Inspection Reports for Graceful Living Assisted Living
624 Jones Ferry Road Carrboro, NC 27510, Carrboro, NC, 27510
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
12.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
58 residents
Based on a September 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 14, 2025
Visit Reason
The Adult Care Licensure Section completed an annual and complaint investigation survey of Graceful Livning Assisted Living on October 14-15, 2025.
Complaint Details
The survey included a complaint investigation component related to medication administration and health care follow-up.
Findings
The facility was found deficient in ensuring proper health care referral and follow-up, medication administration as ordered, and proper observation of medication administration. Specific issues included failure to discontinue medication as ordered for Resident #1, failure to administer prescribed ketoconazole cream for Resident #2, and failure of medication aides to observe residents taking medications properly.
Deficiencies (3)
Failed to ensure health care referral and follow-up for 1 of 5 sampled residents related to clarification of medication orders following a physician's appointment.
Failed to ensure medications were administered as ordered for 1 of 5 sampled residents, including a medicated shampoo.
Failed to ensure the medication aide observed a resident take their medications that were left on the dining room table.
Report Facts
Sampled residents: 5
Medication administration dates: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for following up with physician's office and auditing medication orders |
| Administrator | Facility Administrator | Provided information on facility responsibilities and expectations for medication administration |
| Medication Aide | Medication Aide (MA) | Observed residents taking medications; involved in medication administration process |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 21, 2024
Visit Reason
The Adult Care License Section conducted an annual survey on May 21-22, 2024 to assess compliance with regulations including hot water temperature requirements and medication administration.
Findings
The facility failed to maintain hot water temperatures within the required range of 100-116 degrees F in multiple resident-used fixtures, posing burn risks. Additionally, medication administration errors were identified for two residents, including missed doses and incorrect dosages. The facility also failed to maintain accurate controlled substance records for one resident.
Deficiencies (3)
Failed to ensure hot water temperatures were maintained between 100-116 degrees F in 6 fixtures used by residents, with observed temperatures ranging from 124-129 degrees F.
Failed to ensure medications were administered as ordered for 2 of 4 residents observed during the morning medication pass, resulting in an 8% medication error rate.
Failed to maintain a readily retrievable record that accurately reconciled the receipt and administration of a controlled substance for 1 of 5 sampled residents.
Report Facts
Medication error rate: 8
Hot water temperature: 124
Hot water temperature: 129
Correction date: 2024
Pregabalin doses documented: 13
Pregabalin doses documented: 30
Pregabalin doses documented: 20
Hemoglobin A1C: 8.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Informed about elevated hot water temperatures and medication errors; responsible for oversight and corrective actions | |
| Maintenance Director | MD | Responsible for adjusting hot water heater temperatures and maintaining logs |
| Medication Aide | MA | Observed administering medications; involved in medication errors for Residents #6 and #7 |
| Resident Care Coordinator | RCC | Responsible for training medication aides and overseeing medication administration procedures |
| Primary Care Physician | PCP | Provided clinical input on medication administration errors for Residents #6 and #7 |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
The inspection 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
Capacity: 120
Deficiencies: 14
Date: Dec 6, 2023
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 North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant conditions including lack of current fire and building safety inspection reports, unsafe and unclean outside premises, poor housekeeping and furnishings, inadequate fire safety rehearsals documentation, failure to maintain fire safety equipment and building systems in safe operating condition, electrical and plumbing safety issues, and failure to maintain hot water temperature within required limits.
Deficiencies (14)
Facility did not have current fire and building safety inspection reports maintained in the home and available for review.
Outside grounds were not maintained in a clean and safe condition; leaves covered walkways rendering them nearly invisible.
Walls, ceilings, floors, and furnishings were not kept clean and in good repair; including dust, stains, missing fixtures, and broken soap dispenser.
Fire rehearsal logs did not include a short description of what the rehearsal involved.
Failure to maintain fire safety equipment in a safe operating condition including doors not latching, unsealed penetrations in fire resistant ceilings, missing sprinkler escutcheon rings, and outdated fire extinguisher inspections.
Fire safety equipment obstructed by stored items within 18 inches of sprinkler heads.
