Inspection Reports for
Rose Glen Manor
240 Independence Avenue North Wilkesboro, NC 28659, North Wilkesboro, NC, 28659
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
The Adult Care Licensure Section and the Wilkes County Department of Social Services conducted an annual survey from 08/19/25 to 08/20/25.
Findings
The facility failed to administer medications as ordered for 2 of 7 residents related to a medication to treat pain and an allergy medication. Additionally, the facility failed to store discontinued controlled substances securely in a locked area separately from active medications until disposed of.
Deficiencies (2)
Failed to administer medications as ordered for 2 of 7 residents (#5 and #7), including a discontinued morphine medication and incorrect dosage of cetirizine.
Failed to store discontinued controlled substances securely in a locked area separately from active medications for Resident #5.
Report Facts
Medication error rate: 4.2
Residents present during inspection: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | RCC | Responsible for removing discontinued medications from the medication cart and confirming discontinuations with pharmacy |
| Medication Aide | MA | Administered discontinued morphine to Resident #5 and involved in medication administration errors |
| Administrator | Administrator | Provided information on medication discontinuation process and storage of controlled substances |
| Primary Care Provider | PCP | Provided orders and information related to Resident #5's medication discontinuation |
| Hospice Registered Nurse | RN | Discussed treatment plan and medication orders for Resident #5 |
| Pharmacist | Pharmacist | Provided information about pharmacy error in medication packing for Resident #7 |
Inspection Report
Capacity: 60
Deficiencies: 10
Date: Jul 20, 2023
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including lack of residential washers and dryers in laundry rooms, outside premises not maintained in a clean and safe condition, walls and ceilings not kept clean and in good repair, facility not free of all obstructions and hazards, failure to maintain emergency fire alarm and fire safety equipment in safe operating condition, and failure to maintain exhaust ventilation in specified spaces.
Deficiencies (10)
Facility did not have a minimum of one residential type washer and dryer provided in a separate room accessible by staff, residents and family.
Outside grounds were not maintained in a clean and safe condition; vinyl siding warped and buckling, exterior soffit gaps allowing pest entry.
Walls and ceilings were not kept clean and in good repair with water stains, peeling tape, mildew, damaged door header, and scuffed walls.
Facility was not free of all obstructions and hazards; padlocks on exterior doors may trap occupants.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel in trouble mode due to smoke detector issue.
Failure to maintain building's fire safety systems in safe condition; gaps in fire resistant rated ceilings and obstructions below sprinkler heads.
Use of materials not fire resistant rated allowing fire and smoke to spread beyond area of origin.
Building not maintained in safe and operating condition; kickdown devices on doors obstruct rapid closing to contain smoke or fire.
Failure to maintain fire safety equipment in safe operating condition; doors do not automatically close and latch properly.
Facility did not maintain exhaust ventilation in specified spaces; exhaust fans not working in 100 Hall and 200 Short Hall.
Report Facts
Licensed capacity: 60
Inspection Report
Capacity: 60
Deficiencies: 7
Date: Jan 9, 2020
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
The survey identified multiple deficiencies including staff not aware of the emergency release switch for magnetic locking exit doors, improper storage and handling of portable medical oxygen and compressed gas cylinders, malfunctioning battery powered emergency lights and exit signs, compromised fire rated walls and ceilings, corridor doors propped open preventing proper closure and latching, and improper storage too close to fire sprinkler heads.
Deficiencies (7)
Several staff were not aware of the location or use of the required central emergency release switch for the Special (magnetic) Locking on all exit doors.
Portable medical oxygen cylinders (6 tall and 2 short) were stored in an unapproved plastic crate; a tall helium cylinder was freestanding with no support.
Battery powered emergency lights would not work when tested in multiple areas including AL courtyard, SPC courtyard, and outside the 200 Short Hall exit.
Exit sign in the AL Dining room did not work on battery when tested.
One-hour fire rated walls and/or ceilings were compromised with holes and unsealed penetrations in the riser room.
Corridor doors to the data room and room 104 were propped open preventing them from closing quickly and latching; deficiencies corrected during survey.
Improper storage too close to a fire sprinkler head with boxes stacked within 8 inches of the ceiling in the pantry; deficiency corrected during survey.
Report Facts
Licensed capacity: 60
Oxygen cylinders: 8
Hole size: 108
Storage clearance: 8
Inspection Report
Follow-Up
Deficiencies: 5
Date: Nov 6, 2019
Visit Reason
The Adult Care Licensure Section and Wilkes County Department of Social Services conducted a follow-up survey to verify correction of previous deficiencies related to medication administration.
Findings
The facility failed to administer medications as ordered for 4 of 6 sampled residents, including pain medication, eye drops, and blood pressure/angina medications. Issues included medications not administered as scheduled, unavailable medications, and failure to follow physician orders, which was detrimental to resident health and safety.
Deficiencies (5)
Failure to administer Tramadol as ordered for pain management for Resident #1.
Failure to administer Artificial Tears eye drops as ordered for Resident #1 due to unavailability and failure to update medication records.
