Deficiencies per Year
12
9
6
3
0
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Apr 21, 2025 | 99.5 | 3.5 | 4 | Annual Inspection | |
| Feb 22, 2023 | 100 | 2 | 2 | Annual Inspection | |
| Jun 9, 2020 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Feb 6, 2017 | 102.5 | 4.5 | 2 | Annual Inspection | |
| Feb 11, 2016 | 97 | 2.5 | 0 | Monitoring Visit | |
| Feb 11, 2016 | 94.5 | 0 | 10 | Monitoring Visit | |
| Feb 11, 2014 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Feb 20, 2012 | 100.5 | 2.5 | 2 | Annual Inspection | |
| Aug 31, 2010 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Oct 29, 2009 | 99.25 | 3.75 | 0 | Follow-Up Inspection | |
| Aug 20, 2009 | 95.5 | 4.5 | 9 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Mar 12, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual, follow-up survey and complaint investigation on 03/11/25 to 03/12/25.
Findings
The facility failed to ensure physicians' orders were implemented for residents regarding thrombo-embolic deterrent hose, medication administration including a pain gel, laxative, and pain patch. Documentation discrepancies and medication administration failures were noted for multiple residents.
Complaint Details
The visit included a complaint investigation conducted from 03/11/25 to 03/12/25.
Deficiencies (2)
| Description |
|---|
| Failed to ensure physicians' orders were implemented for 1 of 5 sampled residents (#2) with orders for thrombo-embolic deterrent hose (TED). |
| Failed to ensure medications were administered as ordered for 2 of 5 residents (#2, #5) including a gel to treat pain and a laxative (#2) and a pain patch (#5). |
Report Facts
Residents sampled: 5
Dates of survey: Survey conducted from 2025-03-11 to 2025-03-12.
Medication administration times: Scheduled administration times for medications such as TED hose (9:00am and 10:00pm), Voltaren gel (9:00am and 9:00pm), Metamucil (10:00am), Lidoderm patch (6:00pm application, 6:00am removal).
Lidoderm patches in box: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Interviewed regarding medication administration concerns and audits. |
| Resident Care Coordinator | Resident Care Coordinator | Interviewed about medication administration and documentation. |
| Administrator | Administrator | Interviewed about expectations for medication administration and audits. |
| Medication Aide | Medication Aide | Interviewed regarding medication administration and documentation. |
| Personal Care Aide | Personal Care Aide | Interviewed regarding resident use of TED hose. |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 22, 2025
Visit Reason
Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is needed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Biennial Construction Follow Up Survey |
Inspection Report
Capacity: 70
Deficiencies: 10
Jul 9, 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 Unrestrained 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 and fire safety including non-compliance with delayed egress lock requirements, lack of current fire and building safety inspection reports, unsafe outside premises, poor housekeeping with dust accumulation, improperly oriented fire evacuation plans, incomplete fire safety rehearsal logs, non-operational fire safety and emergency lighting equipment, plumbing safety device issues, and inadequate exhaust ventilation.
Deficiencies (10)
| Description |
|---|
| The left pair of exterior doors in the Dining Room did not initiate the delayed egress process and did not release upon activation of the fire alarm. |
| Facility did not have current fire and building safety inspection reports; most recent fire alarm inspection was November 2022 and sprinkler inspection was January 10, 2023. |
| Outside premises not maintained in a safe condition; a clean out pipe near the sidewalk by Exit Room 14 was missing its cover leaving a 4 inch hole. |
| Ceilings not kept clean and in good repair; heavy dust accumulation on exhaust fans and return air grilles. |
| Posted fire evacuation plans were not oriented to show the direction of egress to the nearest exit. |
| Fire rehearsal logs did not include a short description of what the rehearsal involved. |
| Fire safety equipment not maintained in operating condition; sprinkler system not operational due to repairs, corrosion on sprinkler escutcheon rings, fire alarm control panel showing trouble due to sprinkler system down, emergency lights and exit signs not illuminating on test, holes in fire resistant rated ceilings and resident room doors. |
| Failure to install plumbing safety devices; vacuum breaker missing on sprayer wand in Beauty Salon and no 2 inch air gap between icemaker drain line and floor drain in Kitchen. |
| Fire safety equipment inspections not current; last kitchen hood suppression system inspection was December 2023. |
| Exhaust ventilation not maintained in specified spaces; general pattern of exhaust fans not working. |
Report Facts
Total licensed capacity: 70
Hole size: 4
Hole size: 0.25
Inspection dates: 202211
Inspection dates: Jan 10, 2023
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 18, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey from January 18, 2023 through January 20, 2023 to assess compliance with healthcare regulations.
