Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to ensure the facility maintained medication error rates below 5 percent, focusing on medication administration accuracy.
Findings
The facility failed to maintain a medication error rate below 5%, with two medication errors out of 30 opportunities (6.67%) involving incorrect dosages of Vitamin D3 administered to two residents during medication pass.
Deficiencies (2)
Administration of wrong dosage of Vitamin D3 to Resident #105, giving one 25 mcg tablet instead of two tablets totaling 50 mcg.
Administration of wrong dosage of Vitamin D3 to Resident #36, giving two 10 mcg tablets instead of one 50 mcg tablet.
Report Facts
Medication error rate: 6.67
Medication errors: 2
Medication opportunities: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Administered incorrect dosage of Vitamin D3 to Resident #105 | |
| Nurse #2 | Administered incorrect dosage of Vitamin D3 to Resident #36 | |
| Director of Nursing (DON) | Interviewed regarding medication errors and adherence to five rights of medication administration |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with medication administration standards and food safety regulations, including ensuring medication error rates are below 5% and that expired food items are properly removed.
Findings
The facility failed to maintain a medication error rate below 5%, with two medication errors observed involving incorrect dosages of Vitamin D3 for two residents. Additionally, expired milk was found in the kitchen's walk-in refrigerator, which had not been removed by the expiration date.
Deficiencies (2)
Failed to maintain medication error rate below 5%, with wrong dosage administered to residents.
Failed to remove expired milk from the kitchen's walk-in refrigerator.
Report Facts
Medication error rate: 6.67
Medication errors: 2
Medication opportunities: 30
Expired milk cartons: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Administered incorrect dosage of Vitamin D3 to Resident #105. | |
| Nurse #2 | Administered incorrect dosage of Vitamin D3 to Resident #36. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication errors and nursing responsibilities. |
| Dietary Manager | Dietary Manager (DM) | Responsible for food safety; acknowledged oversight in removing expired milk. |
| Administrator | Administrator | Interviewed regarding expired milk removal responsibility. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Mar 21, 2024
Visit Reason
The inspection was conducted following complaints and concerns related to resident dignity, medication self-administration, activities of daily living assistance, elopement risk, respiratory care, medication storage, food safety, and quality assurance.
Complaint Details
The complaint investigation revealed multiple issues including dignity in care, medication self-administration, assistance with activities of daily living, elopement risk, respiratory care signage, medication storage, food safety, and quality assurance failures. The facility failed to prevent a cognitively impaired resident from eloping through an unalarmed exit door left propped open by staff, resulting in immediate jeopardy.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, failure to assess resident self-administration of medications, inadequate assistance with activities of daily living, failure to prevent elopement of a cognitively impaired resident, lack of oxygen cautionary signage, improper medication storage and labeling, food safety violations including unclean storage areas and unlabeled food, and ineffective quality assurance monitoring leading to repeat deficiencies.
Deficiencies (9)
Failed to provide a dignified dining experience when Nurse Aide stood while assisting a dependent resident during a meal.
Failed to assess if a cognitively impaired resident could self-administer inhalers kept at bedside.
Failed to assist dependent residents with removing unwanted chin hairs and cleaning/trimming dirty fingernails.
Failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised through an unalarmed exit door left propped open.
Failed to post cautionary and safety signs indicating oxygen use for residents receiving supplemental oxygen.
Failed to store medications properly including refrigeration of eye drops and labeling and discarding of insulin pens; medications found on resident's floor.
Failed to maintain clean floors and proper food storage in walk-in cooler, freezer, and dry storage; failed to label and date open food items and discard expired food.
Failed to ensure dumpster area was free of garbage and debris and dumpster doors were closed.
Failed to maintain effective Quality Assessment and Assurance program resulting in repeat deficiencies over multiple surveys.