Electrical emergency and safety lighting equipment and exit signs did not illuminate on test in multiple locations.
Plumbing equipment not maintained in safe and operating condition; loose toilet seats and unsecured toilets.
Electrical equipment not maintained in safe and operating condition; missing globes on overhead lights and detached electrical junction box.
Doors in smoke compartments did not completely close and latch to limit spread of smoke or fire.
Failure to maintain plumbing piping with minimum 2 inch air gap; drain pipe fallen off and laying on floor.
Plumbing safety devices or equipment not properly installed or maintained; shower wand head reaches into tub allowing contamination.
Resident room door had a gap between door and frame that could allow passage of smoke.
Hot water supply at fixtures used by residents was not maintained between 100 and 116 degrees Fahrenheit.
Report Facts
Total licensed capacity: 120
Inspection Report
Follow-Up
Deficiencies: 8
Date: Jan 17, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on January 17, 2023 to January 19, 2023 to verify correction of previous deficiencies.
Findings
The facility failed to ensure exit doors accessible by residents were equipped with sounding devices and staff did not respond to alarms, resulting in a resident with disorientation exiting unsupervised. The facility also failed to provide adequate supervision for a resident with multiple falls and disorientation, resulting in a fall outside the facility. Additional deficiencies included failure to notify physicians of elevated blood sugar readings, failure to implement medication orders, failure to maintain therapeutic diet menus, failure to observe residents taking medications, failure to document controlled substances accurately, and failure to have physician orders for self-administration of medications.
Deficiencies (8)
Failed to ensure each exit door accessible by residents was equipped with a sounding device activated when the door opened for the safety of a resident diagnosed with disorientation.
Failed to provide supervision in accordance with the resident's assessed needs for a resident known to have multiple falls and disorientation, resulting in a fall outside the facility.
Failed to ensure referral and follow-up to meet healthcare needs for a resident related to elevated blood sugar readings and failure to notify the physician.
Failed to ensure implementation of orders related to fingerstick blood sugar daily before meals and at bedtime for a resident.
Failed to ensure there was a matching therapeutic diet menu for physician ordered therapeutic diets for two residents.
Failed to ensure medication aides observed residents taking their medication, resulting in medication being left unattended and accessible to other residents.
Failed to assure a record of controlled substances accurately reconciled the receipt, administration, and disposition of controlled substances for two residents.
Failed to assure physician orders for self-administration of medications for a resident for skin cleanser and moisturizing cream.
Report Facts
Deficiencies cited: 8
Temperature: 47
Duration outside: 45
Medication counts: 11
Medication counts: 3
Medication counts: 27
Medication counts: 22
Medication counts: 29
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 12
Date: Sep 23, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow up-survey, and state involved complaint investigation from September 20, 2022 to September 23, 2022.
Complaint Details
Complaint investigation included issues with housekeeping, pest infestation, health care referral and follow-up, medication administration, and resident safety related to a missing resident.
Findings
The facility failed to maintain clean floors and environment, with debris, dust, dead bugs, raw sewage, and pest infestations including bedbugs and cockroaches in multiple resident rooms. There were issues with housekeeping and pest control. Additionally, the facility failed to ensure health care referral and follow-up for residents with specific needs, failed to provide adequate nutrition services including proper meal service and therapeutic diet menus, and failed to maintain accurate medication administration records and self-administration orders.
Deficiencies (12)
Floors were not kept clean with debris, dust, dead bugs, and raw sewage in resident rooms and bathrooms.
Facility environment was cluttered and infested with bedbugs and cockroaches, posing health risks to residents.
Failed to ensure health care referral and follow-up for residents with specific needs including wheelchair order, physical therapy, oxygen use, and missed medications.
Kitchen and food storage areas were not clean and free from contamination, including dirty reach-in cooler and freezer with pest presence.
Residents were not provided knives at meals and beverages were served in disposable foam cups instead of reusable cups.
Facility failed to have matching therapeutic diet menus for physician-ordered therapeutic diets for residents.
Facility failed to assure two fruit servings including a citrus fruit or 100% vitamin C juice were served daily.
