Inspection Reports for Mt. Pleasant House
935 Page Street Mt. Pleasant, NC 28124, Mt. Pleasant, NC, 28124
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
213% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 74
Deficiencies: 6
Date: Dec 20, 2023
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with building codes and licensing rules applicable to the facility's original structure and its 1996 addition.
Findings
Multiple deficiencies were cited including lack of documentation for fire extinguisher inspections, electrical outlets near water sources lacking ground fault protection, faulty fire safety systems including non-operational smoke detectors and strobes, plumbing issues such as missing air gap on ice machine drain, and non-functioning exhaust fans in housekeeping and restroom areas.
Deficiencies (6)
Portable fire extinguishers lacked routine inspections documentation required to ensure proper performance.
No documentation of the required annual inspection, testing and maintenance of the kitchen fire extinguisher.
Electrical receptacle behind washing machine did not trip on test indicating lack of ground fault protection.
Fire safety systems not maintained in safe operating condition; faulty interconnection between old and new fire alarm panels, notification circuit trouble, some strobes not operational, and five smoke detectors need replacing.
Building plumbing system not maintained safely; ice machine drain lacks required 2 inch air gap.
Exhaust fans in East Hall housekeeping and New Wing restroom are not working, causing potential odor and mildew issues.
Report Facts
Facility licensed capacity: 74
Smoke detectors needing replacement: 5
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 5, 2018
Visit Reason
The visit was a Follow Up Construction Survey conducted to evaluate compliance with physical plant requirements and building code regulations.
Findings
The facility was found to have deficiencies related to access controlled egress locking that did not comply with building code, unprotected PVC pipe penetrations compromising one-hour fire rated ceilings, and failure to provide exhaust ventilation in required housekeeping closets.
Deficiencies (3)
Facility exits with access controlled egress locking lacked sensors on the inside to detect occupants approaching the door to egress.
One-hour fire rated ceilings were compromised by unprotected large PVC pipe penetrations in the boiler room and employee break room.
Facility failed to provide exhaust ventilation in required housekeeping closets, including a large closet enclosing a mop sink and a closet near the New Wing Dining room.
Report Facts
PVC conduits: 6
PVC sleeves: 4
PVC plumbing vent: 1
PVC conduits: 6
Housekeeping closet size: 77
Inspection Report
Capacity: 74
Deficiencies: 8
Date: Mar 8, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant, building, and fire safety codes applicable to the facility's original structure and 1996 addition.
Findings
The facility was found to have multiple deficiencies related to fire safety code compliance, physical plant maintenance, housekeeping hazards, and exhaust ventilation. Specific issues included lack of required fire alarm pull stations near exits, non-compliant access controlled egress locking, compromised fire-rated walls and ceilings, obstructed exit corridors, and missing exhaust ventilation in housekeeping closets.
Deficiencies (8)
Facility fire alarm system did not have required pull stations within 5 feet of each exit; nearest pull station was approximately 20 feet away.
Access controlled egress locking failed to comply with code: no sensor on inside of exits, push to exit switches did not remain unlocked for 30 seconds, and all 4 new wing exits failed to unlock upon fire alarm activation.
Parts of the facility were not kept in good repair, including a delaminating door to room 25 and baseboard falling off walls.
Exit corridors were not maintained free of obstructions and hazards, including combustible storage of 12 wood folding tables, 2 plastic folding tables, and a wood moving cart near the Broad River Rehab room.
One-hour fire rated walls and ceilings were compromised by unsealed holes and penetrations in multiple locations including room 24, business office manager ceiling, basement ceiling, and employee break room.
Large PVC pipe penetrations through fire rated ceilings were not protected by approved assemblies, allowing potential fire spread.
Corridor doors did not close and latch properly to resist fire and smoke passage; issues included a door near the beauty parlor not latching, missing latchset strike, and a 1/2 inch gap between double dining room doors.
Facility failed to provide exhaust ventilation in required locations including large housekeeping closet and housekeeping closet near new wing dining room.
Report Facts
Facility licensed capacity: 74
Combustible items stored: 12
Combustible items stored: 2
Combustible items stored: 1
Housekeeping closet size: 77
PVC conduits: 6
PVC sleeves: 4
PVC conduits: 6
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 3, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies related to building safety and delayed egress locking mechanisms.
Findings
Some deficiencies were not corrected, including the delayed egress locking mechanism not being removed or repaired as required, and fire doors being wedged open preventing proper closing and latching, which could delay emergency exiting and increase fire spread risk.
Deficiencies (4)
The door did not have an irreversible unlocking function when activated, potentially delaying exiting in an emergency.
Delayed egress locking mechanism was not removed or repaired as required by code.
Doors equipped with delayed egress lacked the required visible sign stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS'.
3 hour fire rated doors were wedged open preventing them from closing quickly and latching upon fire alarm activation.
Inspection Report
Follow-Up
Deficiencies: 7
Date: Sep 16, 2016
Visit Reason
This is a follow-up survey conducted to verify correction of deficiencies noted during the previous follow-up survey on 2016-05-26.