Findings
The facility failed to ensure proper referral and follow-up for healthcare needs related to warfarin dosage and INR monitoring for one resident. Additionally, the facility failed to report confirmed COVID-19 cases to the local health department promptly and did not notify residents or their representatives about the COVID-19 outbreak within 24 hours as required.
Deficiencies (3)
| Description |
|---|
| Failed to ensure referral and follow-up to meet healthcare needs for 1 of 5 sampled residents related to obtaining routine INR laboratory results and changes to warfarin dosage. |
| Failed to report confirmed cases of COVID-19 to the local health department immediately upon finding out a resident tested positive. |
| Failed to inform residents and their representatives within 24 hours following confirmation of one or more COVID-19 cases among residents or staff. |
Report Facts
Dates of COVID-19 positive cases: 13
Warfarin doses documented incorrectly: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator and Nurse | Interviewed regarding warfarin monitoring and COVID-19 reporting failures |
| Lead Medication Aide | Medication Aide | Responsible for logging warfarin orders in the facility's INR flow sheet |
| Clinical Nurse | Clinical Nurse of Home Health Agency | Interviewed about obtaining INR values and communication with PCP |
| Health and Wellness Director | Health and Wellness Director | Interviewed about facility's system for monitoring warfarin and INR |
Inspection Report
Capacity: 70
Deficiencies: 7
May 2, 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 Unrestrained 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 including failure to keep walls and ceilings clean and in good repair, hazards related to unsecured oxygen bottles, failure to maintain fire safety equipment in safe operating condition, issues with fire doors not latching properly, missing escutcheon plates on sprinkler heads, rotting exit doors, and lack of exhaust ventilation in required areas such as the laundry and kitchen janitorial closet.
Deficiencies (7)
| Description |
|---|
| Facility failed to keep walls and ceilings clean and in good repair, including dust accumulation on radiation dampers, damaged door trim, damaged door latch, and flaking ceiling finish. |
| Facility was not maintained free from hazards; unsecured oxygen bottle found on floor of closet in Room 45. |
| Failure to maintain fire safety equipment in safe operating condition; fire doors by Room 39 and Activity Room did not latch when fire alarm was activated. |
| Radiation damper for exhaust fan in Spa across from Laundry activated, causing loss of mechanical ventilation; kitchen hood suppression nozzles not directed at cooking surfaces. |
| Holes or gaps at penetrations through fire resistant rated ceilings, missing escutcheon plates on sprinkler heads and HVAC pipes, compromising fire safety. |
| Exit door across from Room 34 rotting at bottom and damaging hinge, only opens about 12 inches without excessive force. |
| Facility did not provide exhaust ventilation in required areas; no working exhaust system in Laundry and non-working exhaust fan in Kitchen Janitorial Closet. |
Report Facts
Total licensed capacity: 70
Inspection Report
Capacity: 70
Deficiencies: 8
Apr 12, 2017
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 Unrestrained 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 and safety including failure to meet building code requirements for delayed egress locking systems, corridors obstructed by equipment, building equipment not maintained in safe operating condition, electrical system issues, ventilation system failures, and fire sprinkler system deficiencies.
