Inspection Reports for Montgomery Senior Living
327 Freeman Street Star, NC 27356, Star, NC, 27356
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
28 residents
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The visit was a 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.
Inspection Report
Capacity: 54
Deficiencies: 3
Date: Oct 29, 2024
Visit Reason
The facility was surveyed for conformance with the 1977 Rules for Licensing of Adult Care Homes of Seven or More Beds, applicable portions of the 2005 Rules for Licensing of Adult Care Homes, and the 1978 Edition of the North Carolina Building Code, Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Deficiencies were cited related to building equipment maintenance, including electrical equipment not maintained in a safe and operating condition, emergency equipment failures, mechanical equipment issues, and exhaust ventilation problems such as missing covers and non-operable exhaust fans.
Deficiencies (3)
Electrical equipment is not maintained in a safe and operating condition, including a fluorescent light fixture missing its cover and emergency lights not illuminating.
Mechanical equipment is not maintained safely, including a clothes dryer exhaust vent not attached to its thru-wall connection.
Exhaust ventilation is not maintained operably, including exhaust fans missing covers and not working in specified areas.
Report Facts
Licensed beds: 54
Special Care Unit beds: 32
Inspection Report
Follow-Up
Census: 28
Deficiencies: 4
Date: Aug 20, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on August 20, 2024 to August 21, 2024 to verify correction of previous deficiencies.
Findings
The facility failed to ensure the special care unit (SCU) was free from chronic urine odors in hallways, common areas, and resident rooms. Additionally, deficiencies were found in staff qualifications including missing medication administration clinical skills checklist for one medication aide, missing criminal background check for one employee, and one personal care aide not completing the required 80-hour training and competency evaluation program.
Deficiencies (4)
Facility failed to ensure the special care unit (SCU) hallways, common areas, and resident rooms were free from chronic urine odors.
Facility failed to ensure 1 of 3 sampled medication aides had a medication administration clinical skills checklist.
Facility failed to ensure 1 of 6 sampled employees had a criminal background check completed.
Facility failed to ensure 1 of 3 sampled personal care aides completed an 80-hour personal care training and competency evaluation program.
Report Facts
Residents in SCU: 28
Sampled medication aides: 3
Sampled employees: 6
Sampled personal care aides: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Medication Aide | Named in deficiency for missing medication administration clinical skills checklist |
| Staff E | Personal Care Aide | Named in deficiency for missing criminal background check |
| Staff D | Personal Care Aide | Named in deficiency for not completing 80-hour personal care training and competency evaluation program |
Inspection Report
Annual Inspection
Census: 43
Capacity: 54
Deficiencies: 17
Date: Jun 10, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on June 3, 2024 to June 10, 2024.
Findings
The facility was found deficient in multiple areas including chronic urine odors in the Special Care Unit (SCU), lack of accessible soap and towels, improper assignment of housekeeping duties to personal care aides, failure to provide adequate personal care and supervision to residents, failure to serve therapeutic diets as ordered, inadequate staffing levels, lack of a special care unit coordinator, incomplete staff training, failure to protect residents from neglect related to sexual activity, failure to provide proper infection control practices, and failure to maintain accurate personal funds ledgers.
Deficiencies (17)
Facility failed to ensure the Special Care Unit (SCU) was free of chronic urine odors in hallways, resident rooms, and bathrooms.
Facility failed to ensure an accessible supply of soap and hand towels in or near resident bathrooms on the SCU for hand hygiene after toileting.
Facility failed to ensure medication aides and personal care aides on the SCU were not routinely assigned housekeeping, dietary aide, and laundry service duties from 7:00am until 9:00pm daily.
Facility failed to provide personal care assistance for 2 of 4 sampled residents on the SCU including morning care, evening care, incontinence care, and toenail care.
Facility failed to provide supervision for 1 of 4 sampled residents on the SCU who was known to wander into other residents' rooms and was observed entering the room of a resident known to be aggressive and combative, resulting in injury.
Facility delayed notifying the primary care provider of a change in condition for 1 of 4 sampled residents on the SCU who was experiencing increased confusion, difficulty walking, decreased appetite and increased sleeping for 3 days before PCP was contacted and resident sent to emergency room.
Facility failed to provide a complete set of non-disposable eating utensils for residents during breakfast meal observation.
Facility failed to maintain a therapeutic diet menu as an accessible reference for kitchen staff serving therapeutic diets including pureed, ground meats and bite size mechanical soft diets for 4 of 4 sampled residents.
Facility failed to serve water to residents residing on the SCU during breakfast and lunch meals.
Facility failed to serve therapeutic diets as ordered for 3 of 4 sampled residents who had orders for mechanical soft with ground meats, nectar thickened liquids, and bite size mechanical soft diets, resulting in increased risk of choking and aspiration.
