Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Deficiencies: 4
Sep 17, 2025
Visit Reason
The Adult Care Licensure Section and Gaston County Department of Social Services conducted a follow-up survey to verify correction of previously identified deficiencies related to healthcare referral, medication administration, and incident reporting.
Findings
The facility failed to ensure proper referral and follow-up for residents' healthcare needs, failed to administer medications as prescribed for multiple residents, and failed to notify the county Department of Social Services of incidents involving resident injuries requiring emergency medical treatment. Documentation and notification deficiencies were noted for Residents #1, #2, #3, and #4.
Deficiencies (4)
| Description |
|---|
| Failed to ensure referral and follow-up to meet routine healthcare needs for Resident #2 related to notifying the Primary Care Physician for systolic blood pressure readings of 110 or less and/or pulse less than 60. |
| Failed to ensure medications were administered as prescribed for Resident #1 related to blood sugar control and insulin administration. |
| Failed to ensure medications were administered as prescribed for Resident #3 related to blood pressure medication valsartan being given despite blood pressure readings outside ordered parameters. |
| Failed to notify the county Department of Social Services for incidents involving Residents #3 and #4 who received injuries requiring emergency medical treatment. |
Report Facts
Medication administration opportunities missed: 6
Missed documentation dates: 4
Valsartan administration outside parameters: 4
Falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding medication administration and notification responsibilities. | |
| Health and Wellness Director | Interviewed regarding oversight of medication administration, audits, and incident reporting. | |
| Administrator | Interviewed regarding expectations for medication administration, documentation, and incident reporting. |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 8, 2025
Visit Reason
The Adult Care Licensure Section and Gaston County Department of Social Services conducted an annual survey and complaint survey on 07/07/25-07/08/25. The complaint investigation was initiated by Gaston County Department of Social Services on 06/16/25.
Findings
The facility failed to ensure exit doors had continuous sounding devices activated, allowing a disoriented resident (#1) to elope without staff knowledge, and failed to provide adequate supervision for this resident. Additionally, the facility failed to ensure proper referral and follow-up for routine healthcare needs of residents #4 and #5, and failed to administer medications as ordered for residents #2, #4, and #5 related to blood pressure and blood sugar management.
Complaint Details
Complaint investigation initiated by Gaston County Department of Social Services on 06/16/25 related to Resident #1 eloping from the facility without staff knowledge.
Severity Breakdown
Type A2 Violation: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| The facility failed to ensure the exit doors had a continuous sounding device activated when Resident #1, who was disoriented and exit seeking, exited without staff being alerted. | Type A2 Violation |
| The facility failed to provide supervision for Resident #1 resulting in the resident leaving the facility without staff knowledge. | Type A2 Violation |
| The facility failed to ensure referral and follow-up to meet routine healthcare needs for Residents #4 and #5 related to notifying the Primary Care Provider for abnormal vital signs and blood sugar levels. | — |
| The facility failed to administer medications as ordered for Residents #2, #4, and #5 related to blood pressure, fluid retention, and elevated blood sugar levels. | — |
Report Facts
Deficiencies cited: 4
Resident #1 elopement distance: 0.2
Resident #4 heart rate less than 60 occurrences: 14
Resident #4 systolic blood pressure less than 100 occurrences: 4
Resident #5 FSBS less than 80 occurrences: 13
Medication administration errors: 7
Medication administration errors: 7
Medication administration errors: 3
Medication administration errors: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Provided information on medication administration responsibilities and notification procedures. | |
| Health and Wellness Director | Provided information on door alarm issues, medication administration, and staff retraining. | |
| Administrator | Provided information on incident response, door alarm issues, and medication administration oversight. | |
| Maintenance Director | Reported on keypad lock issues with kitchen door related to Resident #1 elopement. | |
| Medication Aide | Multiple interviews regarding supervision of Resident #1, medication administration, and door alarm awareness. | |
| Personal Care Aide | Provided observations on Resident #1's wandering and door alarm issues. |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 3, 2025
Visit Reason
Report of Construction Section Biennial Follow-Up Survey conducted on June 3, 2025.
Findings
All deficiencies identified in the previous survey have been corrected. No further action is required.
Inspection Report
Annual Inspection
Deficiencies: 5
Jan 5, 2024
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services completed an annual survey from 01/03/24 to 01/05/24.
