Inspection Reports for Goldsboro Assisted Living & Alzheimer’s Care
2201 Royale Avenue Goldsboro, NC 27534, Goldsboro, NC, 27534
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 17, 2025, found no deficiencies, confirming that previously noted construction-related issues had been corrected. Earlier inspections showed a pattern of deficiencies primarily related to resident supervision, infection control, and medication administration, with several citations for inadequate supervision leading to resident falls and injuries. Complaint investigations included substantiated findings of supervision and infection control issues, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior construction surveys noted multiple building maintenance and safety deficiencies, which were addressed by the latest follow-up. The overall trend suggests improvement in construction compliance, though clinical care issues have appeared intermittently over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously noted deficiencies.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 24, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 23 and April 24, 2024, to assess compliance with personal care and supervision regulations.
Findings
The facility failed to provide adequate supervision for Resident #2, who had a history of multiple falls resulting in serious injuries including a fractured nose and closed head injury. Despite multiple falls over seven weeks, no new interventions were implemented beyond a wheelchair seatbelt and monitoring every two hours, resulting in a Type A2 violation due to substantial risk of serious physical harm.
Deficiencies (1)
Failure to provide supervision for Resident #2 with multiple falls resulting in serious injuries including fractured nose and closed head injury.
Report Facts
Falls: 7
Falls requiring hospital treatment: 4
Correction deadline: May 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding Resident #2's falls and supervision. | |
| Personal Care Aide | Interviewed regarding Resident #2's falls and supervision. | |
| Resident Care Coordinator | Interviewed regarding supervision and monitoring of Resident #2. | |
| Administrator | Interviewed regarding facility's response to Resident #2's falls. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 8, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on September 7-8, 2022 to verify correction of previous deficiencies related to infection prevention and control.
Findings
The facility failed to maintain infection control processes required by CDC and facility policy, as evidenced by a personal care aide providing incontinence care without gloves, spreading feces and contaminating multiple surfaces. Interviews revealed the aide did not wear gloves due to skin irritation and supervisors were unaware of this issue.
Deficiencies (1)
Personal care aide provided incontinence care without gloves, spreading feces to multiple places and contaminating surfaces.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 19, 2020
Visit Reason
The Adult Care Licensure Section conducted an onsite state-involved complaint investigation, follow-up, and COVID-19 Focused Infection Control survey from 11/17/20 through 11/19/20.
Complaint Details
The visit was triggered by a complaint investigation involving falls and injuries to residents #3 and #4, and concerns about infection control practices during the COVID-19 pandemic.
Findings
The facility failed to provide adequate supervision for 2 of 5 sampled residents (#3 and #4), resulting in multiple falls and injuries. Additionally, the facility failed to implement proper infection prevention and control practices related to COVID-19, including improper use and disposal of PPE by staff, inadequate staff training on PPE, and failure to disinfect screening equipment.
Deficiencies (2)
Facility failed to provide adequate supervision for residents #3 and #4, resulting in multiple falls and injuries including skin tears and facial laceration.
Facility failed to ensure proper infection prevention and control practices during COVID-19 pandemic, including staff not wearing or disposing PPE properly, lack of PPE training, and failure to disinfect screening thermometers.
Report Facts
Falls for Resident #4: 7
Falls for Resident #3: 9
COVID-19 positive residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Mentioned in relation to care and assessment of residents after falls and PPE use | |
| Personal Care Aide | Mentioned in relation to resident supervision and PPE use | |
| Resident Care Coordinator (RCC) | Responsible for follow-up on incidents and COVID-19 screening; observed not wearing mask initially | |
| Administrator | Provided PPE training and responsible for COVID-19 compliance | |
| Laundry Aide | Observed wearing PPE improperly and not disposing of PPE correctly | |
| Housekeeper | Mentioned regarding cleaning and improper PPE use | |
| Business Office Manager | Provided information on PPE use and training |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 6, 2020
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey via desk review and onsite infection control visit to verify correction of previous deficiencies.
Findings
The facility failed to implement a physician order for thrombo-embolic deterrent (TED) hose for one resident, and failed to administer medications as ordered for another resident, including discontinuing an anti-hypertensive medication without a physician's order, resulting in adverse health effects.