Facility failed to provide feeding assistance to promote dignity and respect for 2 of 2 sampled residents related to staff standing while feeding residents.
Facility failed to protect 2 of 7 sampled residents in the SCU from neglect related to sexual activity between two SCU residents who were not capable of consenting.
Facility failed to ensure legal guardians reviewed and signed monthly personal funds ledgers for 2 of 2 sampled residents who were adjudicated incompetent.
Facility failed to ensure staffing hours were met on all three shifts in the SCU based on a census of 26-27 for 5 of 13 sampled shifts.
Facility failed to ensure there was a special care unit coordinator for the SCU with a census of 28 residents for 8 hours per day 5 days per week.
Facility failed to ensure that 3 of 6 sampled staff completed 6 hours of orientation on the nature and needs for the residents within the first week of employment and 5 of 6 sampled staff had not completed 20 hours of training specific to the population within 6 months of employment on the SCU and 3 of 5 sampled staff had not completed the 12 hours required annually of which 6 hours were dementia specific.
Facility failed to ensure infection control practices of doffing gloves and hand hygiene were observed during residents' assistance with feeding.
Report Facts
Licensed beds: 54
Residents on AL side: 15
Residents on SCU: 28
Residents in facility: 43
Staffing shortage hours: 12.75
Staffing shortage hours: 12.1
Staffing shortage hours: 3.45
Staffing shortage hours: 9.61
Staffing shortage hours: 5.05
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Did not complete required SCU orientation and training hours. |
| Staff B | Personal Care Aide | Did not complete required SCU orientation and training hours. |
| Staff C | Personal Care Aide | Did not complete required SCU orientation and training hours. |
| Staff E | Medication Aide | Did not complete required SCU orientation and training hours. |
| Staff F | Medication Aide | Did not complete required SCU orientation and training hours. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 16, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 06/15/22-06/16/22 to assess compliance with medication administration regulations.
Findings
The facility failed to administer medications as ordered by a physician for 1 of 5 sampled residents related to a medication for hypertension. Specifically, Resident #3 was administered an incorrect dosage of Amlodipine Besylate due to failure to update the medication cart after a physician's order change.
Deficiencies (1)
Failed to administer medications as ordered by a physician for 1 of 5 sampled residents related to hypertension medication.
Report Facts
Sampled residents: 5
Medication dosage change date: Jun 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Responsible for ensuring medication accuracy in the medication cart; interviewed regarding medication administration error | |
| Medication Aide (MA) | Interviewed about medication administration process and error | |
| Administrator | Interviewed regarding oversight of medication order changes and medication cart audits |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 15
Date: Dec 5, 2019
Visit Reason
The Adult Care Licensure Section and the Montgomery County Department of Social Services conducted an annual and follow-up survey from 2019-12-03 to 2019-12-05.
Findings
The facility had multiple deficiencies including failure to ensure tuberculosis testing upon admission, incomplete care plans within 30 days for sampled residents, failure to ensure follow-up for a rollator walker, inadequate nutrition and food service including improper pureed meals and insufficient snacks, failure to assist a resident with feeding in a dignified manner, failure to provide minimum planned group activities, failure to administer medications as ordered for a resident, failure to document medication administration immediately after administration, failure to immediately notify authorities of staff misappropriation of resident property, incomplete quarterly care plans for special care unit residents, lack of a care coordinator on duty as required, and insufficient space for meal service in the special care unit.
Deficiencies (15)
Facility failed to ensure 1 of 5 sampled residents was tested for tuberculosis disease upon admission.
Facility failed to ensure care plans were developed for 2 of 6 sampled residents within 30 days following admission.
Facility failed to ensure follow-up for 1 of 5 sampled residents related to a rollator walker.
Facility failed to ensure residents on the special care unit were provided with a non-disposable place setting including a knife, spoon and fork.
Facility failed to assure residents were served nutritious and palatable meals; pureed meals were mixed together and unappealing.
Facility failed to offer or make available three snacks a day and shown on the menu as snacks.
Facility failed to assist 1 of 5 residents in the special care unit during the meal service in a manner that enhanced the resident's dignity and respect.
Facility failed to assure a minimum of 14 hours of planned group activities was provided each week for the residents.
Facility failed to administer medications as ordered by a physician for 1 of 5 sampled residents related to medications for shortness of breath, cholesterol, dry eyes, nasal congestion, thyroid disease, and pain.
Facility failed to ensure staff documented the administration of medications immediately following administration and observation of the residents actually taking the medications for 2 of 5 sampled residents related to medications found in the residents' rooms.
Facility failed to immediately notify the local department of social services and law enforcement authorities as required after a reported allegation of staff misappropriation of resident property.
Facility failed to complete quarterly care plans for 2 of 2 sampled residents in the Special Care Unit.
