Inspection Report
Monitoring
Deficiencies: 1
Jun 24, 2025
Visit Reason
The visit was a monitoring inspection conducted to address compliance with previously cited rules and to ensure corrective actions were implemented.
Findings
The facility failed to provide adequate supervision for one of five sampled residents who eloped from the Special Care Unit without staff knowledge, resulting in a Type A1 violation. The failure involved an unalarmed service door that did not close properly, allowing the resident to exit unnoticed.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision for a resident who eloped from the Special Care Unit without staff knowledge. | Type A1 Violation |
Report Facts
Sampled residents: 5
Correction due date: Aug 23, 2025
Penalty amount per day: 400
Penalty amount per day: 1000
Working days for IDR meeting: 15
Distance resident eloped: 449
Speed limit: 35
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 16, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on October 15-16, 2024 to assess compliance with care plan and special care unit resident profile regulations.
Findings
The facility failed to ensure that one of five sampled residents had a care plan signed by a physician within 15 days of assessment. Additionally, the facility failed to complete Special Care Unit resident profiles within 30 days of admission and quarterly thereafter for all five sampled residents.
Deficiencies (2)
| Description |
|---|
| Failed to ensure 1 of 5 sampled residents had an accurate care plan signed by a physician within 15 days of assessment. |
| Failed to ensure 5 of 5 sampled residents had Special Care Unit resident profiles completed within 30 days of admission and updated quarterly thereafter. |
Report Facts
Sampled residents with care plan deficiency: 1
Sampled residents with SCU profile deficiency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for faxing care plans to physicians and completing SCU resident profiles; admitted no process to ensure timely physician signatures and incomplete SCU profiles. | |
| Assistant Health and Wellness Director | Responsible along with HWD for care plan completion and obtaining physician signatures. | |
| Administrator | Responsible for oversight; acknowledged responsibility of HWD and Assistant HWD for care plans and SCU profiles; unaware of incomplete SCU profiles. |
Inspection Report
Capacity: 56
Deficiencies: 15
Jan 24, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with building codes and physical plant requirements for the licensed adult care home.
Findings
Multiple deficiencies were cited related to physical plant and safety issues including delayed egress locking systems not meeting code, corridors obstructed by equipment, outside premises not maintained, housekeeping and mechanical systems not clean or hazard-free, fire safety rehearsals not conducted quarterly on each shift, building equipment and fire safety systems not maintained in safe operating condition, electrical system deficiencies, fire sprinkler system obstructions and missing escutcheon plates, hot water system temperatures exceeding allowed limits, and exhaust ventilation not working in required areas.
Deficiencies (15)
| Description |
|---|
| Delayed Egress Locking System did not initiate irreversible release when force applied. |
| Corridors obstructed by medication carts, chairs, and wheelchairs reducing required width. |
| Outside grounds not maintained in a clean and safe condition; rotted door trim with water infiltration. |
| Mechanical systems not kept clean; excessive dust/lint on exhaust ventilation grilles. |
| Building not maintained free of hazards; sharp edges on mounting brackets and missing panic hardware covers. |
| Fire safety rehearsals not performed quarterly on each shift; missing rehearsals on 2nd shift in 1st and 2nd quarters. |
| Smoke barrier doors do not fit well, have gaps, missing hardware, and fire-resistance-rated enclosures not maintained. |
| Fire alarm system not maintained; smoke detector dangling and trouble signal on control panel. |
| Commercial kitchen hood fire suppression system lacks monthly inspection documentation. |
| Smoke tight corridor doors do not latch properly or have excessive gaps. |
| Electrical system deficiencies including unsecured fixtures, non-functioning GFCI receptacles, missing cover plates, and exposed energized components. |
| Fire sprinkler heads obstructed and escutcheon plates missing or not covering openings, allowing spread of smoke and fire. |
| Fire safety equipment including portable fire extinguishers missing monthly inspection documentation and annual maintenance tags. |
| Hot water temperatures at resident fixtures exceed maximum allowed temperature of 116°F. |
| Exhaust ventilation system not working in required spaces such as the spa. |
Report Facts
Licensed bed capacity: 56
Force applied to delayed egress door releasing device: 15
Corridor width obstruction measurements: 5.33
Corridor width obstruction measurements: 4.33
Corridor width obstruction measurements: 5.5
Corridor width obstruction measurements: 4.17
Hot water temperature: 158
Water heater setting: 177
Fire sprinkler clearance: 18
Gap between door leaves: 0.375
Gap between door leaf and doorframe stop: 0.625
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Construction Section Surveyor | Conducted the Construction Section Biennial Survey |
| Maintenance Director | Interviewed regarding fire safety rehearsals, fire alarm system, and maintenance issues |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 19, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey from October 19, 2022 to October 20, 2022 to assess compliance with healthcare and medication administration regulations.