Facility failed to immediately notify law enforcement and Department of Social Services when a resident was missing for several days and later found deceased.
Residents were not treated with respect related to living with cockroaches and bedbugs and being bitten by bedbugs.
Medications were not administered as ordered for a resident related to glucose tablets for low blood sugar and Miralax for constipation.
Electronic Medication Administration Records were inaccurate as Medication Aide initials did not match signatures on controlled substance count sheets.
Residents self-administered medications without physician orders for self-administration and without assessments.
Report Facts
Resident census: 58
Deficiency count: 12
Blood sugar readings below 70: 9
Missed medication days: 10
Cockroach count: 4
Cockroach count: 3
Cockroach count: 1
Milk gallons purchased: 2
Milk gallons purchased: 2
Milk gallons purchased: 4
Milk gallons purchased: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Manager | Responsible for kitchen and cleaning oversight, interviewed about cleaning and pest control | |
| Administrator | Interviewed about facility operations, resident safety, and pest control | |
| Resident Care Coordinator | Interviewed about resident care, medication administration, and missing resident | |
| Medication Aide | Interviewed about medication administration and documentation | |
| Personal Care Aide | Interviewed about resident care and observations | |
| Cook | Interviewed about meal preparation and kitchen cleaning | |
| Kitchen Manager | Interviewed about meal preparation, kitchen cleaning, and pest control | |
| Pharmacist | Interviewed about medication orders and dispensing | |
| Primary Care Provider | Interviewed about resident care and medication orders | |
| Law Enforcement Representative | Interviewed about missing resident report and investigation | |
| Mental Health Provider | Interviewed about resident mental health care | |
| Soup Kitchen Manager | Interviewed about resident sightings outside facility |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 5, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey with onsite visits on 01/05/21 and 01/11/21, a desk review survey from 01/06/21-01/08/21 and 01/11/21-01/12/21, and a telephone exit on 01/12/21.
Findings
The facility failed to ensure that air vents on an air conditioner unit, ice machine filter, and two fans blades and a fan cover were clean and free of contamination due to thick layers of dust and trash, potentially contaminating stored dishes, food preparation, and dining areas.
Deficiencies (1)
Facility failed to ensure air vents on an air conditioner unit, ice machine filter, and two fans blades and a fan cover were clean and free of contamination related to thick layer of dust and trash.
Report Facts
Date of cleaning: 1
Date of observation: Jan 5, 2021
Date of interview: Jan 8, 2021
Date of interview: Jan 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Responsible for cleaning fans and air vents; interviewed about cleaning practices | |
| Dietary Manager | Interviewed about fan and air vent cleaning responsibilities and schedule | |
| Administrator | Interviewed about expectations for dietary staff cleaning schedule compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 24, 2020
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation and a COVID-19 focused Infection Control Survey with onsite visits on 09/17/20, 09/21/20 and 09/23/20 and a desk review survey on 09/18/20, 09/22/20 and a telephone exit on 09/24/20.
Complaint Details
The complaint investigation focused on failure to ensure physician notification and appropriate podiatry care for residents, including those with diabetes. The investigation included observations, record reviews, and multiple interviews with residents, staff, and providers.
Findings
The facility failed to ensure referral and follow-up for podiatry services for 3 residents (#2, #6, and #7), including one resident with diabetes (#2). The failure to provide appropriate podiatry care and physician notification was detrimental to the residents' health, safety, and welfare.
Deficiencies (1)
Failed to ensure physician notification for 3 of 7 sampled residents (#2, #6, and #7) related to podiatry and nailcare, including a resident diagnosed with diabetes (#2).
Report Facts
Sampled residents: 7
Residents with deficiencies: 3
Dates of onsite visits: 09/17/20, 09/21/20, 09/23/20
Dates of desk review: 09/18/20, 09/22/20
Correction deadline: November 8, 2020
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 21, 2020
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Crescent Green of Carrboro on February 19-21, 2020.