Facility failed to ensure a care coordinator was on duty in the Special Care Unit at least eight hours a day, five days a week.
Facility failed to treat residents with dignity and respect by not having sufficient space for the meal service in the special care unit.
Facility failed to ensure residents received care and services relevant to federal and state laws and rules and regulations related to medication administration.
Report Facts
Current census: 22
Residents sampled: 5
Residents sampled: 6
Residents sampled: 2
Residents in SCU: 22
Care coordinator hours: 8
Care coordinator days: 5
Inspection Report
Capacity: 54
Deficiencies: 7
Date: Oct 2, 2019
Visit Reason
The facility was surveyed for conformance with the 1977 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and the 1978 (Revision 3) Edition of the North Carolina Building Code, Institutional Occupancy.
Findings
The survey identified multiple deficiencies including staff not being aware of emergency release switches for special locking exit doors, lack of current fire alarm inspection reports, unsafe storage of portable medical oxygen cylinders, incomplete fire safety rehearsals, malfunctioning exit signs and emergency lights, corridor doors not closing properly, and unsealed penetrations in the fire-rated ceiling.
Deficiencies (7)
Staff were not aware of the location or use of the required central emergency release switch for the Special (magnetic) Locking on exit doors in Special Care.
The facility did not have current sanitation and fire safety inspection reports; the most recent fire alarm inspection was dated 2-24-2017.
Several (7) portable medical oxygen cylinders were stored in an unapproved plastic crate in the Oxygen Storage room.
Fire drill rehearsals were not conducted regularly with at least one per shift each quarter; missing rehearsals during the 3rd shift in 2nd and 3rd quarters of the year.
Exit signs and emergency lights were malfunctioning or not illuminated in multiple locations including entrance from Special Care to AL side, near room 201, Administrator's office, and kitchen emergency light.
Many corridor doors did not close completely and latch, including sagging door to housekeeping in Special Care, loose latchbolts on med room and housekeeping doors, a hole at the latchset on shower room door, gaps between double doors to Living room, and a disabled latch strike on door to room 214 (corrected during survey).
The required one-hour fire rated ceiling was compromised by unsealed penetrations, including an unsealed penetration in the laundry ceiling at a 2 inch conduit.
Report Facts
Total licensed beds: 54
Portable medical oxygen cylinders improperly stored: 7
Date of most recent fire alarm inspection: Feb 24, 2017
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jan 9, 2018
Visit Reason
The report documents a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies at the facility.
Findings
The survey found that some deficiencies were not corrected and further action is required. Specific issues included unsafe outside premises with damaged ramp support posts, unclean and unrepaired walls and floors, hazards such as cracked glazing, failure to maintain fire safety systems, and missing plumbing safety devices.
Deficiencies (6)
Ramp at the assisted living front exit had damaged masonry at support posts making the handrail extremely loose.
Room 111 bathroom had heavy mildew stains on floor and wall behind the toilet.
Kitchen floor settled and cracked along the edge of the settlement.
SCU right exit door glazing was cracked creating a sharp edge that could cause injury.
Section of trim on the far wall in the assisted living medication room was missing leaving a gap between ceiling and wall.
No vacuum breaker for the utility sink in the housekeeping closet.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Moran | Maintenance Director | Signed as provider/supplier representative on the statement of deficiencies |
Inspection Report
Capacity: 54
Deficiencies: 10
Date: Oct 10, 2017
Visit Reason
The facility was surveyed for conformance with the 1977 Rules for Licensing of Adult Care Homes of Seven or More Beds, applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and the 1978 Edition of the North Carolina Building Code, Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to maintain current fire inspection reports, unsafe and unmaintained outside premises, unpleasant odors and poor housekeeping, hazards such as water on floors and loose floor coverings, failure to maintain fire safety systems and equipment in safe operating condition, and lack of required plumbing safety devices.
Deficiencies (10)
Facility did not maintain current fire inspection reports; most recent was from February 2016.
Outside grounds were not maintained in a safe condition; unstable railings and damaged masonry making handrails loose.
Facility was not maintained free of unpleasant odors; strong odor noted in housekeeping room off the spa.
Walls, ceilings, and floors were not kept clean and in good repair; mildew stains, spalling concrete, cracked and torn vinyl flooring observed.
Facility was not maintained free of hazards; water on bathroom floor creating slip hazard, cracked glazing with sharp edges, unsecured floor hole in supply closet.
Failure to maintain building's fire safety systems in safe condition; holes and gaps in fire resistant ceilings, missing fire caulk at conduit penetrations, gaps in door trims.
Fire safety equipment not maintained in safe operating condition; doors that do not close and latch properly, exit light out (corrected during survey).
Failure to maintain electrical emergency/safety lighting equipment in safe operating condition; exit signs not visible in emergency.
Resident room doors had gaps or holes that could allow passage of smoke.