Findings
The facility failed to ensure proper documentation and administration of treatments and medications for multiple residents. Deficiencies included lack of treatment orders and implementation for compression stockings for Resident #2, and medication administration errors for multiple residents including late administration, missed doses due to unavailable medications, and inaccurate electronic medication administration records (eMAR).
Deficiencies (3)
| Description |
|---|
| Failed to ensure documentation of treatment orders for compression stockings for Resident #2. |
| Failed to ensure administration of medications as ordered during medication passes for 4 of 5 residents, including errors with timing, dosage, and availability of medications. |
| Failed to ensure electronic medication administration records (eMAR) were accurate for Resident #9 and Resident #2, including documentation of medication administration when medications were not available. |
Report Facts
Medication error rate: 27
Medication administration opportunities: 29
Medication doses not administered: 2
Medications remaining: 2
Medications remaining: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for faxing orders, notifying pharmacy, and placing medication refill orders; interviewed regarding medication availability and documentation. |
| Executive Director | Executive Director (ED) | Interviewed regarding expectations for medication availability, administration, and documentation. |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration practices, refill requests, and awareness of medication availability. |
| Health and Wellness Director | Health and Wellness Director (HWD) | Interviewed regarding expectations for medication administration and training needs. |
| Primary Care Provider | Primary Care Provider (PCP) | Interviewed regarding expectations for medication availability, administration, and documentation accuracy. |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 3
Oct 25, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 10/23/19-10/25/19 to assess compliance with health care, medication administration, nutrition, and other regulatory requirements.
Findings
The facility failed to assure medications were administered as ordered for 3 of 5 sampled residents, resulting in risks including hyperglycemia, increased depression and withdrawal symptoms, anxiety, seizures, and other health complications. Additionally, the facility failed to serve adequate milk portions to residents and had inconsistent medication cart audits and ordering processes.
Severity Breakdown
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assure physician orders for blood sugar management and sliding scale insulin were fully implemented for Resident #4. | Type B |
| Failed to serve eight ounces of pasteurized milk at least twice a day to residents. | — |
| Failed to assure medications were administered as ordered for Residents #1, #4, and #5, including blood pressure, diuretic, antibiotic, potassium, vitamin supplements, insulin, sedatives, and dementia medications. | Type B |
Report Facts
Facility census: 46
Milk servings needed: 144
Milk servings needed: 192
Milk servings needed: 128
Milk servings needed: 144
Milk servings needed: 160
Deficiency count: 6
Deficiency count: 8
Deficiency count: 13
Deficiency count: 21
Deficiency count: 10
Deficiency count: 6
Deficiency count: 6
Deficiency count: 18
Deficiency count: 11
Deficiency count: 12
Deficiency count: 11
Deficiency count: 20
Deficiency count: 10
Deficiency count: 32
Deficiency count: 8
Deficiency count: 6
Deficiency count: 16
Deficiency count: 9
Deficiency count: 12
Deficiency count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Responsible for assisting Health and Wellness Director with overseeing medication aides and processing medication orders; responsible for cart audits and following up on medication orders |
| Health and Wellness Director | Health and Wellness Director | Responsible for overseeing medication administration, training medication aides, reviewing medication audits, and following up on medication orders |
| Administrator | Administrator | Responsible for overall facility oversight and ensuring medication administration compliance |
| Medication Aide | Medication Aide | Administered medications to residents and responsible for ordering medications via eMAR system |
| Primary Care Physician | Primary Care Physician | Provided medical orders and interviewed regarding medication administration issues for residents |
Inspection Report
Follow-Up
Deficiencies: 2
May 31, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant and construction compliance at the facility.
Findings
The facility failed to meet code requirements at the time of construction or alteration, including an unapproved locking system on gates and a ventilation system that was not maintained in proper working order, specifically the exhaust ventilation in the Cottage Place Laundry was not functioning due to a closed radiation damper.