Report Facts
Residents reviewed for dignity: 7
Residents reviewed for self-administration: 1
Residents reviewed for activities of daily living: 3
Residents reviewed for accidents: 4
Residents reviewed for respiratory care: 5
Medication carts reviewed: 8
Dumpster areas reviewed: 2
Repeat deficiencies: 6
Distance walked by eloped resident: 100
Temperature readings: 79
Temperature readings: 78
Temperature readings: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in dignity deficiency and elopement incident on 06/09/23. | |
| NA #1 | Nurse Aide | Observed standing while assisting resident during meal, dignity deficiency. |
| Med Aide #1 | Assigned to provide care for residents #29 and #60; did not offer nail or chin hair care. | |
| Director of Nursing | DON | Provided multiple interviews regarding dignity, self-administration, nail care, elopement, and medication storage. |
| Nurse #3 | Observed medication cart with improperly stored eye drops. | |
| Unit Manager | Discussed oxygen orders and lack of oxygen signage. | |
| Director of Clinical Services Pharmacist | Pharmacist | Discussed medication storage and insulin pen handling. |
| Dietary Manager | Interviewed about food storage, labeling, and dumpster area cleanliness. | |
| Maintenance Director | Discussed elopement incident, door alarms, dumpster area, and staff education. | |
| Administrator | Provided multiple interviews regarding oxygen signage, food safety, dumpster area, and quality assurance. | |
| Social Worker Assistant | Interviewed about elopement incident and resident behavior. | |
| Nurse #2 | Cared for Resident #51 and unaware of pills found on floor. | |
| Nurse #4 | Cared for Resident #51 and unaware of pills found on floor. | |
| Regional Director of Operations for Dietary Services | Discussed staff education related to propping exit doors. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Mar 19, 2024
Visit Reason
The inspection was conducted based on complaint investigations and focused on multiple areas including resident dignity, medication self-administration, activities of daily living, accident prevention, respiratory care, medication storage, food safety, and quality assurance.
Complaint Details
The complaint investigation revealed multiple issues including failure to provide dignified care, failure to assess self-administration ability, failure to assist with activities of daily living, failure to prevent elopement, medication storage and labeling issues, food safety violations, and ineffective quality assurance monitoring.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, failure to assess residents for self-administration of medications, inadequate assistance with activities of daily living, failure to prevent elopement of a cognitively impaired resident, lack of oxygen cautionary signage, improper medication storage and labeling, food safety violations, and ineffective quality assurance monitoring leading to repeat deficiencies.
Deficiencies (9)
Failed to provide a dignified dining experience when Nurse Aide #1 stood while assisting a dependent resident during a meal.
Failed to assess if a cognitively impaired resident could self-administer inhalers kept at bedside.
Failed to assist dependent residents with removing unwanted chin hairs and cleaning/trimming dirty fingernails.
Failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised through an unalarmed exit door left propped open.
Failed to post cautionary and safety signs indicating oxygen use for residents receiving supplemental oxygen.
Failed to store medications properly including refrigeration and labeling of opened insulin pens and eye drops; failed to ensure medications left in resident rooms were under direct observation.
Failed to maintain clean floors and proper food storage in walk-in cooler, freezer, and dry storage room; failed to label and date open food items and discard expired food.
Failed to ensure dumpster area was free of garbage and debris and dumpster doors were closed.
Failed to maintain effective Quality Assessment and Assurance program resulting in repeat deficiencies over multiple surveys.
