Deficiencies per Year
20
15
10
5
0
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Apr 24, 2025 | 100.5 | 4.5 | 4 | Annual Inspection | |
| Apr 22, 2022 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Apr 10, 2019 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Dec 22, 2017 | 102.5 | 4.5 | 2 | Annual Inspection | |
| Jun 23, 2016 | 105.5 | 0 | 0 | Re-Issued | |
| Nov 6, 2015 | 98 | 8 | 0 | Annual Inspection | |
| Jan 22, 2015 | 95.75 | 1.25 | 0 | Follow-Up Inspection | |
| Nov 17, 2014 | 94.5 | 2.5 | 3.5 | Follow-Up Inspection | |
| Jul 3, 2014 | 95.5 | 5.5 | 10 | Annual Inspection | |
| Jun 28, 2012 | 100.5 | 4.5 | 4 | Annual Inspection | |
| Nov 24, 2010 | 102.25 | 1.25 | 0 | Follow-Up Inspection | |
| Oct 25, 2010 | 101 | 4.5 | 3.5 | Annual Inspection | |
| Aug 21, 2009 | 104.5 | 4.5 | 0 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Mar 20, 2025
Visit Reason
The Adult Care Licensure Section and the Cleveland County Department of Social Services conducted an annual survey and complaint investigation from 03/19/2025 through 03/20/2025.
Findings
The facility failed to ensure one resident was tested for tuberculosis disease in compliance with public health control measures, and failed to maintain accurate electronic medication administration records for another resident, including documentation errors related to medications for infections and parasites.
Complaint Details
The visit included a complaint investigation conducted concurrently with the annual survey.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 1 of 5 sampled residents was tested for tuberculosis disease in compliance with control measures. |
| Facility failed to ensure the electronic medication administration record (eMAR) was accurate for 1 of 5 sampled residents related to documentation errors for medications treating infections and parasites. |
Report Facts
Sampled residents: 5
Medication capsules dispensed: 14
Medication dosage: 100
Medication dosage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manager | Interviewed regarding tuberculosis testing and medication administration documentation. | |
| Health and Wellness Director (HWD) | Responsible for ensuring completion and documentation of TB tests; left position approximately one month prior to survey. | |
| Lead Medication Aide (MA) | Interviewed about medication administration and documentation errors for Resident #4. | |
| Pharmacist | Interviewed regarding medication dispensing and eMAR documentation. | |
| Special Care Coordinator (SCC) | Interviewed about medication order processing and eMAR review. |
Inspection Report
Capacity: 65
Deficiencies: 20
Sep 18, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with applicable building codes, physical plant requirements, fire safety, housekeeping, and drug storage regulations.
Findings
Multiple deficiencies were cited including failure to meet NC State Building Code requirements for special locking system doors, housekeeping and maintenance issues, fire safety rehearsal and equipment failures, compromised fire-rated walls and ceilings, improper storage near sprinkler heads, malfunctioning emergency release warning devices, inadequate exhaust ventilation, and unsecured medication storage.
Deficiencies (20)
| Description |
|---|
| Emergency release switch at courtyard gate is a momentary push button instead of an on-off switch. |
| No wiring diagram or system components location map posted at fire alarm panel. |
| HVAC exhaust grill and radiation damper in beauty parlor had excessive dust/lint accumulation. |
| Portable medical oxygen cylinders improperly stored without containers or racks, some in cardboard boxes or unapproved crates. |
| Missing cleanout plug on 3 inch cleanout in driveway presenting trip hazard. |
| Wrinkles in carpet in corridor presenting trip hazard. |
| Sand bags and drain pipe in walkway presenting trip hazard. |
| Broken electrical outlet cover in 200 Wing main bathroom exposing energized parts. |
| Broken outside corner wall tile in 200 Wing main bathroom presenting laceration hazard. |
| Toilet loosely mounted to floor in bathroom off Resident Care Director's office. |
| Electrical outlet expander in use in room 221, not approved for institutional occupancies. |
| Fire alarm system non-functional for 3 weeks; fire watch conducted inadequately; fire drill rehearsals not done regularly per shift each quarter. |
| Many corridor doors prevented from closing and latching properly, some wedged open, mail slot in business office door allowing smoke passage. |
| One-hour fire rated walls and ceilings compromised by unsealed holes and penetrations in multiple locations. |
| Improperly fitted or missing sprinkler escutcheons in multiple locations. |
| Battery powered emergency light in Resident Care Director's office not working. |
| Storage stacked too close (within 6 inches) to fire sprinkler heads in kitchen and activity storage rooms. |
| Warning device ('screamer') for emergency release switch at courtyard exit gate not working. |
| Exhaust ventilation not working in bathroom off dining room and housekeeping closet on 200 Wing. |
| Medication storage room and med cart on 200 Wing found unlocked and unsupervised with many medication cards accessible. |
Report Facts
Licensed capacity: 65
Portable medical oxygen cylinders: 20
Fire drill rehearsal missing shifts: 2
Weeks fire alarm non-functional: 3
Storage clearance below sprinkler heads: 6
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 7, 2017
Visit Reason
The Adult Care Licensure Section and the Cleveland County Department of Social Services conducted an annual survey on November 7-9, 2017.