Deficiencies (2)
| Description |
|---|
| Facility failed to meet code requirements in effect at the time of construction or alteration, including an unapproved locking system without a system components location map posted at the FACP. |
| Facility failed to maintain the exhaust ventilation system in proper working order, specifically the radiation damper was closed at the exhaust grille in the Cottage Place Laundry, preventing proper ventilation. |
Inspection Report
Capacity: 56
Deficiencies: 11
Feb 21, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with building codes and physical plant requirements for an adult care home licensed as a Home for the Aged.
Findings
Multiple deficiencies were identified including non-compliance with NC State Building Code regarding secured yard gates, missing required signage on perimeter doors, walls needing repair, broken towel bars, unsafe building equipment and fire safety issues such as gaps in smoke barrier doors, missing fire sprinkler escutcheon plates, obstructed sprinkler heads, and malfunctioning exhaust ventilation systems. Additionally, the use of portable electric heaters was found, which is prohibited.
Deficiencies (11)
| Description |
|---|
| Secured yard gates do not comply with NC State Building Code; missing emergency release switches and system documentation. |
| Three perimeter doors lacked required NC State Building Code signage; signs were re-mounted during survey. |
| Walls in Boar House Kitchen area damaged and in need of repair. |
| Broken towel bar in Boat House Bedroom 40 Bathroom. |
| Smoke barrier doors have gaps and do not latch properly, compromising fire/smoke containment. |
| Fire sprinkler heads missing escutcheon plates, exposing openings that allow spread of fire and smoke. |
| Fire sprinkler heads obstructed by stored items, potentially delaying fire response. |
| Closet doors equipped with barrel bolt hardware that do not provide override function for egress. |
| Corridor doors blocked or malfunctioning, affecting safe and operating condition. |
| Portable electric heater found in Business Office, prohibited in adult care homes. |
| Exhaust ventilation systems in multiple rooms failed to operate properly, preventing odor exhausting. |
Report Facts
Licensed capacity: 56
Perimeter doors missing signage: 3
Perimeter doors total: 8
Fire sprinkler heads missing escutcheon plates: 6
Fire sprinkler heads obstructed: 2
Exhaust ventilation failures: 7
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 1
Nov 16, 2017
Visit Reason
The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual survey and complaint investigation on November 15-16, 2017, initiated by a complaint on October 31, 2017.
Findings
The facility failed to serve eight ounces of pasteurized milk at least twice a day to residents as required. Observations and interviews revealed that milk was often not offered or served to residents despite availability, and staff were unaware of the requirement to serve milk to all residents, especially those with cognitive impairments.
Complaint Details
The complaint investigation was initiated by the Mecklenburg County Department of Social Services on October 31, 2017, regarding failure to serve milk as required.
Deficiencies (1)
| Description |
|---|
| Failed to serve eight ounces of pasteurized milk at least twice a day to residents. |
Report Facts
Current census: 51
Residents not offered or served milk at breakfast in dining room #1: 9
Residents not offered or served milk at breakfast in dining room #2: 7
Residents served milk at breakfast in dining room #3: 1
Residents not offered or served milk at breakfast in dining room #4: 14
Residents not offered or served milk at lunch in dining room #1: 10
Residents not offered or served milk at lunch in dining room #2: 2
Residents not offered or served milk at lunch in dining room #3: 17
Residents not offered or served milk at lunch in dining room #4: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dining Services Coordinator | Responsible for ordering milk, training PCAs and MAs, unaware of milk serving requirements | |
| Executive Director | ED | Interviewed regarding facility operations and milk serving practices |
| Personal Care Aide | PCA | Responsible for serving drinks, interviewed about milk serving practices |
| Medication Aide | MA | Responsible for serving drinks, interviewed about milk serving practices |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 9, 2017
Visit Reason
Biennial Follow-Up Construction Survey to assess outstanding deficiencies related to physical plant renovations and maintenance.
Findings
The facility was undergoing renovations including HVAC installation that did not meet code requirements, specifically missing ceiling radiation dampers and lack of manufacturer's installation instructions. Additionally, housekeeping deficiencies were noted with damaged kitchen countertops in multiple community areas and failure to provide adequate exhaust ventilation in certain locations.