Findings
The facility was found to have bedbug activity in resident rooms #117, #212, and #311, indicating failure to maintain a clean and hazard-free environment. Additionally, the facility failed to implement physician-ordered fingerstick blood sugar (FSBS) monitoring and insulin administration for sampled residents, and failed to maintain proper infection control procedures for glucometer use, resulting in sharing glucometers between residents. The kitchen area was also found to have contamination risks due to dusty air vents and improper storage of cleaning supplies near food preparation areas.
Deficiencies (5)
Presence of bedbug activity in resident rooms #117, #212, and #311 indicating failure to maintain clean and hazard-free environment.
Failure to ensure physician ordered fingerstick blood sugars (FSBS) were implemented for Resident #5.
Failure to ensure proper cleaning and sanitation in kitchen including dusty air vents blowing over stored dishes and food preparation area.
Failure to administer medications as ordered for residents receiving insulin, including failure to hold insulin when FSBS was below ordered parameters.
Failure to implement infection control policy consistent with CDC guidelines for glucometer use, resulting in sharing glucometers between residents #4, #5, #13, and #15.
Report Facts
FSBS documentation discrepancies: 55
FSBS documentation discrepancies: 44
FSBS documentation discrepancies: 36
Levemir insulin administration: 7
Levemir insulin administration: 6
Humalog insulin administration: 13
Humalog insulin administration: 4
Glucometer readings: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed regarding bed bug protocol, medication administration, and infection control procedures. | |
| Maintenance staff | Interviewed regarding bed bug findings and treatment. | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and contamination issues. | |
| Contracted Consultant Pharmacist | Interviewed regarding medication administration and glucometer monitoring. | |
| Nurse Practitioner | Interviewed regarding medication administration and resident care. | |
| Medication Aides | Multiple interviewed regarding FSBS testing, insulin administration, and glucometer use. |
Inspection Report
Routine
Capacity: 120
Deficiencies: 17
Date: Aug 2, 2018
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 North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged, as part of a biennial construction section survey.
Findings
Multiple deficiencies were cited related to physical plant conditions including lack of current fire safety reports, missing hand grips in showers, corridor obstructions, unsafe outside premises, inadequate lighting, poor housekeeping and furnishings, fire safety rehearsal record deficiencies, malfunctioning emergency lighting, fire door issues, fire safety equipment maintenance failures, plumbing issues, mechanical equipment problems, and hot water temperature exceeding allowed limits.
Deficiencies (17)
Facility did not have all current building safety reports available for review, including fire sprinkler system inspection report.
Hand grips were not installed at all showers, specifically missing in 200 Hall Women's Bath shower unit.
Corridors were not free of equipment and obstructions; a hoyer lift partially obstructed an exit door by Room 222.
Outside premises were not maintained in a clean and safe condition, including separated planter box boards, rotted rails, dirty and worn seat cushions, and falling exterior soffit outside Room 300.
Outdoor walkways and exits were not illuminated as required.
Ceilings, walls, floors, and furnishings were not kept in good repair; examples include damaged walls, unfinished ceiling patches, stained floors, loose handrails, and holes in walls and doors.
Facility was not maintained free of hazards, including unsecured oxygen bottles, use of extension cords, and popped floor tiles creating tripping hazards.
Fire safety rehearsals were not conducted in accordance with fire code; records lacked short descriptions of rehearsals.
Electrical emergency/safety lighting equipment was not maintained in safe operating condition; multiple emergency lights failed battery tests.
Failure to maintain fire safety equipment including fire doors with holes, gaps, missing door strikes, doors that do not latch, and unapproved devices used to keep doors open.
Fire rated ceiling assemblies had holes, gaps, and missing escutcheon plates at sprinkler heads, compromising fire safety.
Storage was not maintained at least 18 inches below sprinkler heads, with items stored too close to ceilings in several areas.
Plumbing devices and equipment were not maintained in safe and operating condition, including loose sinks, leaking water heater, and non-working electric water cooler.
Plumbing safety devices were not installed or maintained properly, including broken hand held spray nozzle brackets and missing vacuum breakers in tubs.
Fire safety equipment such as kitchen hood suppression system was not maintained or inspected as required; nozzle heads were not properly aimed.
Mechanical equipment was not maintained in safe and operating condition, including dusty exhaust fans and improper dryer venting.