Findings
The facility failed to correct previous deficiencies related to physical plant requirements, specifically regarding special locking (magnetic locks) on exit doors not meeting NC State Building Code. Several areas lacked automatic fire detection systems, and the delayed egress locking mechanism was not operational or properly signed, potentially delaying emergency egress.
Deficiencies (7)
Facility equipped with special locking (magnetic locks) on exit doors failed to meet NC State Building Code requirements for buildings without approved supervised automatic fire detection or sprinkler systems.
New Wing Activity Room Storage lacked an automatic fire detection system.
No access to New Wing Dining Storage to verify presence of automatic fire detection device.
New Wing Business Manager Office closet lacked an automatic fire detection system.
Delayed egress locking mechanism on East Corridor Exit to Sun Room was not operational; provider must repair or remove components.
Building failed to meet NC State Building Code at initial licensing by lacking all required components of a properly operational delayed egress locking system.
Doors with delayed egress lacked readily visible signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS'.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 8, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey on June 7, 2016 and June 8, 2016 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure physician notification for ordered laboratory tests that were not completed for 2 of 5 sampled residents and failed to assure blood pressure medications were administered as ordered for 2 of 5 sampled residents. There was no process to verify all ordered lab tests were obtained and reviewed, and medication orders were sometimes entered incorrectly and not caught by staff.
Deficiencies (2)
Failed to ensure physician notification for physician ordered laboratory tests that were not completed for 2 of 5 sampled residents.
Failed to assure blood pressure medications (Diltiazem and Hydrochlorothiazide) were administered as ordered for 2 of 5 sampled residents.
Report Facts
Sampled residents: 5
Residents with lab test issues: 2
Residents with medication administration issues: 2
Diltiazem doses dispensed: 8
Diltiazem doses dispensed: 13
Diltiazem doses dispensed: 17
Diltiazem doses dispensed: 12
Inspection Report
Follow-Up
Deficiencies: 5
Date: May 26, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies and to require corrective action on outstanding deficiencies.
Findings
The facility failed to meet NC State Building Code requirements related to special locking on exit doors, delayed egress locking systems, fire detection systems, fire alarm components, and installation of hand grips in bathrooms. Several deficiencies were observed including lack of automatic fire detection in multiple rooms, malfunctioning delayed egress locks, missing signage on delayed egress doors, absence of manual fire pull in the basement exit stair, and lack of hand grips in resident bathrooms.
Deficiencies (5)
Facility equipped with special locking (magnetic locks) on exit doors failed to meet NC State Building Code requirements for buildings not protected throughout by an approved supervised automatic fire detection or sprinkler system.
Delayed egress lock on East Corridor Exit to Sun Room did not initiate irreversible unlocking process within 3 seconds as required by code.
Most doors with delayed egress lacked visible signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS' or the letters were not at least one inch high.
Basement Exit Stair lacked a manual fire pull station.
Resident commodes, tubs, and showers in the New Wing Bedroom Bathrooms were not equipped with hand grips, affecting resident safety and stability.
Inspection Report
Capacity: 74
Deficiencies: 14
Date: Mar 29, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant requirements and building codes applicable to the facility's original structure and 1996 addition.
Findings
Multiple physical plant deficiencies were identified including lack of automatic fire detection in certain rooms, improperly functioning delayed egress locking systems, inadequate fire alarm and protection systems, housekeeping issues, electrical safety concerns, fire safety equipment disrepair, and ventilation system failures. These deficiencies affect the safety and operation of the facility.
Deficiencies (14)
Facility equipped with special locking (magnetic locks) on exit doors failed to meet NC State Building Code requirements due to lack of automatic fire detection in several rooms.
Delayed egress lock on East Corridor Exit to Sun Room did not initiate the irreversible unlocking process within 3 seconds as required.
Most doors with delayed egress lacked proper signage with required wording and letter size.
Basement Exit Stair lacked a manual fire pull station.
Fire protection systems did not adequately protect openings through fire-resistance-rated construction, including missing radiation dampers on ducts.
Showers in New Wing Bedroom Bathrooms were not equipped with hand grips.
Portable medical oxygen cylinders were not properly secured, posing a hazard.
Walls, ceilings, and floors were not kept clean and in good repair; mold, broken tiles, stains, and dirt buildup were observed.
Electrical power receptacles in wet locations lacked ground fault interrupters.
Building components such as corridor doors and fire safety equipment were damaged or not functioning properly, including emergency lighting and fire alarm annunciation devices.
Exit path was obstructed by vegetation growth at the Sun Room Front Entrance.
Fire rated doors did not close completely or latch properly, compromising smoke and fire containment.
Fire and smoke resistance of doors and finishes were not maintained; ceilings covered with burlap sacks and gaps around penetrations in fire-resistance-rated ceilings were found.
Local exhaust ventilation system failed to remove required air to dissipate odors in housekeeping and soiled linen areas.
Report Facts
Facility licensed capacity: 74
Portable medical oxygen cylinders: 4
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