Findings
The facility failed to administer clonidine, vitamin D3, and lovastatin as ordered for 2 of 4 residents observed during the 8am medication pass on 11/8/17. Medication administration errors were documented for Resident #7 and Resident #8, including missed doses due to unavailable medications and discrepancies between physician orders and medications on hand.
Deficiencies (3)
| Description |
|---|
| Failed to administer clonidine 0.1mg 24 hr. patch as ordered for Resident #8 due to lack of medication availability. |
| Failed to administer vitamin D3 400 units daily as ordered for Resident #8; resident was given vitamin D3 2000 unit capsules instead, which did not match the physician's order. |
| Failed to administer lovastatin 40mg twice daily as ordered for Resident #7 due to medication unavailability on several occasions. |
Report Facts
Medication administration opportunities for clonidine: 14
Medication administration opportunities for vitamin D3: 92
Medication administration opportunities for vitamin D3: 8
Medication administration opportunities for lovastatin: 51
Medication administration opportunities for lovastatin: 60
Medication administration opportunities for lovastatin: 57
Medication administration opportunities for lovastatin: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in findings related to medication administration errors for Residents #7 and #8. |
| Staff B | Medication Aide | Interviewed regarding medication administration procedures and documentation. |
| Resident Care Coordinator | Involved in obtaining medications from pharmacies and managing medication availability. | |
| Administrator | Interviewed about medication supply issues and corrective actions. |
Inspection Report
Capacity: 65
Deficiencies: 6
Aug 3, 2017
Visit Reason
This is a Construction Section Biennial Survey to ensure the facility meets applicable building codes and adult care home rules.
Findings
Deficiencies were cited related to failure to maintain exterior doors and gates, sprinkler head installations, fire protection in electrical ceiling penetrations, and roof/ceiling assembly integrity due to water damage.
Deficiencies (6)
| Description |
|---|
| Facility failed to maintain the exterior finishes of the exterior doors with peeling paint. |
| Facility failed to maintain the exterior gates in the courtyards; wooden exit gate drags on sidewalk and is difficult to open in emergencies. |
| Facility failed to maintain sprinkler head installation in ceilings; openings adjacent to sprinkler head escutcheons due to service and repair. |
| Facility failed to provide fire protection in all electrical ceiling penetrations through fire rated roof/ceiling assemblies. |
| Facility has not maintained the one-hour roof/ceiling assembly construction due to water migration damaging ceiling sheet-rock and invalidating integrity. |
| There is an opening in the ceiling construction adjacent to the emergency corridor light outside Room 323. |
Report Facts
Total licensed capacity: 65
Number of electrical conduits: 3
Inspection Report
Capacity: 65
Deficiencies: 8
Oct 29, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes, adult care home regulations, and physical plant standards.
Findings
Multiple deficiencies were identified including issues with the fire sprinkler system, housekeeping hazards such as broken wall tiles, improper storage near sprinkler heads, malfunctioning fire doors and emergency lights, compromised fire-rated walls and attic draft stops, and non-functioning exhaust ventilation in the soiled utility room.
Deficiencies (8)
| Description |
|---|
| Fire sprinkler system deficiencies including accelerator not resetting, obstructed sprinkler head, and missing sprinkler escutcheons. |
| Broken wall tiles in the shower room on 200 Hall presenting sharp edges. |
| Improper storage too close to fire sprinkler head in kitchen supply room, stacked within 4 inches of ceiling. |
| Cross-corridor doors near RCC office and other doors failing to latch or close properly, including doors wedged or held open with mechanical devices. |
| Several battery powered emergency lights not working in multiple areas including storage, activity room, corridors, maintenance office, medroom, shower room, and kitchen. |
| Compromised one-hour fire rated walls and ceilings with unsealed holes and penetrations in multiple locations. |
| Compromised attic draft stop walls with doors removed or not replaced and holes unsealed after sprinkler pipe installation. |
| Exhaust fan not working in the soiled utility room in the BTR, failing to maintain required ventilation. |
Report Facts
Licensed capacity: 65
Date of inspection: Oct 29, 2015
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