Failure to install and maintain required plumbing safety devices; vacuum breaker missing for utility sink in housekeeping closet.
Report Facts
Licensed beds: 54
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 29, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey on September 29, 30 and October 3, 2016 to assess compliance with regulations for Brookstone Haven of Star Assisted Living.
Findings
The facility was found deficient in multiple areas including failure to secure hazardous cleaning agents in locked storage on the Special Care Unit, failure to serve therapeutic diets as ordered for a resident on a renal diet, improper medication administration of Vitamin D2 for a resident, and failure to ensure a care coordinator was on duty in the Special Care Unit at least eight hours a day, five days a week.
Deficiencies (4)
Storage areas containing hazardous cleaning agents on the Special Care Unit were not locked and accessible to residents.
Therapeutic renal diet was not served as ordered by the physician for one resident.
Medications, specifically Vitamin D2, were not administered as ordered by a licensed prescribing practitioner for one resident.
No care coordinator was on duty in the Special Care Unit at least eight hours a day, five days a week.
Report Facts
Residents in Special Care Unit: 16
Vitamin D2 capsules dispensed: 5
Fluid restriction: 32
Therapeutic diet sample size: 5
Medication sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for SCU and ALU, did not stay 8 hours daily in SCU, also performed Medication Aide duties. |
| Regional Director | Regional Director | Interviewed regarding chemical storage and RCC duties. |
| Executive Director | Executive Director (ED) | Interviewed regarding staffing and RCC coverage. |
| Personal Care Aide | Personal Care Aide (PCA) | Reported no RCC for SCU and described staffing patterns. |
| Medication Aide | Medication Aide (MA) | Covered medication passes in SCU and ALU, monitored fluid intake for Resident #2. |
| Cook | Cook | Reported lack of training on therapeutic diet spreadsheet and meal preparation for renal diet. |
| Dietician | Dietician | Provided dietary guidance for Resident #2's renal diet. |
| Nurse Aide | Nurse Aide (NA) | Described use and access to storage closets. |
| Housekeeper | Housekeeper | Described training and use of chemical storage. |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Described scheduling and duties including medication aide work. |
| Medication Aide | Medication Aide (MA) | Interviewed about Vitamin D2 administration frequency. |
| Nurse Practitioner | Nurse Practitioner (NP) | Primary care provider for Resident #3, unaware of medication over-administration. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 6, 2016
Visit Reason
The visit was a Follow-Up Construction Survey to verify correction of deficiencies noted during the Biennial Construction Survey.
Findings
The deficiencies noted during the Biennial Construction Survey have been corrected except for the item where an additional time waiver was granted. The facility failed to meet NC State Building Code at the time of initial licensing for corridor doors that were not 1 ¾ inches thick and of solid core construction or equivalent.
Deficiencies (1)
Corridor doors including Front Corridor's Bedroom doors, Main Electrical Room Door, and Back Corridor's storage and supply closets were 1 3/8 inch thick and of hollow construction, not meeting the required 1 ¾ inches thick solid core construction.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Conducted the Follow-Up Construction Survey on April 6, 2016. |
Inspection Report
Census: 54
Capacity: 54
Deficiencies: 10
Date: Nov 4, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant requirements, fire safety, and building codes for Brookstone Haven of Star Assisted Living.
Findings
Multiple physical plant deficiencies were identified including inadequate fire detection, non-compliant corridor doors, lack of premises identification, missing current sanitation and fire safety inspection reports, failure to conduct fire safety rehearsals quarterly on each shift, and unsafe building conditions such as breaches in fire-resistance-rated construction and improper storage of medical oxygen cylinders.
Deficiencies (10)
No fire alarm detection in the connecting corridor between the front corridor and firewall.
Corridor doors not 1 3/4 inches thick and not solid core construction.
No premises identification (address) visible from the street.
Facility failed to maintain current annual building sanitation and fire marshal inspection reports.
Facility failed to rehearse the fire plan quarterly on each shift and fire plan rehearsal records lacked descriptions.
Building not maintained in safe and operating condition due to breaches in fire-resistance-rated construction compromising integrity.
Extension cord used in Executive Director Office to power coffee pot, not permanent wiring.
Exit doors had signage reading 'NOT A EXIT' deterring usage.
Corridor doors did not resist passage of smoke due to improper fitting, gaps, holes, or failure to latch properly.
Portable medical oxygen cylinders stored unsecured in beverage crates.
Report Facts
Licensed capacity: 54
Number of portable medical oxygen cylinders: 8
Length of connecting corridor without fire alarm detection: 68
Area of patched fire-resistance-rated ceiling assembly: 4
Thickness of non-compliant corridor doors: 1.375
Gap size in corridor door assembly: 0.25
Diameter of holes in Med Room Corridor door: 0.25
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