Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 31, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to report suspected abuse or misappropriation of resident property, failure to update comprehensive care plans regarding bed rails, failure to complete bed rail assessments including risk and consent documentation, and failure to provide pneumococcal and influenza vaccinations to a resident with signed consent.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to report suspected misappropriation of resident property to law enforcement. The allegation was substantiated as the facility did not report to law enforcement because the resident declined to make a police report. Additional complaints involved failure to update care plans and complete bed rail assessments, and failure to provide vaccinations despite signed consent.
Findings
The facility failed to report an allegation of misappropriation of resident property to law enforcement due to resident refusal, failed to update care plans to include bed rail use for multiple residents, failed to complete proper bed rail assessments including entrapment risk evaluations and consent documentation, and failed to provide pneumococcal and influenza vaccinations to a resident despite signed consent. These deficiencies affected multiple residents and involved breakdowns in communication and procedural compliance.
Deficiencies (4)
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to develop complete care plans within 7 days of comprehensive assessment including bed rail use for 4 residents.
Failed to complete bed rail assessments including entrapment risk evaluation, documentation of alternatives, and consent for 4 residents.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, resulting in failure to provide vaccinations to a resident with signed consent.
Report Facts
Residents affected: 1
Residents affected: 4
Residents reviewed for vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Signed bed rail assessments and involved in bed rail findings | |
| Director of Nursing | DON | Provided statements regarding failure to report misappropriation and bed rail assessment responsibilities |
| Social Worker | Interviewed regarding failure to report misappropriation to law enforcement | |
| Therapy Manager | Interviewed regarding bed rail assessments and alternatives | |
| Admissions Coordinator | Obtained vaccination consents and involved in communication breakdown | |
| Nurse Practitioner | NP | Maintained vaccination list and interviewed about vaccination process |
| Administrator | Interviewed regarding reporting, bed rail assessments, and vaccination processes |
Inspection Report
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home survey conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
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