Hot water temperature in resident areas exceeded allowed maximum; water temperature in 300 Hall bath was 124 degrees Fahrenheit.
Report Facts
Total licensed capacity: 120
Water temperature: 124
Inspection Report
Follow-Up
Census: 84
Deficiencies: 8
Date: Jan 10, 2018
Visit Reason
Follow-up survey conducted to verify correction of previous deficiencies related to physical environment, housekeeping, staffing, personal care, nutrition, and food service.
Findings
The facility failed to assure exit door alarms were activated for disoriented residents, maintain a clean and hazard-free environment due to bedbug infestations and room repairs needed, ensure adequate staffing levels, prevent PCAs from performing routine laundry duties during daytime hours, provide appropriate incontinence care, and serve therapeutic diets as ordered including proper fruit servings and sugar-free beverages. Kitchen and food storage areas were also found unclean with grease build-up and contamination risks.
Deficiencies (8)
Failed to assure exit door alarms were activated on all exit doors to alert staff when disoriented residents exited.
Failed to maintain the facility clean and free of hazards including presence of bedbug activity in resident rooms, a hole in a resident's room wall, and room furnishings needing repair.
Failed to assure adequate staffing for multiple shifts with staffing hours below required levels.
Failed to prevent Personal Care Aides from performing routine laundry duties between 7am and 9pm.
Failed to ensure adequate and appropriate incontinence care for a resident including cleansing skin between adult brief changes.
Failed to assure kitchen and food storage areas were clean and free from contamination including grease build-up, stains, and debris on equipment and floors.
Failed to assure therapeutic diets were served as ordered including serving a citrus fruit or 100% vitamin C juice and serving sugar-free beverages for residents with diabetes.
Failed to ensure residents received care and services that were adequate, appropriate, and in compliance with relevant laws related to housekeeping and furnishings hazards.
Report Facts
Exit doors without sounding device: 10
Bed bug infestation: 2
Staffing hours: 9
Staffing hours: 14
Blood sugar level: 350
Blood sugar level: 395
Blood sugar level: 9.1
Blood sugar level: 209
Blood sugar level: 345
Blood sugar level: 500
Sugar content: 17
Sugar content: 19
Fruit servings: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Co-Owner #1 | Interviewed regarding staffing, bed bug protocol, and therapeutic diet compliance | |
| Co-Owner #2 | Interviewed regarding bed bug protocol, alarm system, and food purchasing | |
| Administrator | Interviewed regarding staffing, bed bug protocol, kitchen cleaning, and therapeutic diet compliance | |
| Resident Coordinator of Medical Records | MRC | Interviewed regarding staffing, bed bug protocol, and alarm system |
| Maintenance Person | Interviewed regarding bed bug treatment and room repairs | |
| Cook | Interviewed regarding kitchen cleaning and food preparation | |
| Personal Care Aide | PCA | Interviewed regarding laundry duties and incontinence care |
| Medication Aide | MA | Interviewed regarding staffing and medication administration |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 7
Date: Aug 2, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation on August 2, 2017 through August 4, 2017 and August 7, 2017.
Complaint Details
The complaint investigation was triggered by incidents involving Resident #4, who was disoriented and exited the facility without staff knowledge on two occasions, including one time when she almost reached a busy road. The facility also investigated issues related to call light systems, staffing, supervision, and medication management.
Findings
The facility failed to maintain operational exit door alarms, resulting in a disoriented resident exiting the building unnoticed. The facility also lacked an operational call light system for residents needing assistance, had inadequate staffing on third shift, failed to provide adequate supervision for a resident with dementia who eloped, had unsanitary kitchen conditions, failed to provide two servings of fruit daily, and did not notify the physician of a resident refusing medications.
Deficiencies (7)
Failed to assure 10 of 10 exit door alarms were maintained in operational conditions and activated with a sounding device when opened, resulting in a disoriented resident exiting the building without staff knowledge.
Failed to assure that an operational call light system was in place for residents who were non ambulatory or needing assistance with assistive devices for 2 of 2 sampled residents.
Failed to assure there was adequate staff on third shift for 4 of 4 shifts on 07/28/2017-07/31/2017.
