Deficiencies per Year
16
12
8
4
0
Moderate
Unclassified
Inspection Report
Follow-Up
Deficiencies: 1
Aug 13, 2025
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified construction deficiencies.
Findings
The facility failed to submit Construction Documents and specifications to the Division of Health Service Regulation/Construction Section during remodeling. Specifically, the fire alarm system was replaced without submitting plans and specifications for review and approval as of the survey date.
Deficiencies (1)
| Description |
|---|
| Failure to submit Construction Documents and specifications to the Division during construction or remodeling, including replacement of the fire alarm system without prior approval. |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 13, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to construction and remodeling compliance.
Findings
The facility failed to submit required Construction Documents and specifications to the Division of Health Service Regulation for review and approval during remodeling. Specifically, plans for replacing the fire alarm system had not been submitted as of the survey date.
Deficiencies (1)
| Description |
|---|
| Failure to submit Construction Documents and specifications to the Division of Health Service Regulation/Construction Section during construction or remodeling, including plans for fire alarm system replacement. |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 10, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previous deficiencies and to identify any new deficiencies related to construction and building safety compliance.
Findings
The facility failed to submit required construction documents and specifications for review and approval during ongoing construction related to fire alarm system replacement. Additionally, the fire safety systems were not maintained in a safe operating condition, including an alarm system indicating trouble and unsealed penetrations in fire-rated ceilings.
Deficiencies (3)
| Description |
|---|
| Failure to submit Construction Documents and specifications to the Division for review and approval during construction or remodeling. |
| Failure to maintain fire safety systems in a safe operating condition, including a fire alarm system indicating trouble and requiring replacement. |
| Holes or gaps at penetrations through fire resistant rated ceilings that could allow fire and smoke to spread beyond the area of origin. |
Report Facts
Survey date: Jul 10, 2024
Inspection Report
Annual Inspection
Deficiencies: 9
Jun 27, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey with a complaint investigation from 06/25/24 to 06/27/24.
Findings
The facility was found deficient in multiple areas including medication staff qualifications, staff registry checks, implementation of physician orders, food safety and service, therapeutic diet adherence, medication administration, medication observation, and use of physical restraints without physician orders.
Complaint Details
The survey included a complaint investigation conducted from 06/25/24 to 06/27/24.
Severity Breakdown
Type B Violation: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 medication aides completed clinical skills checklist prior to administering medications. | — |
| Facility failed to ensure 1 of 6 staff had no substantiated findings on the Health Care Personnel Registry upon hire. | — |
| Facility failed to ensure physician orders were implemented for 1 of 5 residents related to daily application and removal of TED hose. | — |
| Facility failed to ensure foods were free from contamination related to food being transported uncovered. | — |
| Facility failed to ensure mealtime table service included a complete place setting with knife, fork, and spoon in the Special Care Unit. | — |
| Facility failed to ensure therapeutic diets were served as ordered for 1 of 3 residents with a diet order for finger foods. | — |
| Facility failed to administer medications as ordered for 2 of 5 residents including failure to hold blood pressure medications per parameters and failure to administer medications due to lack of supply. | Type B Violation |
| Facility failed to ensure medication aides observed residents take their medications for 3 of 3 residents as evidenced by medication observed in residents' rooms. | — |
| Facility failed to ensure there was a written physician order for mechanical device (bedrails) for 1 of 1 resident with bedrails. | — |
Report Facts
Medication administration opportunities: 19
Medication administration opportunities: 25
Medication administration opportunities: 19
Medication administration opportunities: 18
Medication administration opportunities: 60
Medication administration opportunities: 60
Medication tablets: 22
Medication tablets: 18
Medication tablets: 30
Medication tablets: 29
Medication tablets: 30
Medication tablets: 29
Inspection Report
Annual Inspection
Deficiencies: 3
Aug 11, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 08/09/23 through 08/11/23 to assess compliance with regulations.
Findings
The facility failed to provide adequate supervision for a resident with multiple falls, failed to implement a physician's order for wound care, and failed to serve therapeutic diets as ordered for another resident.
Deficiencies (3)
| Description |
|---|
| Failed to provide supervision for Resident #2, resulting in 6 documented falls over 3 months without documented increased supervision or interventions after falls. |
| Failed to ensure implementation of an order to dress Resident #3's toe wound twice daily; dressing was only changed once daily and the order was missing from the August 2023 eMAR. |
| Failed to serve therapeutic diets as ordered for Resident #2, who had an order for a mechanical soft diet with chopped meats but was served a BLT sandwich with unchopped bacon. |
Report Facts
Number of documented falls: 6
Fall dates documented: 14
Duration of 72-hour post-fall monitoring: 72
Date range of wound dressing order: 21
Meal observation date: Aug 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Director of Health and Wellness | Interviewed regarding supervision and interventions for Resident #2. |
| Resident Care Coordinator | Resident Care Coordinator | Interviewed regarding fall protocols and wound care orders. |
| Medication Aide | Medication Aide | Interviewed regarding wound care and fall observations. |
| Area Executive Director | Area Executive Director | Interviewed regarding expectations for supervision, wound care, and dietary compliance. |
| Dietary Manager | Dietary Manager | Interviewed regarding meal preparation and therapeutic diet compliance. |
| Physical Therapist | Physical Therapist | Interviewed regarding Resident #2's therapy and fall risk. |
Inspection Report
Annual Inspection
Deficiencies: 6
Nov 17, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 11/16/21 and 11/17/21 to assess compliance with state regulations for the facility.
