Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jul 1, 2024 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jul 28, 2022 | 74.75 | 13.75 | 0 | Follow-Up Inspection | |
| Jun 10, 2022 | 61 | 2.5 | 41.5 | Annual Inspection | |
| Mar 10, 2022 | 105.5 | 0 | 0 | Complaint Investigation | |
| Mar 11, 2019 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jul 20, 2017 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Feb 2, 2016 | 97.25 | 3.75 | 0 | Follow-Up Inspection | |
| Nov 24, 2015 | 93.5 | 5.5 | 12 | Annual Inspection | |
| Feb 3, 2014 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jan 29, 2013 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Sep 6, 2011 | 92 | 8 | 6 | Annual Inspection | |
| Oct 27, 2010 | 98 | 2.5 | 0 | Follow-Up Inspection | |
| Sep 29, 2010 | 95.5 | 0 | 10 | Complaint Investigation | |
| Jun 16, 2010 | 105.5 | 5.5 | 0 | Annual Inspection | |
| May 21, 2009 | 105.5 | 5.5 | 0 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 26, 2024
Visit Reason
Report of a Construction Section Biennial Follow Up Survey conducted to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected. No further action is required at this time.
Inspection Report
Capacity: 96
Deficiencies: 3
Aug 16, 2023
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and construction regulations applicable to the facility.
Findings
The facility was found deficient in meeting code requirements for means of egress, failure to submit construction documents for fire alarm panel replacement, and failure to maintain floors in good repair, including a tripping hazard in the lobby.
Deficiencies (3)
| Description |
|---|
| Facility failed to have proper means of egress; a recently added screen door swings opposite to egress direction and was removed pending replacement. |
| Facility failed to submit construction documents and specifications for review and approval prior to replacement of the fire alarm panel in April 2022. |
| Facility failed to maintain floors smooth and in good repair; lobby floor drain cover plate is at least 1/4 inch above floor level creating a tripping hazard. |
Report Facts
Licensed bed capacity: 96
Date of fire alarm panel replacement: 202204
Tripping hazard height: 0.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Conducted the Construction Section Biennial Survey. | |
| Executive Director | Interviewed regarding failure to submit construction documents. | |
| Maintenance Director | Interviewed regarding failure to submit construction documents. |
Inspection Report
Annual Inspection
Deficiencies: 10
Apr 22, 2022
Visit Reason
The Adult Care Licensure Section and the Catawba County DSS conducted an annual and follow-up survey from 04/20/22 to 04/22/22 to assess compliance with regulations.
Findings
The facility had multiple deficiencies including failure to ensure staff qualifications and training, failure to revise care plans after significant changes, inadequate supervision of residents with fall risks, failure to notify physicians of critical lab values, and medication administration errors including missed doses and unavailable medications. The facility also failed to complete required special care unit resident profiles and care plans timely.
Severity Breakdown
Type A1: 1
Type A2: 2
Type B: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 6 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. | — |
| Failed to ensure 6 of 6 sampled medication aides completed training on the care of diabetic residents prior to administering insulin and checking fingerstick blood sugars. | — |
| Failed to revise Resident #1's care plan within 10 days of a significant change in condition related to a left tibia plateau fracture and non-weight bearing status. | — |
| Failed to provide supervision in accordance with Resident #1's assessed needs after multiple falls resulting in fractures and injuries. | Type A1 |
| Failed to ensure referral and follow-up to meet routine and acute health care needs for Residents #3 and #6 related to elevated fasting blood sugars and missed doses of blood thinner and mood stabilizer medications. | Type A2 |
| Failed to implement physician's orders for Resident #4 related to blood pressure checks prior to administration of hydralazine and administration of PRN medication for elevated systolic blood pressure. | — |
| Failed to clarify medication orders with the provider for Resident #4 related to an antidepressant medication dosage discrepancy. | — |
| Failed to administer medications as ordered for Residents #2, #3, and #4 including blood thinners, blood pressure medications, antidepressants, anxiety medications, and antifungal suspension; and failed to have medications available for administration. | Type A2 |
| Failed to complete Special Care Unit Resident Profiles and Care Plans within 30 days of admission, quarterly, and within 10 days of significant change for Residents #1 and #4. | — |
| Failed to ensure 6 of 6 sampled medication aides completed required Medication Aide Training and 2 of 6 completed clinical skills checklist prior to administering medications. | Type B |
Report Facts
Missed warfarin doses: 19
Missed Latuda doses: 6
Missed nystatin doses: 7
Missed clopidogrel doses: 18
Missed amlodipine doses: 16
Missed hydralazine doses: 27
Missed ferrous sulfate doses: 14
Missed lorazepam doses: 34
Medication error rate: 12.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete required Medication Aide Training and clinical skills checklist prior to administering medications. |
| Staff F | Medication Aide | Failed to complete required Medication Aide Training and clinical skills checklist prior to administering medications. |
| Business Office Manager | Responsible for assembling pre-employment packets including Medication Aide Training documentation. | |
| Resident Care Coordinator | Responsible for processing Medication Aide Training and clinical skills check off, tracking medication orders, and reviewing incident reports. | |
| Health and Wellness Director | Responsible for Medication Aide Training oversight, care plan completion, and medication audits. | |
| Administrator | Facility administrator involved in oversight of care plans, medication administration, and staff training. |
Inspection Report
Capacity: 96
Deficiencies: 9
Dec 7, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to ensure the facility meets applicable state rules and building codes for adult care homes and institutional occupancy.
