Inspection Report
Capacity: 40
Deficiencies: 5
Apr 16, 2025
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2002 Edition of the North Carolina Building Code, Institutional Occupancy, and the 2004 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including microbial growth hazards, missing towel bars, electrical outlets in wet locations lacking ground fault circuit interrupters, fire safety equipment not maintained in safe operating condition, gaps in fire resistant ceilings, and non-operational exhaust fans in several rooms.
Deficiencies (5)
| Description |
|---|
| Microbial growth (black substance) observed on ceiling and walls in the closet of room 103, indicating unsafe facility maintenance. |
| Towel bar missing from brackets in the Spa on the 100 hall, indicating failure to maintain required bedroom furnishings. |
| Multiple electrical outlets in laundry rooms and behind kitchen machines are not GFCI protected, posing electrical safety hazards. |
| Fire safety components not maintained safely: sprinklers dirty and out of service since April 12, 2025 due to leaking piping; multiple repairs pending from Annual Sprinkler Inspection report; gaps/holes in fire resistant ceilings in halls 100 and 200. |
| Exhaust fans in rooms 103, 209, 201, and 105 are not working, failing to maintain required exhaust ventilation. |
Report Facts
Total licensed beds: 40
Inspection Report
Capacity: 40
Deficiencies: 11
Jul 24, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2002 Edition of the North Carolina Building Code, Institutional Occupancy, and the 2004 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 including failure to maintain floors and corridors free of obstructions, hazards related to water backflow and unsecured oxygen cylinders, lack of individual towel bars in bedrooms, incomplete fire safety rehearsal documentation, malfunctioning emergency exit signs and lights, fire safety penetrations not properly firestopped, doors held open by unapproved methods, unsafe electrical conditions, use of prohibited portable electric heaters, and inadequate exhaust ventilation in required areas.
Deficiencies (11)
| Description |
|---|
| Facility failed to maintain floors smooth and in good repair; carpet seams unraveling throughout corridors. |
| Hazard present due to possibility of backflow of contaminated water into domestic water supply; lack of vacuum breakers on shower hoses and shampoo sink. |
| Nine portable medical oxygen cylinders unsecured in an unapproved plastic crate at nurse station. |
| Facility failed to provide individual towel bars for each resident in bedrooms or adjoining bathrooms. |
| Fire safety rehearsals not fully documented; missing short descriptions of what rehearsals involved. |
| Emergency exit sign and emergency lights failed to illuminate on backup power. |
| Fire-resistance-rated ceiling penetrations not properly firestopped in multiple locations including bedroom closet, WIFI device areas, nurse station, and riser room. |
| Corridor and kitchen doors blocked or held open by unapproved devices, preventing proper closure to limit smoke and fire spread. |
| Electrical system unsafe: missing weather resistant cover on GFCI receptacle, use of multiple plug adaptor without overcurrent protection. |
| Use of prohibited portable electric heater found in janitor closet. |
| Facility failed to provide adequate exhaust ventilation in required rooms; odor present and ventilation systems not removing required air volume. |
Report Facts
Licensed bed capacity: 40
Number of portable oxygen cylinders unsecured: 9
Date of survey: Jul 24, 2019
Inspection Report
Capacity: 40
Deficiencies: 10
Jul 6, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2002 Edition of the North Carolina Building Code, Institutional Occupancy, and the 2004 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were identified including improper use of bathrooms for storage, unsafe outside premises due to a wasp nest, ceilings with water damage and mildew, doors not maintained in good repair, oxygen bottles stored without restraint, fire safety system failures including gaps in fire resistant ceilings and doors not latching, emergency equipment not operating properly, and failure to provide required exhaust ventilation in several areas.
Deficiencies (10)
| Description |
|---|
| Facility was utilizing two of the HC bathrooms as storage with several wheelchairs and walkers stored in the rooms. |
| Outside premises were not maintained in a safe condition due to a large, active wasp nest near the exit from 200 Hall. |
| Facility failed to maintain ceilings in good repair with large yellow water stains, black mildew spots, and damaged finishes in multiple areas. |
| Facility did not maintain doors in good repair; kitchen to dining door was dragging on the frame making it difficult to close. |
| Oxygen bottles were stored without any means of restraint to prevent falling or being knocked over in multiple locations including Room 107, Med Room, and Oxygen Storage. |
| Failure to maintain fire safety systems due to penetrations or gaps in fire resistant rated ceilings in multiple rooms and areas. |
| Doors that open to corridors did not completely close and latch, including corridor door in Room 209. |
| Unapproved device (wedge) used to keep kitchen corridor door open, impeding fire safety. |
| Emergency equipment not maintained in operating condition; wall mounted emergency light in Med Room did not illuminate on battery power. |
| Facility failed to provide required exhaust ventilation; exhaust fans were not working in Room 105 bath, 100 Hall Men's bath, Room 207 bath, and Beauty Salon. |
Report Facts
Total licensed capacity: 40
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 24, 2016
Visit Reason
The Adult Care Licensure Section and the Sampson County Department of Social Services conducted an annual survey of Autumn Wind Assisted Living of Roseboro from 08/24/2016 to 08/26/2016.