Failed to provide supervision according to the resident's current symptoms for 1 of 7 sampled residents with dementia who eloped from the facility.
Failed to assure the kitchen appliances, kitchen equipment, and floors of the kitchen and food storage areas were clean and protected from contamination.
Failed to provide two servings of fruit each day to residents of the facility.
Failed to notify the prescribing physician of a resident who had been refusing to take his medication and refusing to allow staff to assess his medications.
Report Facts
Exit door alarms not operational: 10
Residents present: 85
Staffing shortfall: 8
Fruit servings needed: 5185
Fruit servings available: 556
Medication pills left: 13
Medication pills left: 3
Medication pills left: 59
Medication pills left: 57
Medication pills left: 7
Medication pills left: 4
Medication pills left: 2
Medication pills left: 17
Medication pills left: 2
Medication pills left: 29
Medication pills left: 50
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 2, 2017
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building equipment maintenance.
Findings
The facility has not satisfactorily corrected prior deficiencies; specifically, the kitchen range hood exhaust fan was still not working as of the previous observation on 09/02/2016.
Deficiencies (1)
The kitchen range hood exhaust fan was not working.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Dec 13, 2016
Visit Reason
This is a biennial follow-up construction survey conducted to verify correction of previously cited deficiencies related to building maintenance and safety.
Findings
The facility has not satisfactorily corrected prior deficiencies including damaged resident room furniture, damaged interior doors, improperly mounted plumbing fixtures, leaking water heater with improper piping, non-illuminated exit signage, incomplete maintenance of kitchen range fire suppression system, and non-operational exhaust ventilation in several rooms.
Deficiencies (7)
Resident room dresser tops and construction not maintained in Rooms 121 and 302.
Interior doors damaged, scratched, and with damaged finishes in Rooms 121 and 206.
Plumbing fixtures not properly mounted in Room 218 toilet.
Water heater leaking at supply side pipe joint and pressure relief valve piping is a garden hose in Laundry Room/300 Hall.
Exit sign not illuminated at 100/200 Hall exit door.
Kitchen range fire suppression system maintenance incomplete; deficiencies include overdue hydrostatic testing, non-working exhaust fan, loose piping, and missing fryguard.
Non-operational exhaust ventilation in Laundry Room-200 Hall, Soiled Linen Room-200 Hall, and Storage Room C.
Report Facts
Survey date: Dec 13, 2016
Hydrostatic testing interval: 12
Inspection Report
Capacity: 120
Deficiencies: 12
Date: Sep 2, 2016
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 North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant maintenance including loose corridor handrails, damaged and non-operational doors, improperly mounted plumbing fixtures, lack of individual towel bars in resident rooms, failure to maintain emergency lighting and exit signage, breaches in fire-rated ceiling assemblies, water heater leaks, incomplete maintenance of kitchen fire suppression systems, and non-operational exhaust ventilation in several rooms.
Deficiencies (12)
Facility has not maintained the corridor handrails; loose outside Room 108.
Resident room dresser tops and construction not maintained in Rooms 121 and 302.
Interior doors damaged, scratched, and with damaged finishes including exterior exit door in 100 Hall, Room 121 entry and bathroom doors, and Room 206 bathroom door.
Interior and exterior doors do not latch in multiple locations including exit door in 100 Hall, Rooms 106, 311, 321, and 119 (door hardware reversed).
Plumbing fixtures not properly mounted in Rooms 121 (toilet), 218 (toilet), and 302 (sink).
Facility failed to provide and maintain individual towel bars in Rooms 111, 218, 302, and 308.
Emergency wall lights at multiple locations did not illuminate in emergency mode (Outside Lounge 2A-200 Hall, Between Rooms 217/219 Hall, Outside Room 325 Hall).
Breach of one-hour roof/ceiling assembly with a 2"x4" opening in ceiling under shower track adjacent to ceiling light in Spa in 300 Hall.
Water heater in Laundry Room/300 Hall leaking at supply side pipe joint; pressure relief valve piping is garden hose.
Exit sign not illuminated at 100/200 Hall exit door.
