Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jan 14, 2026 | 102 | 3 | 0 | Follow-Up Inspection | |
| Oct 23, 2025 | 99 | 4.5 | 5.5 | Annual Inspection | |
| May 22, 2023 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Aug 11, 2021 | 100.5 | 2.5 | 2 | Annual Inspection | |
| Feb 26, 2021 | 83.5 | 0 | 22 | Complaint Investigation | |
| Feb 18, 2020 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jul 18, 2017 | 90.5 | 2.5 | 0 | Follow-Up Inspection | |
| Feb 6, 2017 | 88 | 2.5 | 10 | Follow-Up Inspection | |
| Oct 20, 2016 | 95.5 | 5.5 | 10 | Annual Inspection | |
| Nov 13, 2013 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Sep 22, 2011 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Aug 31, 2010 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Oct 21, 2009 | 97.75 | 3.75 | 0 | Follow-Up Inspection | |
| Aug 21, 2009 | 94 | 3 | 9 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 11, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 09/09/25 through 09/11/25 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure one resident completed a tuberculosis skin test prior to admission as required. Additionally, medication administration errors were found for two residents related to sliding scale insulin, including failure to administer insulin as ordered and lack of documentation of insulin administration.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 7 sampled residents completed a tuberculosis skin test prior to admission in compliance with control measures. | — |
| Failure to ensure medications were administered as ordered for 2 of 7 sampled residents including errors with sliding scale insulin. | Type B Violation |
Report Facts
Residents with medication errors: 2
Residents sampled for TB testing: 7
Opportunities with missing insulin documentation: 18
Opportunities with missing insulin documentation: 60
Opportunities with missing insulin documentation: 18
Opportunities with missing insulin documentation: 27
Opportunities with missing insulin documentation: 91
Opportunities with missing insulin documentation: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for auditing residents' TB screening and medication administration records. |
| Director of Marketing | Director of Marketing | Responsible for providing admission requirements including TB testing to residents or responsible persons. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for oversight of medication administration and communication with staff. |
| Administrator | Administrator | Oversight of facility compliance and staff responsibilities. |
| Medication Aide | Medication Aide | Administered insulin but did not document amounts due to eMAR system limitations. |
| Pharmacist | Pharmacist | Contracted pharmacy responsible for adding insulin entries to eMAR. |
| Endocrinologist | Endocrinologist | Ordered sliding scale insulin parameters and expected proper administration and documentation. |
| Primary Care Provider | Primary Care Provider | Expected insulin administration per sliding scale and documentation. |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 24, 2024
Visit Reason
Biennial Construction Section Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies have been corrected. No further action is necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Biennial Construction Section Follow Up Survey. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 23, 2020
Visit Reason
The Adult Care Licensure Section conducted a Complaint Investigation and a COVID-19 Focused Infection Control Survey with an onsite visit on 12/17/20, desk reviews from 12/18/20 through 12/23/20, and an exit via telephone on 12/23/20.
Findings
The facility failed to provide personal care assistance to Resident #1 with bathing and incontinence care, failed to provide adequate supervision for Residents #2 and #3 who were found undressed together on multiple occasions including engaging in sexual activity, and failed to increase supervision for Resident #1 after multiple falls. These failures compromised resident safety and dignity.
Complaint Details
Complaint investigation triggered by concerns about personal care neglect for Resident #1 and supervision failures related to Residents #2 and #3 involving inappropriate sexual activity and falls.
Severity Breakdown
Type B Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure staff provided personal care assistance to Resident #1 with bathing and incontinence care as required by care plans. | — |
| Facility failed to provide supervision for Residents #2 and #3 related to multiple incidents of undressing together and sexual activity. | Type B Violation |
| Facility failed to increase supervision for Resident #1 after multiple falls despite documented history and risk factors. | Type B Violation |
Report Facts
Days Resident #1 did not receive assistance to bathroom: 31
Days Resident #1 did not receive assistance with bladder incontinence: 31
Number of falls Resident #1 had between 12/05/20 and 12/06/20: 3
30-minute safety checks start date for Resident #2: Nov 20, 2020
30-minute safety checks start date for Resident #3: Nov 7, 2020
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 26, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 09/24/19 through 09/26/19 at Brighton Gardens of Greensboro.
Findings
The facility failed to ensure that one of six sampled staff had a required second tuberculosis test after hire, and one of three sampled medication aides lacked proper documentation of medication administration training and clinical skills validation prior to administering medication.
Deficiencies (2)
| Description |
|---|
| Facility failed to assure that 1 of 6 sampled staff (Staff C) were tested for tuberculosis disease upon hire with a required second TB skin test within the first year of employment. |
| Facility failed to assure 1 of 3 sampled medication aides (Staff E) had documentation of completed medication administration clinical skills validation, required training hours, or verification of previous employment before administering medication. |
Report Facts
Number of sampled staff missing second TB test: 1
Number of sampled medication aides missing proper documentation: 1
Dates of medication administration by Staff E: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to have required second TB skin test documented |
| Staff E | Medication Aide | Lacked documentation of medication administration training and clinical skills validation prior to administering medication |
| Administrator | Interviewed regarding personnel records and deficiencies | |
| Resident Care Coordinator | Responsible for conducting medication training and clinical skills validation | |
| Business Office Manager | Responsible for maintaining personnel records; was in training or unavailable during survey |
Inspection Report
Capacity: 125
Deficiencies: 8
Sep 20, 2018
Visit Reason
Biennial Construction Section Survey to assess compliance with physical plant requirements, building codes, and housekeeping standards.