Failure to administer FreshKote eye drops as ordered for Resident #6 due to medication not being requested and unopened medication bottle.
Failure to administer Diltiazem HCL 180mg as ordered for Resident #5 due to medication not being available and lack of refill directions.
Failure to administer gabapentin 100mg and diltiazem 100mg as ordered for Resident #3 due to medication not being reordered because resident was incorrectly listed as a Hospice patient.
Report Facts
Residents sampled: 6
Residents with medication issues: 4
Missed doses: 6
Remaining tablets: 49
Missed administration days: 22
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 28, 2019
Visit Reason
The Adult Care Licensure Section and the Wilkes County Department of Social Services conducted an annual survey on August 28-29, 2019, with an exit conference on August 30, 2019.
Findings
The facility failed to administer medications as ordered for multiple residents, including failure to administer insulin, iron supplements, cholesterol medication, and other prescribed drugs. Medication administration errors were documented for five sampled residents, resulting in a Type B violation detrimental to resident health and safety.
Deficiencies (1)
Failed to administer medications as ordered for multiple residents, including insulin, iron supplements, cholesterol medication, and others.
Report Facts
Missed doses of Humalog insulin: 5
Hemoglobin A1C results: 9.8
Hemoglobin A1C results: 7.9
Medication doses documented but not available: 60
Medication doses documented but not available: 74
Medication doses documented but not available: 120
Medication doses documented but not available: 34
Medication doses documented but not available: 34
Medication doses documented but not available: 63
Medication doses documented but not available: 61
Medication doses documented but not available: 61
Medication doses documented but not available: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director (RCD) | Responsible for monthly record audits and medication cart audits; unaware of missed doses and medication issues. | |
| Resident Care Coordinator (RCC) | Responsible for weekly eMAR audits and medication cart audits; unaware of missed doses and medication issues. | |
| Medication Aide (MA) | Responsible for medication administration and documenting 'on order' medications; initials documented for missed insulin dose. | |
| Administrator | Unaware of missed medication doses and lack of medication cart and eMAR audits. | |
| Physician Assistant (PA) | Resident #4's PA unaware of missed insulin doses and continued administration of discontinued iron supplement. | |
| Physician | Multiple physicians for residents unaware of missed medication doses; expressed expectation that medications be administered as ordered. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Apr 11, 2018
Visit Reason
This was a biennial follow-up construction survey to verify correction of previously identified deficiencies.
Findings
The facility failed to correct several deficiencies including lack of hand grips in resident showers, improper storage of oxygen cylinders, inadequate fire safety rehearsals documentation, failure to maintain fire safety equipment and emergency lighting, and issues with door closures that could affect smoke and fire containment.
Deficiencies (6)
Hand grips were not provided in the small showers of the residents' bathrooms, with the nearest grab bar approximately 20 inches away and not useful for assistance.
Facility was not maintained free of hazards due to unsecured oxygen tanks stored improperly in beverage crates or storage rooms.
Fire safety rehearsals did not meet requirements as records lacked a short description of what the rehearsal involved.
Failure to maintain fire safety equipment in safe operating condition; cross corridor doors did not latch when released by fire alarm.
Electrical emergency/safety lighting was not maintained; exterior emergency light by Room 221 did not illuminate on battery backup.
Fire safety components not maintained; dining room doors had large gaps and kitchen pantry door was propped open with a box.
Report Facts
Oxygen cylinders: 6
Oxygen tanks: 4
Door gap measurement: 0.25
Door gap measurement: 0.5
Inspection Report
Capacity: 60
Deficiencies: 10
Date: Jan 11, 2018
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code(s), Institutional Occupancy during a Construction Section Biennial Survey.
Findings
The survey identified multiple deficiencies including lack of current sanitation and fire safety inspection reports, absence of hand grips in resident showers, walls not kept clean and in good repair, unsecured oxygen tanks posing hazards, inadequate fire safety rehearsals documentation, failure to maintain fire safety systems and emergency lighting, doors propped open improperly, unsafe plumbing configurations, and insufficient exhaust ventilation in required areas.
Deficiencies (10)
Facility did not have current building sanitation and fire safety inspections.
Hand grips were not provided in the small showers of the residents' bathrooms.
Walls at the bathroom door and other areas were heavily scuffed, damaged, and not kept clean and in good repair.
Facility was not maintained free of hazards due to unsecured oxygen tanks in storage room.
Fire safety rehearsals did not include a short description of what the rehearsal involved.
Failure to maintain building's fire safety systems in a safe condition including gaps in fire rated ceilings and doors that did not latch properly.
Electrical emergency/safety lighting equipment was not maintained in safe operating condition; several emergency lights failed to illuminate on battery backup.
Doors were propped open with unapproved devices impeding quick closure.
Plumbing piping was not installed or maintained in a safe configuration; icemaker drain line lacked required air gap.
Facility did not provide exhaust ventilation at the required rate in specified areas; exhaust fans not working and strong chemical odors present.
Report Facts
Licensed capacity: 60
Unsecured oxygen tanks: 4
Hand grip distance: 20
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