Findings
Multiple deficiencies were cited including lack of hand grips in tubs accessible to residents, unclean and unrepaired mechanical and plumbing systems, incomplete fire safety rehearsal documentation, emergency lighting failures, corridor doors not latching properly to contain smoke, loose interior door handles, and failure to maintain hot water temperatures within required limits.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide tubs accessible to residents with hand grips. |
| Building mechanical systems not kept clean and in good repair; excessive dust/lint on HVAC return grilles. |
| Building plumbing systems not kept clean and in good repair; leaking recirculation pump and fallen pipe extension. |
| Walls, floors, or floor coverings not kept clean and in good repair; wet floor and wall with hole in Wellness Office. |
| Fire plan rehearsals not fully documented; missing time, location of simulated fire, and staff action. |
| Emergency lights did not illuminate on backup power during test. |
| Corridor doors do not resist passage of smoke; missing latch bolt on Bedroom B-07 door. |
| Interior door handle very loose and may not function properly (Bedroom B-8). |
| Hot water temperature at resident fixtures below minimum required temperature (85°F and 90°F observed). |
Report Facts
Total licensed capacity: 96
Hot water temperature: 85
Hot water temperature: 90
Inspection Report
Capacity: 96
Deficiencies: 7
Dec 9, 2015
Visit Reason
Biennial Construction Survey to ensure the facility meets applicable rules and building codes including the 1996 Rules for Homes for the Aged and Disabled, 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
The survey found multiple deficiencies including discolored carpet due to bleach, compromised one-hour fire rated walls and ceilings with unsealed penetrations, non-functioning emergency light, unsafe latching hardware on doors, improperly installed water heater relief valve, unsafe storage of portable medical oxygen cylinders, and missing electrical outlet plates.
Deficiencies (7)
| Description |
|---|
| Approximately 2 square feet of carpet in the corridor at the janitor closet on C Hall discolored by bleach. |
| One-hour fire rated walls and ceilings compromised by unsealed holes and penetrations, including a PVC pipe in the water heater room and missing sprinkler escutcheons in rooms B2, B3, and corridor near B4. |
| Battery powered emergency light #61 would not work when tested, failing to provide at least 90 minutes of emergency lighting. |
| Hasp and padlock on pantry and mop closet doors off kitchen, creating potential entrapment hazard; deficiency corrected during survey. |
| Relief valve on water heater not piped to outside or within 6 inches of floor as required by code. |
| Portable medical oxygen cylinders stored improperly in an unapproved crate and no container in room B12. |
| Missing receptacle plate in room D10 exposing energized electrical parts. |
Report Facts
Total licensed beds: 96
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 8, 2015
Visit Reason
The Adult Care Licensure Section and the Catawba County Department of Social Services conducted an annual survey and complaint investigation on October 6-8, 2015.
Findings
The facility failed to provide adequate supervision for Resident #2 on a Special Care Unit related to choking hazards and falls, and failed to protect residents' rights related to a social media incident and inappropriate placement of Resident #1 on a secure unit. Multiple falls and safety concerns were documented for Resident #2, and Resident #1 was moved to a secure unit without proper physician consultation or family agreement.
Complaint Details
The visit included a complaint investigation triggered by an anonymous report of a staff member taking and posting a picture of Resident #2 sitting on the toilet on social media. The incident led to suspension and termination of involved staff and notification of family, police, and Social Services. The complaint was substantiated with findings of abuse and neglect.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide supervision of Resident #2 on a Special Care Unit in accordance with assessed needs related to choking hazards and falls. | Type A2 Violation |
| Failed to assure residents were treated with respect, dignity, and privacy related to posting a picture of Resident #2 on social media and inappropriate placement of Resident #1 on a secure unit. | — |
| Failed to provide care and services which are adequate, appropriate, and in compliance with relevant laws and regulations. | — |
Report Facts
Falls documented: 16
Falls witnessed by staff: 5
Fall dates: 14
Severity level: 1
Dates of survey: 2015-10-06 to 2015-10-08
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Personal Care Aide | Named in social media incident involving Resident #2; showed remorse but did not prevent or report the incident. |
| Staff H | Personal Care Aide | Named in social media incident involving Resident #2. |
| Staff I | Medication Aide | Took the picture posted on social media; stated video taken was unrelated to resident. |
| Regional Director of Operations | Interviewed regarding falls and social media incident; provided information on facility policies and actions taken. | |
| Executive Director | Interviewed regarding social media incident and facility response. | |
| Regional Nurse | Performed BCRS assessments and involved in decision to move Resident #1 to secure unit. | |
| Resident Care Coordinator | Involved in care planning and communication with family; blamed falls incident on medication changes. |
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