Findings
The facility failed to provide adequate supervision for Resident #2 who sustained 10 unwitnessed falls in two months, resulting in serious injury and hospitalization. The facility also failed to ensure immediate response and intervention after a fall with mental status changes, failed to follow-up on a required pulmonologist appointment, and failed to administer a prescribed medication to prevent hepatic encephalopathy. Additionally, the facility failed to provide non-disposable place settings during meals and failed to offer snacks to all residents between meals.
Severity Breakdown
Type A2 Violation: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide supervision for Resident #2 who sustained 10 unwitnessed falls in two months, resulting in serious injury including a large left-sided subdural hemorrhage requiring emergency surgery and ICU admission. | Type A2 Violation |
| Failed to ensure immediate response and intervention after Resident #2 displayed confusion and mental status changes following a fall, resulting in hospitalization with serious brain injury. | Type A2 Violation |
| Failed to ensure referral and follow-up to meet acute health care needs of Resident #2 related to a missed pulmonologist appointment and failure to administer prescribed medication (Xifaxan) to prevent hepatic encephalopathy, resulting in hospitalization. | Type A2 Violation |
| Failed to ensure mealtime service consisted of non-disposable place settings for all residents; styrofoam containers and plastic utensils were used for residents eating in their rooms. | — |
| Failed to ensure snacks were offered to all residents three times a day as required; snacks were inconsistently provided and often only given upon resident request. | — |
Report Facts
Number of unwitnessed falls: 10
Number of head injuries: 5
Medication non-administration days: 25
Snack frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Interviewed regarding supervision, fall response, medication follow-up, and snack distribution. | |
| Administrator | Interviewed regarding supervision, fall response, medication follow-up, and meal/snack service. | |
| Medication Aide | Interviewed regarding fall documentation, resident monitoring, and medication administration. | |
| Pulmonology Nurse Practitioner | Interviewed regarding missed pulmonology follow-up and CPAP use. | |
| Primary Care Physician | Interviewed regarding resident's falls, supervision expectations, and medication orders. | |
| Dietary Manager | Interviewed regarding meal service and use of styrofoam containers. |
Inspection Report
Capacity: 89
Deficiencies: 14
Jan 9, 2019
Visit Reason
This document is a Construction Section Biennial Survey conducted to ensure the facility meets applicable adult care home licensing rules and North Carolina State Building Code requirements.
Findings
The survey identified multiple deficiencies including unclean mechanical systems, unsafe storage of portable medical oxygen cylinders, improperly maintained fire safety systems including fire alarms, sprinkler system issues, malfunctioning exit signs, compromised fire-rated walls and ceilings, and electrical safety hazards such as unprotected and broken GFCI receptacles.
Deficiencies (14)
| Description |
|---|
| HVAC exhaust grill and radiation damper in the laundry had excessive dust/lint accumulation. |
| Improper handling and storage of portable medical oxygen cylinders in multiple locations. |
| Ice machine drain line extended into the floor drain, risking contamination. |
| Shower wand hose in Spa lacked vacuum breaker, risking water contamination. |
| Evacuation plan posted near room 31 was not oriented correctly. |
| Fire plan rehearsals records lacked sufficient description of activities. |
| Fire alarm system showed 'Trouble' condition and did not sound alarm during test; delayed egress doors failed to release. |
| Sprinkler system deficiencies including water turned off due to pipe blow-out and lack of spare heads. |
| Multiple exit signs malfunctioned or had incorrect directional indicators. |
| Many corridor doors did not close and latch properly, with holes at latchsets and improper fitting doors. |
| One-hour fire rated walls and ceilings compromised by holes, unsealed penetrations, cracks, and unfinished openings in multiple locations. |
| Outside receptacle near exit at room 61 was not GFCI protected. |
| Broken GFCI receptacle in bathroom off room 15. |
| No documentation of required monthly inspections for range hood fire suppression system. |
Report Facts
Total licensed capacity: 89
Portable medical oxygen cylinders improperly stored: 35
Fire safety rehearsals frequency: 4
Access opening size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Harrell | Surveyor conducting the Construction Section Biennial Survey. | |
| Ed Miller | Surveyor conducting the Construction Section Biennial Survey. | |
| Maintenance Director | Maintenance Director | Interviewed regarding fire alarm system repairs and sprinkler technician activities. |
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 19, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on December 18-19, 2018 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to assure physician notification for elevated blood sugars in one resident, administered incorrect medication doses or discontinued medications without proper orders for three residents, and had inaccurate electronic Medication Administration Records (eMAR) for two residents.