Deficiencies (3)
Failed to implement a physician order for application of thrombo-embolic deterrent (TED) hose for Resident #5.
Failed to administer medications as ordered for Resident #4 related to discontinuing an anti-hypertensive medication without a physician's order.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to medication administration for Resident #4.
Report Facts
Deficiencies cited: 3
Dates of survey: 2020
Duration medication not administered: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Responsible for processing and approving physician orders, failed to implement TED hose order and discontinued clonidine without physician order. | |
| Medication Aide/Supervisor (MAS) | Reported Resident #5 was not wearing TED hose and instructed elevation of feet. | |
| Personal Care Aide (PCA) | Provided care to Resident #5 and Resident #4, reported observations about swelling and resident complaints. | |
| Pharmacist | Contracted pharmacy provider who did not receive updated orders for TED hose or medication discontinuation. | |
| Primary Care Provider (PCP) | Ordered TED hose and clonidine for residents, unaware of medication discontinuation. | |
| Administrator | Oversaw facility policies, unaware of medication discontinuation and TED hose issues. |
Inspection Report
Annual Inspection
Census: 51
Capacity: 56
Deficiencies: 4
Date: Jan 9, 2020
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from January 7, 2020 through January 9, 2020.
Complaint Details
The inspection included a complaint investigation related to personal care aides performing non-routine duties and failure to follow health care protocols for residents.
Findings
The facility failed to ensure personal care aides did not perform non-routine duties such as laundry and meal service delivery during restricted hours, failed to complete required 2-step tuberculosis testing for one resident, failed to send a resident to the emergency room after falls with head injury, and failed to serve a resident's therapeutic nectar thickened liquids diet as ordered.
Deficiencies (4)
Personal care aides performed non-routine duties of laundry and meal service delivery between 7:00am and 9:00pm.
Failure to assure 2-step tuberculosis testing was completed upon admission for one resident.
Failure to send a resident to the emergency department after two falls with head injury.
Failure to serve therapeutic nectar thickened liquids as ordered for one resident.
Report Facts
Census in Special Care Unit: 23
Census in Assisted Living Section: 28
Total Facility Capacity: 56
Loads of Laundry: 2
Deficiency Correction Date: Feb 9, 2020
Deficiency Correction Date: Feb 24, 2020
Inspection Report
Capacity: 56
Deficiencies: 1
Date: Apr 9, 2019
Visit Reason
Biennial Construction Section Survey conducted to assess conformance with the 1984 Homes For the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the 1978 North Carolina Building Code, Institutional Occupancy.
Findings
The facility was found to have deficiencies related to building equipment maintenance, specifically the dryer venting in the Main Laundry Room was not sealed, allowing cold outside air and other elements to enter the space.
Deficiencies (1)
Dryer venting that penetrates the exterior wall in the Main Laundry Room is not sealed allowing cold outside air and other elements to enter the space.
Inspection Report
Capacity: 56
Deficiencies: 12
Date: Apr 20, 2017
Visit Reason
The facility was surveyed for conformance with the 1984 Homes For the Aged and Disabled Minimum Standards and Regulations, applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the 1978 (Revision 5) Edition of the North Carolina Building Code, Institutional Occupancy during a Biennial Construction Survey.
Findings
The survey found multiple deficiencies including lack of current sanitation inspection, mechanical ventilation issues, non-operating call system affecting resident safety, unsafe exit lights, plumbing fixture problems, unsecured oxygen tanks, damaged corridor ceiling, unlocked housekeeping storage, unclean and unsafe outside premises, unpleasant odors in resident rooms, damaged furniture, and floors not maintained in good repair.
Deficiencies (12)
Facility did not have a current Sanitation Inspection for the building; last conducted on 11/17/2014.
Mechanical ventilation not maintained in operating condition in two locations: exhaust fan in water heater closet not secure and exhaust fan in Laundry Room not working.
Call system not maintained in operating condition in one Resident bedroom (Room 126), affecting safety of two Residents.
Exit lights were not maintained in a safe condition; emergency light/sign at kitchen exit was dangling from wires.
One plumbing fixture not maintained in operating condition: toilet seat improperly sized in bathroom off Room 104.