Report Facts
Residents reviewed for dignity: 7
Residents reviewed for self-administration: 1
Residents reviewed for activities of daily living: 3
Residents reviewed for accidents: 4
Residents reviewed for respiratory care: 5
Medication carts reviewed: 8
Dumpster areas reviewed: 2
Repeat deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in dignity deficiency and elopement incident. | |
| Nurse #2 | Named in medication administration observation for Resident #51. | |
| Nurse #3 | Observed medication storage issues on 200-hall medication cart. | |
| Nurse #4 | Observed medication administration for Resident #51. | |
| Nurse #5 | Named in elopement incident witness statement. | |
| Med Aide #1 | Observed medication storage and administration issues. | |
| Med Aide #2 | Named in elopement incident witness statement. | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, medication, and elopement. |
| Director of Clinical Services Pharmacist | Pharmacist | Interviewed regarding medication storage and labeling. |
| Dietary Manager | Interviewed regarding food storage and dumpster area. | |
| Maintenance Director | Interviewed regarding elopement incident and dumpster area. | |
| Administrator | Administrator | Interviewed regarding multiple deficiencies and quality assurance. |
| Regional Director of Operations for Dietary Services | Interviewed regarding elopement incident. | |
| Social Worker Assistant | Interviewed regarding elopement incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The inspection was conducted due to a complaint alleging abuse of Resident #2 during wound care on 03/12/2023, where staff allegedly did not honor the resident's request to stop care and turn her back onto her back.
Complaint Details
The complaint was substantiated. Resident #2 reported that on 03/12/23, during wound care, staff ignored her requests to stop and turn her back, causing her distress and physical discomfort. The Director of Nursing confirmed the staff should have stopped care when requested by the resident. Staff members involved were terminated.
Findings
The facility failed to protect Resident #2 from mistreatment when a Nurse Aide and Treatment Nurse continued wound care despite the resident's repeated requests to stop and turn her back, causing distress and actual harm. The allegation was substantiated, and corrective actions including staff termination and education were implemented.
Deficiencies (1)
Failure to protect Resident #2 from abuse when staff did not honor her request to stop care and turn her back, resulting in actual harm.
Report Facts
Date of incident: Mar 12, 2023
Date of survey completion: Mar 22, 2023
Date of investigation completion: Mar 17, 2023
Number of residents reviewed for abuse: 3
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Named in abuse finding for not honoring resident's request to stop care |
| Treatment Nurse | Treatment Nurse | Named in abuse finding for not honoring resident's request to stop care and for providing wound care despite resident's objections |
| Nurse #1 | Nurse | Interviewed regarding incident and grievance; involved in reporting and follow-up |
| Director of Nursing | Director of Nursing | Conducted investigation and confirmed substantiation of abuse; reported findings |
| Administrator | Administrator | Received grievance, confirmed abuse investigation, and oversaw staff education |
| Medication Aide #1 | Medication Aide | Reported resident complaints about treatment during wound care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a suspicious injury and possible abuse of Resident #3, who was found with facial swelling and bruising that progressed over several days.
Complaint Details
The investigation was triggered by a complaint regarding bruising and suspected abuse of Resident #3. The bruising was first noted as redness and swelling on 1/22/2023 and progressed to bruising on 1/23/2023. Resident #7 reported that Resident #8 had thrown something at Resident #3. The facility reported the incident as resident-to-resident abuse on 1/24/2023. The investigation was incomplete, lacking interviews with all relevant staff and witnesses.
Findings
The facility failed to protect Resident #3 from abuse and did not conduct a thorough investigation into the suspicious injury. Resident #3 was found with bruising under both eyes and a bruise on her left ear, with staff interviews revealing inconsistent observations and delayed reporting. The Director of Nursing reported the injury as resident-to-resident abuse after another resident reported that her roommate had thrown something at Resident #3. The hospital evaluation could not rule out elder abuse but found no fractures. The facility's investigation lacked comprehensive staff interviews and follow-up.
Deficiencies (2)
Failed to protect Resident #3 from abuse and suspicious injury.
Failed to respond appropriately to alleged violations and conduct a thorough investigation.