Deficiencies (3)
| Description |
|---|
| Failed to assure physician notification for Resident #3 regarding elevated finger stick blood sugars (FSBS) above 300 for three consecutive checks. |
| Failed to administer medication as ordered for Residents #1, #4, and #5, including incorrect doses of vitamin D and Toviaz, discontinuing Toprol without proper order, and not administering Flonase. |
| Failed to ensure accurate electronic Medication Administration Records (eMAR) for Residents #1 and #5, including incorrect vitamin D dosing and missing Flonase administration entries. |
Report Facts
Sampled residents: 5
Elevated FSBS readings: 6
Vitamin D doses: 2
Toviaz doses: 2
Flonase administration entries: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for oversight of medication order entry and audits; involved in findings related to medication administration and eMAR accuracy |
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for oversight of medication order entry and audits; involved in findings related to medication administration and eMAR accuracy |
| Medication Aide | Medication Aide (MA) | Responsible for medication administration and order entry; involved in failures to notify physician and medication administration errors |
| Administrator | Facility Administrator | Provided statements regarding expectations and concerns about medication administration and oversight |
Inspection Report
Capacity: 89
Deficiencies: 9
Jan 25, 2017
Visit Reason
This is a Construction Section Biennial Survey requiring the facility to meet the 1996 Rules for Licensing of Adult Care Homes, applicable portions of the 2005 Rules, and the North Carolina State Building Code.
Findings
Multiple deficiencies were cited including unsafe hand grips in bathrooms, damaged exterior pathways and fences, unclean HVAC grilles, non-functioning emergency lighting and exit signs, lack of fire protection in roof penetrations, non-functional ground-fault circuit interrupters, doors that do not latch properly, and inadequate exhaust ventilation in certain areas.
Deficiencies (9)
| Description |
|---|
| Hand grips in bathrooms not maintained in a safe condition, risking falls. |
| Exterior pathways and protective structures damaged creating trip hazards and fallen fences. |
| HVAC supply and return air grilles have excessive particulate build-up. |
| Emergency lighting failed to illuminate in multiple locations during emergency mode. |
| Emergency exit lighting not illuminated at dining room exterior exit. |
| Fire protection missing in penetrations of fire rated roof/ceiling assemblies in housekeeping closets. |
| Ground-fault circuit interrupter receptacles did not reset in wet areas. |
| Interior door (Beauty Shop) does not latch, preventing containment of fire and smoke. |
| Mechanical exhaust fans not exhausting interior air in Kitchen Mop Sink Closet. |
Report Facts
Licensed capacity: 89
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 8, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation initiated by the Gaston County Department of Social Services.
Findings
The facility was found to have multiple deficiencies including poor housekeeping with stained carpets in resident rooms, failure to ensure tuberculosis testing for staff, and medication order and administration issues for sampled residents.
Complaint Details
Complaint investigation was initiated by the Gaston County Department of Social Services on August 19, 2015.
Deficiencies (4)
| Description |
|---|
| Facility failed to assure walls, ceilings and floors were in good repair in 7 resident bedrooms with multiple carpet stains and debris. |
| Facility failed to assure 1 of 5 sampled staff was tested upon employment for tuberculosis disease in compliance with control measures. |
| Facility failed to assure medication orders were clarified for 1 of 7 sampled residents regarding Ketotifen and Vicodin 5/325. |
| Facility failed to assure medications were administered as ordered by a licensed prescribing practitioner to 2 of 7 sampled residents, including missed blood pressure parameters and unadministered eye drops. |
Report Facts
Number of resident bedrooms with carpet stains: 7
Number of sampled staff for TB testing: 5
Number of sampled residents with medication order issues: 7
Number of sampled residents with medication administration issues: 2
Number of doses of Flunisolide nasal spray administered in August 2015: 4
Number of days blood pressure monitoring missed for Resident #8: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personal Care Aide | Failed to have documented TB test upon employment |
| Executive Director | Interviewed regarding housekeeping and TB testing responsibilities | |
| Business Office Coordinator | Responsible for scheduling TB testing for new employees | |
| Medication Aide | Interviewed regarding medication administration and order clarifications | |
| Resident Care Director | Responsible for completing FL2 forms and clarifying medication orders | |
| Facility Administrator | Interviewed regarding medication order process |
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