Facility not maintained in safe condition: nail protruding from door to Room 108 in SCU; one oxygen tank not secured in oxygen storage room.
Rated corridor ceiling not maintained in good condition; damaged rated assembly above ceiling at attic hatch by Room 120 compromising 1 hour assembly.
Housekeeping storage not separated in a locked area; utility room open to corridor allowing access to cleaning supplies without supervision.
Outside grounds not maintained in a clean and safe condition; broken bed and wood flat propped against shop building; garbage bags and trash on ground outside dumpster.
Building not kept free of unpleasant odors in three Resident rooms (Rooms 127, 120 bathroom, and 109 in SCU wing).
Built-in furniture not maintained in good repair; finish bubbled and flaking in Room 127 wardrobe; damaged drawers in Room 126.
Floors not maintained in good repair; vinyl floor tile chipped and loose at door to shared bath in Room 120, creating slipping hazard affecting two Residents.
Report Facts
Total licensed capacity: 56
Special Care Unit beds: 24
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 3, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 2/3/16 and 2/4/16 to assess compliance with regulations for Goldsboro Assisted Living & Alzheimer's Care.
Findings
The facility failed to provide supervision in accordance with residents' assessed needs, resulting in multiple falls and knee injuries for Resident #4. Additionally, therapeutic diets were not served as ordered for Residents #1 and #6, and documentation of restraint use was incomplete for Resident #2.
Deficiencies (4)
Failed to ensure supervision was provided in accordance with Resident #4's assessed needs, resulting in multiple falls and knee injuries.
Failed to assure therapeutic diets were served as ordered for Residents #1 and #6, including reduced concentrated sweets diet and low fat/low cholesterol diet.
Failed to assure documentation of restraint use while in use for Resident #2, including missing signatures and lack of 15-minute checks documentation.
Failed to assure residents were free from neglect related to personal care and supervision.
Report Facts
Falls: 29
Restraint check interval: 2
Restraint missing documentation: 2
Plan of correction completion date: Mar 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Interviewed regarding Resident #4's falls and restraint documentation. | |
| Dietary Manager | Interviewed regarding food ordering, menus, and therapeutic diet compliance. | |
| Administrator | Interviewed regarding supervision, restraint use, and dietary issues. | |
| Supervisor/Memory Care Coordinator | Interviewed regarding monitoring of Resident #4. | |
| Medication Aide | Interviewed regarding monitoring and assistance of Resident #4. | |
| Nursing Assistant | Interviewed regarding restraint checks and documentation for Resident #2. | |
| Dietary Cook | Interviewed regarding meal preparation and menu adherence. |
Inspection Report
Capacity: 56
Deficiencies: 8
Date: Feb 17, 2015
Visit Reason
This report is of a Biennial Construction Survey conducted to assess the facility's conformance with applicable licensing rules and building codes.
Findings
Multiple deficiencies were noted including unsafe handrails, compromised fire-resistance ratings of building components, malfunctioning exit signage, electrical hazards, unsecured doors, loose toilet, improperly secured oxygen bottles, and non-functioning exhaust ventilation fans.
Deficiencies (8)
Handrails were not maintained in a safe manner; handrail coming loose from corridor wall outside the right SCU shower room.
Fire wrap insulation on kitchen range hood exhaust duct not secured; damaged 1-hour fire resistance rated corridor tunnel assembly; unprotected penetrations in draft wall, hot water room ceiling, kitchen ceiling, and Resident Care Coordinator's office wall; missing fusible link on HVAC radiation damper.
Exit sign at Activity Room exit not working on battery backup.
Electrical hazards including broken outlet in room 122 (replaced immediately), cracked outlet in SCU Dining Room, GFCI outlet in shared bath not tripping, and expansion adapters on outlets in rooms 126 and 124.
Doors not maintained safely: Laundry and Housekeeping Closet doors wedged open; cross corridor door not latching; loose doorknob on room 103 bathroom door.
Toilet in room 111 bathroom coming loose from floor, exposing residents to leaks.
Oxygen bottles improperly secured in beverage crates in Resident Care Coordinator's office.
Exhaust fans not working in shared bathroom 132/134, SCU Tub Room, and SCU left shower room.
Report Facts
Licensed capacity: 56
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