Report Facts
Date of injury observation: Jan 22, 2023
Date of bruising observation: Jan 23, 2023
Date of hospital visit: Jan 23, 2023
Date of report completion: Mar 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Observed red area below Resident #3's right eye on 1/22/2023 and documented in incident report |
| Nurse #2 | Nurse | Reported discoloration under Resident #3's eyes on 1/22/2023 and provided signed statement |
| Nurse #3 | Nurse | Cared for Resident #3 on 1/21 and 1/22/2023; observed redness and swelling but did not report to DON |
| Nurse #4 | Nurse | Observed bruising on Resident #3 on 1/23/2023 and notified Director of Nursing and family member |
| Nurse #5 | Nurse | Cared for Resident #3 on 1/21/2023; reported no bruising or swelling observed |
| Director of Nursing | Director of Nursing | Reviewed activity report, observed Resident #3's injuries, reported incident as resident-to-resident abuse, and coordinated investigation |
| Restorative Aide | Restorative Aide | Spoke Spanish and interviewed Resident #3 about pain and injury on 1/23/2023 |
| Nurse Practitioner | Nurse Practitioner | Examined Resident #3 on 1/23/2023 and assessed injuries |
| Physician | Physician | Examined Resident #3 on 1/23/2023 and expressed concern about possible abuse |
| Administrator | Administrator | Partially involved in investigation and provided statement about incident and investigation |
| Assistant Administrator | Assistant Administrator | Reported information about bruising and resident report of roommate throwing something |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 29, 2022
Visit Reason
The inspection was conducted due to repeated resident grievances regarding poor call bell response times, as well as concerns related to medication administration, care planning for high-risk medications, food safety, sanitation, and medical record accuracy.
Complaint Details
The complaint investigation was triggered by repeated resident grievances about poor call bell response times documented in Resident Council meetings from May through September 2022, with residents reporting wait times from 20 minutes to over an hour, and staff turning off call lights without providing care.
Findings
The facility failed to resolve repeated complaints about call bell response times over several months, failed to develop care plans for high-risk medications for two residents, failed to properly label and store food items and maintain proper refrigerator temperatures, failed to maintain cleanliness around the grease trap and dumpsters, and failed to maintain accurate medication administration records for one resident.
Deficiencies (5)
Failed to resolve repeated grievances related to poor call bell response times over 5 consecutive months.
Failed to develop care plans for the use of anticoagulant, antianxiety, antidepressant, antipsychotic, and opioid medications for 2 of 5 residents reviewed.
Failed to label and date refrigerated food items and maintain nourishment refrigerator temperature at or below 41 degrees.
Failed to ensure garbage was contained in a closed dumpster and maintain a clean grease trap free of buildup.
Failed to maintain an accurate medication administration record (MAR) for 1 sampled resident.
Report Facts
Residents affected: 9
Call light wait times: 30
Temperature: 49
Grease trap service last date: Jul 18, 2022
Grease trap service agreement expiration: Sep 26, 2022
Tylenol dose: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #68 | Resident Council member | Interviewed about long call light response times |
| Resident #92 | Resident Council member | Reported call light being turned off without care provided |
| Resident #66 | Resident Council member | Reported staff turning off call lights without providing care |
| Resident #17 | Resident Council member | Reported call light response issues and staff turning off call lights without care |
| Resident #40 | Resident Council member | Reported call light was on for 2 hours before staff responded |
| Activity Director | Activity Director (AD) | Facilitated Resident Council meetings and reported repeated call light response concerns |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Monitored call light response and notified Director of Nursing |
| Social Worker #1 | Social Worker (SW #1) | Responsible for coordinating response to Resident Council grievances |
| Director of Nursing | Director of Nursing (DON) | Aware of call light response issues, provided staff re-education, and planned monitoring improvements |
| Administrator | Facility Administrator | Aware of ongoing call light response issues and planned re-implementation of Manager on Duty on weekends |
| Minimum Data Set Nurse | MDS Nurse | Acknowledged failure to develop care plans for high-risk medications for Residents #14 and #33 |
| Dietary Manager #1 | Dietary Manager (DM #1) | Observed unlabeled food items and confirmed staff food should not be stored in resident refrigerators |
| Nurse #1 | Nurse | Unaware nourishment refrigerator was left open with temperature at 49 degrees |
| Maintenance Manager | Maintenance Manager | Reported grease trap service schedule and condition |
| Unit Manager | Unit Manager | Administered Tylenol to Resident #16 but failed to document administration timely |
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