Deficiencies per Year
12
9
6
3
0
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jul 8, 2024 | 100.5 | 4.5 | 4 | Annual Inspection | |
| Jan 3, 2023 | 96.5 | 2.5 | 6 | Annual Inspection | |
| May 7, 2019 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Mar 21, 2017 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Feb 11, 2014 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Nov 2, 2011 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Oct 25, 2010 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Aug 21, 2009 | 101.5 | 5.5 | 4 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 30, 2025
Visit Reason
This report documents a Biennial Follow Up Construction Survey conducted to verify correction of previously noted deficiencies.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 19, 2024
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual and follow-up survey from 06/18/24 to 06/19/24.
Findings
The facility failed to ensure that 2 of 5 sampled residents were tested for tuberculosis disease as required, and failed to maintain accurate electronic Medication Administration Records (eMAR) for oxygen orders for one resident.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 2 of 5 sampled residents were tested for Tuberculosis disease in compliance with guidelines. |
| Facility failed to ensure the electronic Medication Administration Records (eMAR) were accurate for 1 of 5 sampled residents related to an order for oxygen. |
Report Facts
Sampled residents: 5
Residents with TB testing deficiency: 2
Residents with eMAR deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding tuberculosis testing and medication administration issues | |
| Health and Wellness Director | HWD | Responsible for ensuring TB skin tests were completed; left employment abruptly in May 2024 |
| Medication Aide | MA | Interviewed about oxygen order documentation and medication administration |
| Special Care Coordinator | Interviewed regarding physician orders and oxygen management | |
| Pharmacist | Interviewed about pharmacy role in entering orders into eMAR | |
| MA Supervisor | Interviewed about staff instructions regarding eMAR order entry |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 16, 2022
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual survey and complaint investigation on November 15 - 16, 2022. The complaint investigation was initiated on September 23, 2022.
Findings
The facility was found deficient in multiple areas including food safety due to contamination risks from an unclean ice machine and improperly sealed and dated food items in the pantry. Resident rights violations were noted related to staff disrespect and poor treatment of residents. Medication administration records were inaccurate for one resident, including failure to document holding medication when blood pressure was low and failure to transcribe a controlled substance order onto the medication administration record.
Complaint Details
Complaint investigation initiated on September 23, 2022, related to food safety and resident treatment concerns.
Deficiencies (3)
| Description |
|---|
| Food and beverage contamination risk due to build-up substance in the ice machine and food items in the pantry not sealed or dated when opened. |
| Failure to treat residents with respect and dignity as evidenced by staff attitude and disrespectful behavior reported by multiple residents. |
| Inaccurate medication administration records for Resident #1 including failure to document holding Metoprolol when systolic blood pressure was below 110 and failure to transcribe Diazepam order onto eMAR. |
Report Facts
Dates of ice machine cleaning documented: 7
Metoprolol administration errors: 10
Metoprolol administration errors: 3
Metoprolol administration errors: 2
Diazepam tablets on hand: 5
Diazepam tablets administered: 1
Inspection Report
Capacity: 96
Deficiencies: 12
Aug 4, 2016
Visit Reason
Biennial Construction Survey to assess compliance with the 1996 Regulations for Homes for the Aged and Disabled and applicable portions of the 2005 Regulations for Adult Care Homes of Seven or More Beds and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including lack of hand grips in bathrooms, presence of scatter rugs creating tripping hazards, unclean and stained furnishings, improper storage of medical oxygen cylinders, fire safety and firestopping issues, malfunctioning emergency exit signs, interior doors not latching properly, sprinkler system and HVAC units not maintained or operating safely, electrical hazards, and inadequate exhaust ventilation in several areas.
Deficiencies (12)
| Description |
|---|
| Facility failed to provide commodes, tubs and showers accessible to residents with hand grips. |
| Presence of scatter or throw rugs creating tripping hazards. |
| Walls, ceilings, floors, and furniture not kept clean and in good repair; presence of chronic unpleasant odors. |
| Portable medical oxygen cylinders not properly secured, creating hazard. |
| Exhaust fan falling out of ceiling, creating hazard. |
| Fire safety equipment and firestopping not maintained; missing or damaged fire-resistance enclosures and gaps around penetrations. |
| Emergency exit signs not working on backup power or misrepresenting egress pathways. |
| Interior doors not maintained in safe and operating condition; doors not latching properly or damaged. |
| Fire sprinkler escutcheon plates dropped down from ceiling, allowing spread of fire and smoke. |
| Heating, ventilation and air conditioning units out of order, not providing conditioned air. |
| Electrical system hazards including missing and broken cover plates exposing energized components. |
| Exhaust ventilation system not maintained or not removing required amount of air in multiple areas, allowing buildup of odors. |
Report Facts
Licensed capacity: 96
Number of rugs creating tripping hazard: 3
Number of portable medical oxygen cylinders improperly stored: 3
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