Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Deficiencies: 0
Sep 9, 2025
Visit Reason
Follow-up survey conducted by Tod Hancock on September 9, 2025, to verify corrections related to construction section deficiencies.
Findings
Corrections have been made and no further action is needed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Construction Section Follow Up Survey |
Inspection Report
Follow-Up
Capacity: 66
Deficiencies: 4
Oct 30, 2024
Visit Reason
This is a Construction Section Biennial Follow-Up Survey conducted to assess compliance with physical plant requirements and fire safety codes at the facility.
Findings
Multiple deficiencies were found including non-compliance with fire safety equipment maintenance, malfunctioning maglock on a courtyard gate, fire sprinkler system main valve turned off with the facility on fire watch since April 18, 2024, fire alarm system supervisory alarms due to disconnected wiring, and failure to maintain exhaust ventilation in specified areas such as laundry rooms.
Deficiencies (4)
| Description |
|---|
| Maglock on the left courtyard gate is not working and the gate has been temporarily nailed shut. |
| Fire sprinkler equipment is not maintained in operating condition; main OS&Y valve turned off and gauge reading 0 psi. |
| Failure to maintain emergency fire alarm system devices; supervisory alarm due to disconnected tamper switch wiring. |
| Facility did not maintain exhaust ventilation in specified spaces including laundry room and housekeeping closet fans not working. |
Report Facts
Licensed capacity: 66
Date facility has been on fire watch: Apr 18, 2024
Scheduled sprinkler system service date: Nov 11, 2024
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 10, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from February 8, 2023 through February 10, 2023.
Findings
The facility failed to provide adequate supervision for a resident with a history of multiple falls resulting in injuries, constituting a Type B violation. Additionally, the facility failed to ensure timely health care referral and follow-up for a resident who sustained a head injury after a fall, constituting a Type A2 violation.
Complaint Details
The inspection included a complaint investigation related to supervision and health care referral following falls and injuries of residents.
Severity Breakdown
Type B Violation: 1
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide supervision for Resident #1 who experienced eleven unwitnessed falls in three months resulting in multiple injuries including skin tears. | Type B Violation |
| Failed to ensure Resident #6 was sent to the hospital for evaluation after a fall with a head injury, resulting in increased pain and worsening spine compression fractures. | Type A2 Violation |
Report Facts
Number of falls: 11
Dates of survey: Survey conducted from February 8, 2023 through February 10, 2023.
Inspection Report
Routine
Capacity: 66
Deficiencies: 14
Jun 20, 2019
Visit Reason
Report of a Construction Section Biennial Survey conducted on June 20, 2019, to assess compliance with licensing and building code requirements for an adult care home.
Findings
Multiple deficiencies were cited including failure to meet building code requirements for special locking arrangements, lack of current fire and sanitation inspection reports, poor housekeeping with dust accumulation, unsafe storage of oxygen cylinders, improperly maintained fire extinguishers, improperly posted evacuation plans, incomplete fire safety rehearsal documentation, unsafe and non-operating building equipment including fire alarm and electrical systems, fire safety hazards such as holes in fire-resistance barriers, blocked corridor doors, and inadequate hot water temperature and ventilation systems.
Deficiencies (14)
| Description |
|---|
| Failed to have required procedures for doors with special locking arrangements accessible to all evacuation staff. |
| Failed to maintain current sanitation and fire safety inspection reports in the facility. |
| Building mechanical systems not kept clean; excessive dust/lint accumulation in HVAC and ventilation systems. |
| Oxygen cylinders stored unsecured in an unapproved plastic crate, posing hazard if cylinders fall. |
| Fire extinguishers improperly maintained; one extinguisher locked in inaccessible Med Room. |
| Evacuation plans not properly posted or oriented, affecting emergency guidance. |
| Fire safety rehearsals not fully documented for the last 12 months; missing staff lists and rehearsal descriptions. |
| Fire alarm system not maintained in safe and operating condition; dirty sampling tubes on HVAC duct detectors. |
| Holes and gaps in fire-resistance-rated walls and ceilings compromising smoke/fire containment. |
| Corridor doors did not resist smoke passage due to holes and were blocked open by objects. |
| Electrical system unsafe due to use of multiple plug adaptor without overcurrent protection; boxes blocking electrical panel clearance. |
| Building components broken or missing, including panic hardware missing end covers exposing sharp edges. |
| Hot water temperature at resident fixtures below minimum required (96°F in Bedroom 217 Bathroom). |
| Ventilation system failed to operate properly in Bedroom 203 Shared Bedroom. |
Report Facts
Total licensed capacity: 66
Hot water temperature: 96
Date of inspection: Jun 20, 2019
Oxygen cylinders: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 31, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual survey on October 30 - 31, 2018.
