residents and lacked required assessments and recommendations. | — |
| Facility failed to serve a resident's physician-ordered 2 gram sodium diet; resident was served a regular diet instead. | — |
| Medications (furosemide, fexofenadine, and Seroquel) were not administered as ordered for 3 residents; diphenhydramine was given in place of fexofenadine without an order. | Type B Violation |
| Medication Administration Records inaccurately documented administration of fexofenadine when diphenhydramine was given instead. | — |
| Facility failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to medication administration. | — |
Report Facts
Number of resident bedrooms/bathrooms with housekeeping deficiencies: 9
Number of sinks with hot water temperature violations: 8
Number of sampled residents without TB testing upon admission: 1
Number of sampled residents without quarterly LHPS evaluations: 2
Number of residents with medication administration errors: 3
Number of doses of fexofenadine documented as administered but not available: 52
Number of missed doses of furosemide: 6
Number of days Seroquel not administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for LHPS assessments, medication oversight, and housekeeping communication | |
| Resident Care Coordinator | Responsible for TB testing assurance and medication oversight | |
| Medication Aides | Administered medications and documented administration; involved in medication ordering | |
| Administrator | Oversight of facility operations and regulatory compliance |
Inspection Report
Capacity: 86
Deficiencies: 13
Jan 26, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety standards for the facility licensed for 86 beds.
Findings
Multiple deficiencies were cited related to building safety and maintenance, including malfunctioning delayed egress locks, unsecured oxygen cylinders, lack of ground fault interrupters on electrical outlets in wet locations, missing exit signs, fire sprinkler system issues, and general housekeeping and maintenance problems.
Deficiencies (13)
| Description |
|---|
| Delayed egress lock near Bedroom 47 did not initiate unlocking process as required. |
| Delayed egress locking doors reenergize when fire alarm is silenced. |
| Loose connection of commode to floor in Bedroom 33. |
| Vinyl floor tiles stained around commode in Shower Room near Bedroom 31. |
| Four portable medical oxygen cylinders stored standing up unsecured in Oxygen Room. |
| Excessive accumulation of dust/lint on exhaust fan in Bedroom 29 Bathroom and HVAC return grille in Executive Director's Office. |
| Ground-fault circuit-interrupter (GFCI) electrical outlet on Left Porch did not trip when tested. |
| No exit signs on either side of Cross-Corridor doors near Bedroom 43. |
| Excessive gaps (¼ inch to ¾ inch) between leaves of firewall cross-corridor double-egress doors. |
| Exit sign near Sunroom did not illuminate on backup power. |
| Corridor door in Bedroom 35 did not latch due to screw in strike. |
| Fire sprinkler escutcheon plates dropped or not covering holes in multiple rooms allowing spread of smoke and heat. |
| Light fixture missing in corridor near Bedroom 16. |
Report Facts
Licensed bed capacity: 86
Number of unsecured oxygen cylinders: 4
Gap size in firewall doors: 0.75
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 5
Aug 27, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on August 26-27, 2015.
Findings
The facility failed to maintain clean and well-repaired walls, ceilings, and floors in multiple resident bedrooms, with numerous carpet stains and damage observed. Additionally, the facility did not ensure all staff had completed required criminal background checks and failed to provide adequate staffing to meet residents' personal care and supervision needs.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to assure walls and floors were clean and in good repair in 15 resident bedrooms, with multiple carpet stains and damage observed. | — |
| Facility failed to assure 1 of 5 sampled staff had a criminal background check in accordance with regulations. | — |
| Facility failed to assure there were staff available to perform laundry, housekeeping, and kitchen duties in addition to attending to residents' personal care needs. | — |
| Facility failed to assure 1 of 5 sampled residents was adequately supervised in accordance with assessed needs, resulting in a Type B Violation. | Type B Violation |
| Facility failed to assure residents receive care and services which are adequate, appropriate, and in compliance with federal and state laws related to personal care and supervision. | — |
Report Facts
Resident census: 61
Number of resident bedrooms with deficiencies: 15
Number of sampled staff without criminal background check: 1
Number of sampled residents inadequately supervised: 1
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