Findings
Multiple deficiencies were cited including failure to meet NC State Building Code requirements for special locking systems, chronic unpleasant odors in certain rooms, unsafe storage of oxygen cylinders, broken electrical receptacle, failure to maintain fire-rated floor/ceiling assemblies, damaged emergency lighting, improper storage height near sprinkler heads, and inadequate ventilation in specified rooms.
Deficiencies (8)
| Description |
|---|
| No wiring diagram of the Special Locking Magnetic holding/release devices posted adjacent to the fire alarm panel. |
| Facility failed to prevent chronic unpleasant odors; Room 172 has unpleasant odors. |
| Oxygen bottles in multiple rooms are not secured or stored in approved racks. |
| Wall receptacle is broken in Room 333. |
| Electrical conduits penetrating ceiling and floor construction are not fire-stopped in multiple locations. |
| Emergency exterior light outside Stair Tower #4/SCU is damaged. |
| Storage of diapers to the ceiling in Room 321 could impair sprinkler function. |
| Facility failed to provide ventilation where odors are generated in SCU restrooms adjacent to Living Room and SCU Spa. |
Report Facts
Total licensed beds: 125
Inspection Report
Follow-Up
Deficiencies: 2
Jan 5, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 01/04/17 and 01/05/17 to evaluate the facility's compliance with supervision requirements for residents at high risk of falls.
Findings
The facility failed to provide adequate supervision for 2 of 2 sampled residents (Residents #1 and #8) who were identified as high fall risks and had multiple falls with injuries. Despite numerous documented falls and injuries, there was no evidence that staff increased supervision in response to these incidents, resulting in a Type A2 Violation.
Severity Breakdown
Type A2 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide supervision for Resident #1, a high fall risk with multiple falls and injuries, in accordance with assessed needs and symptoms. | Type A2 Violation |
| Failure to provide supervision for Resident #8, who had multiple falls with injuries, in accordance with assessed needs and symptoms. | Type A2 Violation |
Report Facts
Unwitnessed falls: 11
Unwitnessed falls: 14
Fall risk checks per shift: 5
Rounds frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1's hospice nurse | Hospice Nurse | Instructed staff not to store Resident #1's wheelchair and walker within reach to discourage independent use. |
| Assisted Living Coordinator | Assisted Living Coordinator | Provided information on rounds frequency and supervision practices for residents. |
| Executive Director | Executive Director | Provided information on facility's Falls Management Program and communication practices. |
| Resident #1's Power of Attorney | Power of Attorney | Expressed concerns about supervision and frequency of staff visits to Resident #1. |
Inspection Report
Capacity: 125
Deficiencies: 8
Oct 7, 2016
Visit Reason
The report documents a Biennial Construction Survey conducted to assess compliance with applicable standards and building codes for the facility licensed for 125 beds.
Findings
Multiple deficiencies were cited including failure to maintain floor coverings presenting trip hazards, damaged ceilings due to water migration, failure to provide emergency unlocking for courtyard gates, improper storage of oxygen cylinders, malfunctioning smoke-barrier and interior doors, blocked electrical panel clearances, and lack of mechanical exhaust ventilation in laundry areas.
Deficiencies (8)
| Description |
|---|
| Floor coverings in heavily trafficked areas are unglued due to moisture migration, presenting a trip hazard. |
| Damaged ceilings due to water migration in Front Living Room/Lobby and Room 166/SCU. |
| Courtyard gate in Memory Care lacks an emergency on/off switch, affecting emergency evacuation. |
| Oxygen bottles not stored in approved racks in Rooms 236, 318, 331, and 362. |
| Smoke-barrier door adjacent to Room 361 has damaged magnetic catch; smoke-barrier doors in Special Care Unit do not latch. |
| Interior doors in Room 223 and Third Floor Meeting Room do not latch. |
| Electrical circuit control panels blocked with stored items, impeding required working clearances. |
| Lack of mechanical exhaust fans in all Laundry Rooms adjacent to Elevator Lobby and Laundry Room in Special Care Unit, causing housekeeping odors. |
Report Facts
Licensed bed capacity: 125
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 30, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brighton Gardens of Greensboro from September 28-30, 2016 to assess compliance with health care regulations.
Findings
The facility failed to ensure appropriate referral and follow-up for Resident #7 who experienced respiratory difficulty and low oxygen saturations with exertion. The resident's deteriorating condition was not promptly communicated to the physician, resulting in delayed hospital transfer and treatment.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure referral and follow-up for a resident experiencing respiratory difficulty and low oxygen saturations with exertion. | Type A2 Violation |
| Failure to provide care and services adequate, appropriate, and in compliance with relevant laws regarding referral and follow-up to the primary care physician. | — |
Report Facts
Duration of resident stay: 12
Oxygen saturation levels: 78
Oxygen saturation levels: 68
Oxygen saturation levels: 72
Oxygen saturation levels: 96
Dates of survey: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist (PT) | Reported episodes of low oxygen saturation during ambulation and communicated with nursing staff. | |
| Wellness Nurse, LPN | Faxed oxygen saturation information and CXR request to PCP; did not report abnormal vitals to Resident Care Director. | |
| Resident Care Director (RCD), RN | Expected staff to report low oxygen levels; was unaware of critical oxygen desaturation episodes until 9/22/16. | |
| Administrator | Was not aware of Resident #7's low oxygen levels or CXR results at the time they occurred. |
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