Findings
No specific findings or deficiencies are detailed in the report.
Inspection Report
Follow-Up
Deficiencies: 1
Aug 23, 2017
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of a previously identified deficiency related to building code compliance.
Findings
The facility has one remaining deficiency involving failure to prevent dead-end travel distances greater than twenty feet due to interior alterations. The door to correct this condition is on order with a five week lead time and expected shipment the week of September 4, 2017.
Deficiencies (1)
| Description |
|---|
| Failed to prevent dead-end travel distances of greater than twenty feet due to interior alterations that do not comply with the NC Building Code. |
Report Facts
Lead time for door shipment: 5
Inspection Report
Capacity: 66
Deficiencies: 7
Jun 22, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for the Licensing of Adult Care Homes and applicable building codes for the facility licensed as a Home for the Aged.
Findings
Multiple deficiencies were cited including failure to prevent dead-end travel distances over twenty feet, failure to maintain fire resistant seals on attic access panels, unlatched interior doors, excessive particulate buildup on HVAC vents, blocked electrical service panel access, gaps in fire resistant ceilings, and inadequate exhaust ventilation in certain storage areas.
Deficiencies (7)
| Description |
|---|
| Failed to prevent dead-end travel distances greater than twenty feet due to removal of hallway door in Dogwood community. |
| Failed to maintain attic access panels with fire resistant seal due to broken latching hardware in Sunflower community. |
| Interior doors at Rooms 217A and 302A do not latch due to unadjusted door hardware. |
| Excessive particulate buildup on return-air grilles in all mechanically ventilated areas. |
| Electrical service panels in Main Boiler Room blocked by doors and stored items, preventing access. |
| Gaps and open penetrations in fire resistant rated ceilings in Mechanical Room/Magnolia community not sealed with fire resistant sealant. |
| Mechanical exhaust fan not exhausting interior air in Storage Room in Dogwood community. |
Report Facts
Licensed capacity: 66
Inspection Report
Annual Inspection
Deficiencies: 5
May 30, 2017
Visit Reason
The Adult Care Licensure Section and the Catawba County Department of Social Services conducted an annual survey and complaint investigation from May 23, 2017 through May 30, 2017. The county initiated the complaint investigation on April 4, 2017.
Findings
The facility failed to assure referral and follow-up for a critical missed medication (warfarin) for 7 consecutive days for Resident #6, resulting in stroke and death. The facility also failed to administer medications as ordered to multiple residents, including errors with warfarin, methotrexate, temazepam, loratadine, cephalexin, sertraline, docusate/senna, pantoprazole, and others. Additionally, the facility failed to maintain narcotic count records for one resident and failed to perform required controlled substance screening for a staff member prior to employment.
Complaint Details
The complaint investigation was initiated on April 4, 2017, related to missed medication administration and medication errors, including a critical missed warfarin medication for Resident #6.
Severity Breakdown
Type A1 Violation: 2
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to assure referral and follow-up for Resident #6's critical missed warfarin medication for 7 consecutive days, resulting in stroke and death. | Type A1 Violation |
| Failed to administer medications as ordered by a licensed prescribing practitioner to multiple residents, including warfarin, methotrexate, temazepam, loratadine, cephalexin, sertraline, docusate/senna, pantoprazole. | Type A1 Violation |
| Failed to maintain narcotic count record sheets for Resident #4's temazepam 30mg. | — |
| Failed to assure quarterly on-site medication reviews that identified and prevented medication related problems for Resident #3. | — |
| Failed to perform controlled substance examination and screening for Resident Care Manager prior to employment. | Type B Violation |
Report Facts
Missed warfarin doses: 7
Methotrexate tablets: 27
Cephalexin capsules: 13
Temazepam capsules: 2
Loratadine tablets: 30
Seroquel tablets: 29
Prednisone tablets: 10
Autologous eye drop bottles: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Manager | Resident Care Manager | Failed to have controlled substance screening prior to employment; tested positive for controlled substances after hire; involved in medication administration errors and documentation issues. |
| Executive Director Pro Tem | Executive Director Pro Tem | Interviewed regarding medication errors, staff training, and failure to notify primary care provider of missed medications. |
| Resident Care Manager | Resident Care Manager | Instructed medication aides to document medication refusal instead of medication not available; responsible for medication order review and medication administration oversight. |
| Pharmacy Consultant | Pharmacy Consultant | Performed medication review for Resident #3; unaware of medication administration issues. |
| Nurse Practitioner | Nurse Practitioner | Primary care provider for Resident #2; unaware of medication administration errors; concerned about medication safety. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 1, 2015
Visit Reason
The Adult Care Licensure Section and the Catawba County Department of Social Services conducted a follow-up survey and complaint investigation initiated on September 25, 2015, related to concerns about resident supervision and care.