Deficiencies (3)
| Description |
|---|
| Facility did not meet code requirements during renovation due to missing ceiling radiation dampers and lack of installation instructions for HVAC system. |
| Facility failed to maintain kitchen countertops in service areas; broken edges and unglued laminate in multiple community locations. |
| Mechanical exhaust fans not exhausting interior air in Mop Sink Closet in Garden Path Community, causing inadequate ventilation. |
Report Facts
Mechanical permit number: Mechanical permit #M3113410 for HVAC installation
Inspection Report
Follow-Up
Deficiencies: 3
Dec 29, 2016
Visit Reason
The report documents a Biennial Follow Up Construction Survey conducted to assess compliance with physical plant requirements and corrections from previous deficiencies.
Findings
The facility was found deficient in meeting NC State Building Code requirements for delayed egress locking systems, housekeeping maintenance of countertops, and exhaust ventilation in certain areas. Specific issues included missing signage on exit doors, delayed egress door malfunction, broken kitchen countertops, and inadequate mechanical exhaust ventilation in the mop sink closet.
Deficiencies (3)
| Description |
|---|
| Building failed to meet NC State Building Code requirements for delayed egress locking system; exit doors lacked required visible signage and front door did not unlock after 3 seconds of pushing. |
| Facility failed to maintain countertops in service areas; kitchen countertops had broken edges and unglued laminate in multiple community locations. |
| Facility failed to provide required exhaust ventilation; mechanical exhaust fans not exhausting interior air in mop sink closet in Garden Path Community. |
Inspection Report
Follow-Up
Deficiencies: 5
Sep 16, 2016
Visit Reason
The visit was a Follow Up Survey conducted to verify correction of deficiencies noted during the Biennial Survey on 05/05/2016.
Findings
Deficiencies from the prior Biennial Survey remain uncorrected, including failure to submit construction documents for exit gate alterations, inadequate emergency release switches on magnetically locked exits and nurse stations, failure to maintain kitchen counter-tops in service areas, and lack of proper exhaust ventilation in specified facility areas.
Deficiencies (5)
| Description |
|---|
| Facility altered exiting without submitting Construction Documents for review and approval, resulting in non-compliance with NC Building Code. |
| Magnetically locked exit gates lack emergency release switches within 3 feet as required by Building Code. |
| On/off emergency release switches are not provided at Nurse's stations as required by Building Code. |
| Facility failed to maintain kitchen counter-tops in service areas; broken edges and unglued laminate found in multiple community locations. |
| Mechanical exhaust fans are not exhausting interior air in Garden Path Community Bathrooms, Cottage Place Community Bathrooms, and Mop Sink Closet in Garden Path Community. |
Report Facts
Date of prior Biennial Survey: May 5, 2016
Date of magnetic lock installation: Aug 1, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Billy S. Bryant | Surveyor who conducted the Follow Up Survey |
Inspection Report
Capacity: 56
Deficiencies: 8
May 5, 2016
Visit Reason
Biennial Construction Survey to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes, and the 1996 Edition of the North Carolina State Building Code.
Findings
Multiple deficiencies were cited including unapproved alterations to facility exits, failure to maintain HVAC systems and exhaust ventilation, unsafe building penetrations, and failure to maintain fire safety equipment and interior doors to contain fire and smoke.
Deficiencies (8)
| Description |
|---|
| Facility altered exits without submitting Construction Documents for review and approval, resulting in non-compliance with NC Building Code, including magnetic locks on exit gates without emergency release switches within 3 feet and lack of on/off emergency release switches at Nurse's stations. |
| Facility failed to maintain and service HVAC supply and return air grilles, with excessive particulate build-up in multiple community areas and kitchen. |
| Facility failed to maintain counter-tops in service areas; broken edges and unglued laminate in multiple community locations. |
| Facility failed to maintain HVAC ductwork; excessive particulate and grease build-up on internal duct insulation in air handling units. |
| Facility did not maintain building equipment safely; unsealed ceiling penetrations through roof/ceiling assembly not sealed with fire-rated material in multiple locations. |
| Facility fire protection equipment in HVAC system not maintained safely; excessive particulate build-up on sampling tubes affecting smoke detection in multiple mechanical rooms. |
| Facility failed to maintain operating condition of interior doors to contain fire and smoke; gap at top of door to Resident Room 31 allowing smoke passage. |
| Facility failed to provide required exhaust ventilation in specified areas; mechanical exhaust fans not exhausting interior air in bathrooms and mop sink closet in multiple community areas. |
Report Facts
Licensed capacity: 56
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