Findings
The facility failed to maintain hot water temperatures within the required range at multiple resident bathrooms, resulting in delays or refusals of showers. Additionally, the facility failed to ensure proper referral and follow-up with healthcare providers for residents, failed to implement physician orders including lab tests and medication clarifications, and failed to properly administer and document medications as ordered.
Deficiencies (6)
| Description |
|---|
| Hot water temperatures were not maintained at 100° to 116° F for 6 of 6 fixtures in resident bathrooms, with temperatures ranging from 80° to 93° F causing delays or refusals of showers. |
| Failed to ensure referral and follow-up with healthcare providers for 2 of 5 sampled residents regarding home health referral and compression stocking orders. |
| Failed to ensure physician's orders were implemented for 1 of 5 sampled residents related to an order for a urine sample to rule out infection. |
| Failed to ensure clarification of medication orders for 1 of 5 sampled residents with conflicting or unclear medication orders for diabetic, thyroid, blood pressure, supplement, and pain medications. |
| Failed to administer medications as ordered for 1 of 5 sampled residents; diabetic medications were administered without checking required blood sugar levels. |
| Failed to observe resident taking medications before documenting administration for 1 of 5 sampled residents; medications were left in a cup and resident took them without observation. |
Report Facts
Hot water fixtures with temperature issues: 6
Medication pass error rate: 6
Duration of hot water heater malfunction: 14
Number of medication orders reviewed: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding hot water heater issues and temperature adjustments | |
| Administrator | Interviewed regarding facility operations, hot water issues, and medication administration expectations | |
| Resident Care Coordinator | Interviewed regarding follow-up on physician orders and home health referrals | |
| Medication Aide | Observed administering medications and interviewed regarding medication administration practices | |
| Personal Care Aide | Interviewed regarding hot water issues and medication administration awareness | |
| Contracted Plumber | Interviewed regarding repairs to hot water system | |
| Primary Care Provider | Interviewed regarding medication orders, home health referrals, and expectations for facility communication |
Inspection Report
Capacity: 96
Deficiencies: 14
Jun 27, 2018
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1999 Rev) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant safety and maintenance, including lack of current fire and safety inspection reports, unsecured janitor closets, unclean and unrepaired housekeeping and furnishings, inadequate fire safety rehearsals, electrical safety issues, fire sprinkler system problems, smoke barrier and corridor door deficiencies, and improper control of kitchen equipment.
Deficiencies (14)
| Description |
|---|
| Facility failed to maintain current (within last 12 months) annual fire marshal inspection and fire alarm/sprinkler system inspection reports. |
| Janitor closets were not locked, allowing access to hazardous substances. |
| Building plumbing equipment and mechanical systems were not maintained clean and in good repair; ceiling stained and ventilation grilles had excessive dust/lint. |
| Bedrooms missing required individual towel bars. |
| Fire safety rehearsals were not performed regularly on each shift quarterly and lacked adequate documentation of rehearsal content. |
| Electrical outlets in wet locations lacked ground fault interrupters. |
| Fire sprinkler heads removed for testing were not replaced, leaving areas without fire sprinkler protection. |
| Fire sprinkler heads obstructed by stored items; emergency lighting malfunctioning or lacking backup power confirmation. |
| Firestop sealants missing or gaps present in fire-resistance-rated ceiling assemblies allowing smoke and heat spread. |
| Electrical system unsafe due to use of power taps for medical equipment, open breaker slots, multi-plug adaptors without overcurrent protection. |
| Corridor doors failed to latch properly, were wedged open, or locked in a manner that could trap occupants, compromising smoke/fire containment. |
| Fire sprinkler escutcheon plates missing or dropped, exposing openings that allow smoke and heat spread. |
| Commercial kitchen hood fire suppression system lacked required inspections, maintenance, and documentation; system was red tagged with deficiencies. |
| Ovens and ranges in resident areas lacked proper staff control; range in dining room was energized and used without staff present. |
Report Facts
Total licensed capacity: 96
Special care unit capacity: 24
Date of survey: Jun 27, 2018
Inspection Report
Annual Inspection
Capacity: 96
Deficiencies: 7
Aug 25, 2016
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code, as part of a biennial survey.
Findings
The inspection identified multiple deficiencies including lack of current fire and building safety inspection reports, presence of strong urine odor in a resident room, missing or broken towel racks in resident rooms, failure to maintain emergency lighting and fire safety equipment in operating condition, gaps in fire resistant ceilings, absence of required plumbing safety devices, and non-operating central exhaust system.
Deficiencies (7)
| Description |
|---|
| Facility did not have current fire and building safety inspection reports maintained in the home and available for review. |
| Facility is not free from unpleasant odor; strong urine odor detected in Room B17. |
| Facility did not provide required furnishings for each resident in good repair; out of 6 checks for towel racks, some were missing or broken. |
| Failure to maintain electrical emergency/safety related equipment in operating condition; emergency lights and exit signs did not operate on battery power. |
| Failure to maintain facility's fire safety equipment in safe operating condition; doors did not latch properly and gaps/openings in fire resistant ceilings were observed. |
| Failure to install and maintain required plumbing safety devices; hand held rinse wand had no visible anti-siphon/vacuum breaker installed. |
| Facility did not have required exhaust ventilation as required; central exhaust system was not operating. |
Report Facts
Total licensed capacity: 96
Number of towel racks checked: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Billy S. Bryant | Surveyor who conducted the biennial survey | |
| Resident Care Coordinator | Named in finding related to door not latching properly |
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