Kitchen range fire suppression system red tagged with deficiencies including overdue hydrostatic testing, non-working exhaust fan, loose piping, and missing fryguard.
Non-operational exhaust ventilation in Laundry Room-200 Hall, Soiled Linen Room-200 Hall, and Storage Room C.
Report Facts
Total licensed capacity: 120
Hydrostatic testing interval: 12
Opening size: 8
Inspection Report
Follow-Up
Census: 83
Deficiencies: 1
Date: May 12, 2016
Visit Reason
The Adult Care Licensure Section conducted a Follow Up survey on 5/10/16 and 5/12/16 to verify correction of previous deficiencies related to nutrition and food service.
Findings
The facility failed to assure residents were served the required 8 ounces of pasteurized milk twice a day and 4 ounces for evening snack as listed on the menu. Observations, interviews, and record reviews revealed inconsistent milk availability and serving practices, including residents not being offered milk regularly and insufficient milk supply.
Deficiencies (1)
Facility failed to assure residents were served 8 ounces of pasteurized milk twice a day and 4 ounces for evening snack as required by regulation.
Report Facts
Resident census: 83
Milk purchased: 6
Milk purchased: 7
Milk purchased: 2
Milk serving size: 8
Milk serving size: 4
Milk cup size: 5.5
Residents requesting milk: 15
Milk needed per meal: 3.75
Milk needed per meal: 5
Milk needed for evening snack: 1.5
Milk needed for evening snack: 2.5
Percentage of residents drinking milk: 75
Milk used per meal: 1.5
Inspection Report
Annual Inspection
Census: 83
Capacity: 120
Deficiencies: 9
Date: Feb 25, 2016
Visit Reason
The Adult Care Licensure Section and the Orange County Department of Social Services conducted an annual survey and complaint investigation on 2/23/2016 - 2/25/2016.
Complaint Details
The visit included a complaint investigation related to supervision of residents with falls and resident rights violations.
Findings
The facility failed to provide adequate supervision for a resident with a history of falls, failed to provide proper table service with all required utensils, failed to maintain and identify menus properly, failed to document substitutions in menus, failed to offer milk twice daily as required, failed to provide 14 hours of planned group activities per week, failed to implement severe weather procedures during a tornado warning, failed to respect resident rights related to privacy and dignity, and allowed an unqualified staff member to perform medication aide duties.
Deficiencies (9)
Failed to provide supervision for 1 of 4 sampled residents who had falls and sustained injury.
Failed to assure table service included a place setting consisting of at least a knife, fork, and spoon for residents in the dining room.
Failed to maintain menus for regular, no added salt and no concentrated sweets diets in the kitchen and identified as to the current menu day and cycle.
Failed to assure substitutions made in the menu were of equal nutritional value, appropriate for therapeutic diets, and documented.
Failed to offer 8 ounces of milk twice a day to 7 of 7 sampled residents who were to receive milk.
Failed to ensure 14 hours of a variety of planned group activities per week for residents.
Failed to assure staff implemented severe weather conditions procedures in accordance with the facility's emergency procedures guide during tornado warnings.
Failed to assure full recognition of individuality and right to privacy for 1 resident and respect, consideration and dignity for 1 resident related to pureed diet preparation.
Allowed 1 staff member to perform unsupervised medication aide duties without completing required training, competency evaluation, and state medication exam.
Report Facts
Facility capacity: 120
Census: 83
Deficiencies cited: 9
Medication doses documented by Staff D: 10
Hours of planned activities required: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide / Personal Care Aide | Named in medication aide training and competency deficiency; documented medication administration without completing required training and exam. |
| Resident Care Coordinator | Named in supervision and emergency procedures findings. | |
| Administrator | Named in supervision, emergency procedures, and medication aide training findings. | |
| Medication Aide | Named in supervision and emergency procedures findings. | |
| Personal Care Aide | Named in emergency procedures findings. | |
| Kitchen Supervisor | Named in food service and pureed diet preparation findings. | |
| Cook | Named in food service and pureed diet preparation findings. | |
| Activities Intern | Named in activities program deficiency. | |
| Activities Director | Named in activities program deficiency. |
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