Findings
The facility failed to maintain hot water temperatures within the required range at multiple fixtures, with temperatures exceeding the maximum allowed. Additionally, the facility failed to ensure tuberculosis (TB) testing was completed and documented for two of five residents sampled upon admission, in compliance with control measures.
Severity Breakdown
Type B Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to assure hot water temperature for 14 of 14 fixtures were maintained between 100°F and 116°F, with temperatures ranging from 117.6°F to 131.2°F. | Type B Violation |
| Failed to assure 2 of 5 residents sampled were tested upon admission for tuberculosis disease in compliance with control measures. | Type B Violation |
Report Facts
Number of fixtures with hot water temperature violations: 14
Hot water temperature range: 131.2
Hot water temperature range: 117.6
Residents sampled for TB testing: 5
Residents not tested for TB upon admission: 2
Correction date for violations: Oct 10, 2016
Inspection Report
Follow-Up
Deficiencies: 6
Nov 5, 2015
Visit Reason
This is a follow-up survey conducted to verify whether previously identified deficiencies have been corrected at Autumn Wind Assisted Living of Roseboro.
Findings
The follow-up survey found that several deficiencies remain uncorrected, including blocked corridors, mold/mildew in the handicap bathroom shower, non-functioning exterior flood light, fire safety system issues, plumbing system deficiencies, and ceiling repairs needed.
Deficiencies (6)
| Description |
|---|
| Corridors blocked by drink machines, narrowing corridor to approximately five feet, failing to maintain minimum six feet clearance. |
| Mold or mildew growth in the caulk of the shower in the handicap bathroom. |
| Exterior flood light outside the Sprinkler Riser Room is used for parts and no longer functioning. |
| Smoke doors near Room 101 do not completely close and latch upon activation of the fire alarm. |
| Faucet hose on the sink of the Beauty Shop is not equipped with an anti-siphon device. |
| Ceiling in the bathroom around the exhaust fan is in need of repair. |
Report Facts
Corridor clearance: 5
Inspection Report
Census: 40
Capacity: 40
Deficiencies: 7
Aug 20, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 2004 Minimum Standards and Regulations for Homes for the Aged and Disabled, the 2005 Rules for Adult Care Home of Seven or More Beds, and the 2002 Edition of the North Carolina State Building Code.
Findings
The facility was found to have multiple deficiencies including corridors obstructed by equipment, mold/mildew in the handicap bathroom shower, hazards such as doors held open improperly and loose grab bars, fire safety systems not maintained properly, plumbing issues risking contamination, and ceiling repairs needed to maintain fire safety.
Deficiencies (7)
| Description |
|---|
| Corridors blocked by medicine carts, furniture, and drink machines, narrowing corridors to approximately five feet. |
| Mold or mildew growth on tile in the shower of the handicap bathroom. |
| Doors held open with wedges preventing proper closing in emergencies; loose grab bar beside toilet; multiple plug outlet in bathroom; non-functioning exterior flood light; corridor door not latching. |
| Ice machine drain line extends into floor drain approximately 4 inches, risking siphoning of brown water. |
| Smoke doors near Room 101 do not completely close and latch upon fire alarm activation. |
| Faucet hose on sink in Beauty Shop lacks anti-siphon device. |
| One-hour rated ceilings in bathroom around exhaust fan need repair; unprotected penetrations around conduits above electrical panels in Electrical Room. |
Report Facts
Licensed capacity: 40
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 19, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on February 19-20, 2015 to assess compliance with staff qualifications and medication aide training requirements.
Findings
The facility failed to ensure that all staff had no substantiated findings on the North Carolina Health Care Personnel Registry and that Health Care Personnel Registry checks were completed before hire. Additionally, two medication aides did not meet the required training and competency evaluation requirements to administer medications.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to assure 1 of 6 staff (Staff C) had no substantiated findings on the Health Care Personnel Registry and 1 of 6 staff (Staff E) had no HCPR check performed before hire. | Type B Violation |
| Facility failed to assure 2 of 3 staff (Staff C and Staff D) performing medication aide duties met training and competency requirements including employment verification and completion of required medication aide training hours. | — |
Report Facts
Staff sampled: 6
Staff performing medication aide duties: 3
Dates of medication administration by Staff C: 8
Dates of medication administration by Staff D: 7
Correction date deadline: Apr 6, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide/Nursing Assistant | Named in deficiency for substantiated finding on HCPR and medication aide training noncompliance |
| Staff E | Housekeeper | Named in deficiency for lack of HCPR check before hire |
| Staff D | Medication Aide/Nursing Assistant | Named in deficiency for medication aide training noncompliance |
| Office Manager | Responsible for completing HCPR checks and employment verification; involved in findings | |
| Administrator | Aware of substantiated findings and training requirements; involved in findings | |
| Nurse Consultant/Licensed Health Professional Support Nurse | Performed clinical skills validations and competency testing for medication aides |
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