Findings
The facility failed to adequately supervise Resident #2 according to assessed needs, failed to notify physicians regarding elopement, bruising, and need for higher level of care for Residents #2, #3, and #4, and failed to report an injury of unknown source to the Health Care Personnel Registry for Resident #3. Multiple incidents of elopement, falls, and injuries were documented with inadequate follow-up and communication.
Complaint Details
Complaint investigation initiated by Catawba County Department of Social Services on September 25, 2015, focused on supervision failures and notification issues related to Resident #2's elopements and other resident care concerns.
Severity Breakdown
Type A2 Violation: 2
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision for Resident #2 leading to multiple elopements from dialysis and the facility. | Type A2 Violation |
| Failure to notify physician concerning elopement, bruising, and need for higher level of care for Residents #2, #3, and #4. | Type A2 Violation |
| Failure to report injury of unknown source (Resident #3's ulnar fracture) to the Health Care Personnel Registry within 24 hours. | Type B Violation |
Report Facts
Number of sampled residents: 5
Number of falls for Resident #4: 6
Number of elopements from dialysis for Resident #2: 3
Correction date for Type A2 violations: 2015
Correction date for Type B violation: 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Unit Coordinator | Reported incidents and communicated with PCP and family regarding Resident #2 and Resident #3 | |
| Executive Director | Interviewed regarding Resident #2 elopements and Resident #3 injury reporting; completed Health Care Personnel Registry report | |
| Primary Care Provider | Physician for Residents #2, #3, and #4; involved in care decisions and notifications | |
| Transportation Provider Supervisor | Provided information about transportation and supervision issues for Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 17, 2015
Visit Reason
The Adult Care Licensure Section and the Catawba County Department of Social Services conducted a biennial, follow-up survey, and complaint investigation from 07/14/15 to 07/15/15, with an exit conference via telephone on 07/17/15.
Findings
The facility failed to assure referral and follow-up for one of four sampled residents with falls (Resident #6) by not sending the resident out for medical evaluation after an unwitnessed fall. Staff did not follow the facility's fall protocol, resulting in neglect and failure to report to the Health Care Personnel Registry. Staff A was removed from the supervisor position and employment. A Plan of Protection was submitted to address these issues.
Complaint Details
Complaint investigation conducted from 07/14/15 to 07/15/15. The complaint was substantiated as the facility failed to send Resident #6 for medical evaluation after an unwitnessed fall and failed to follow fall protocols, resulting in neglect. Staff A was removed from the supervisor position and employment.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure referral and follow-up for a resident with falls by not sending the resident out for medical evaluation after an unwitnessed fall. | Type A1 Violation |
| Facility failed to comply with Health Care Personnel Registry reporting requirements by neglecting to report a staff member's neglect within 24 hours of an incident. | — |
| Facility failed to assure that Resident #6 was free from neglect related to residents' rights and failed to send the resident out for medical evaluation after an unwitnessed fall per the facility's fall protocol. | — |
Report Facts
Dates of investigation: 07/14/15 to 07/15/15
Date of exit conference: 07/17/15
Date of incident report: 07/06/15 at 2:30am and 5:20am
Correction due date: August 16, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide/Supervisor | Named in findings related to failure to send resident for medical evaluation after fall and neglect; removed from supervisor position and employment. |
| Staff B | Personal Care Aide | Discovered Resident #6 had fallen and reported to supervisor. |
| Staff C | Personal Care Aide | Worked night of Resident #6's fall; provided observations and assisted resident. |
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