Deficiencies (8)
| Description |
|---|
| Building failed to meet NC State Building Code at time of alteration by not having all required components of a properly operational delayed egress locking system. |
| Corridors were not free of all equipment and other obstructions, blocking emergency egress. |
| Building was not maintained in a safe and operating condition due to improperly working delayed egress system and delayed egress locks not releasing upon fire alarm activation. |
| Building's emergency equipment was not maintained in safe and operating condition; exit signs had incorrect directional indicators and emergency lighting was missing in some areas. |
| Building fire safety was compromised due to unsealed penetrations in fire-resistance-rated ceiling assemblies and incomplete exit sign coverage. |
| Electrical system was not maintained safely; GFCI receptacles lacked power, electrical panels were obstructed, and improper use of power taps was observed. |
| Ventilation system was not maintained in safe and operating condition, causing build-up of odors in multiple areas. |
| Building sprinkler system was not maintained safely; fire sprinkler escutcheon plates had dropped down exposing openings that allow spread of smoke and heat. |
Report Facts
Total licensed beds: 70
Delayed egress door unlock time: 15
Alarm technician ETA: 17.5
Clear working space at electrical panels: 8
Clear working space at electrical panels: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor conducting the Construction Section Biennial Survey | |
| Billy Bryant | Surveyor conducting the Construction Section Biennial Survey | |
| Executive Director | Instructed staff to use keypad for emergency exiting due to delayed egress lock issues | |
| Maintenance Director | Instructed staff to use keypad for emergency exiting and called alarm technicians for emergency service |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 20, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 01/19/17 and 01/20/17 to verify correction of previous deficiencies related to medication administration.
Findings
The facility failed to assure that Lisinopril 40 mg was administered according to the physician's order for Resident #2. The medication was given on multiple occasions when the resident's systolic blood pressure was less than 140, contrary to the order to hold the medication under those conditions.
Deficiencies (1)
| Description |
|---|
| Failure to hold Lisinopril 40 mg for Resident #2 when systolic blood pressure was less than 140 as ordered. |
Report Facts
Times systolic blood pressure was less than 140 in November 2016: 18
Times Lisinopril was administered when it should have been held in November 2016: 11
Times systolic blood pressure was less than 140 in December 2016: 16
Times Lisinopril was administered when it should have been held in December 2016: 7
Times systolic blood pressure was less than 140 in January 2017: 7
Times Lisinopril was administered when it should have been held in January 2017: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Interviewed about nursing oversight and order clarity |
| Executive Director | Executive Director | Interviewed regarding oversight and training plans |
Inspection Report
Capacity: 70
Deficiencies: 6
Mar 25, 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 and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure. This was a Biennial Construction Survey.
Findings
Multiple deficiencies were found including lack of current fire official inspection report, potential backflow hazard in the salon, electrical outlets in wet locations without ground fault interrupters, disabled fire sprinkler system components, fire doors held open, and compromised fire resistant rated construction with gaps and holes.
Deficiencies (6)
| Description |
|---|
| A current (within the calendar year) fire official inspection report was not available for review at the time of the survey. |
| The hand held rinse wand in the salon extends to the bottom of the sink and does not have a vacuum breaker/anti-siphon device installed, creating a backflow hazard. |
| Electrical GFCI outlets in the mop sink room and public restroom adjacent to therapy room did not trip when tested. |
| A component of the fire sprinkler system was disabled (accelerator valve by-passed), impacting water flow to an area of coverage. |
| The automatic closer on the fire resistant rated door from the kitchen to the dining room was removed and the door was held open. |
| Holes and gaps in fire resistant rated construction were observed, including an open ended pipe sleeve for communication cable, a 1" diameter hole near the fire sprinkler pipe, and a gap in the fire resistant rated ceiling where the illuminated exit sign detached. |
Report Facts
Total licensed capacity: 70
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