Deficiencies per Year
16
12
8
4
0
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Nov 26, 2024 | 101.5 | 3.5 | 2 | Annual Inspection | |
| Apr 19, 2022 | 101.5 | 3.5 | 2 | Annual Inspection | |
| Mar 5, 2019 | 100 | 0 | 0 | Annual Inspection | |
| Nov 6, 2015 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Jun 28, 2013 | 105.5 | 5.5 | 0 | Annual Inspection | |
| May 8, 2012 | 105.5 | 5.5 | 0 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 23, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 10/22/24 - 10/23/24 to assess compliance with personal care and supervision regulations.
Findings
The facility failed to provide adequate personal care assistance to Resident #5, who required help with bathing and nail care. Observations revealed long, jagged fingernails with brown debris and extremely dry, flaking skin on the resident's feet. Documentation showed bathing was recorded as completed three times daily, but staff interviews and observations indicated the resident was not bathed as scheduled.
Deficiencies (1)
| Description |
|---|
| Failed to provide personal care assistance for Resident #5, including nail care and bathing, resulting in long, jagged fingernails with brown debris and extremely dry, flaking skin on feet. |
Report Facts
Bathing frequency documented: 3
Bathing frequency scheduled: 2
Number of sampled residents with deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide (MA) / Personal Care Aide (PCA) | Reported not cutting residents' fingernails due to diabetes concerns and inability to recall last bathing assistance for Resident #5. | |
| Assisted Living Coordinator (ALC) / Licensed Practical Nurse (LPN) | Notified about Resident #5's long fingernails and dry feet during survey; responsible for entering care plan tasks and acknowledged errors in bathing documentation. | |
| Primary Care Provider (PCP) | Reported Resident #5's profound decline, need for personal care assistance, and observed long fingernails during visit. | |
| Administrator | Acknowledged discrepancies in bathing documentation and scheduling for Resident #5. | |
| Personal Care Aide (PCA) | Reported last assisting Resident #5 with bed bath one week prior and noted fingernails were a little long. |
Inspection Report
Capacity: 85
Deficiencies: 15
Jan 10, 2024
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 2005 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 related to physical plant and safety including non-compliance with emergency release switches on electromagnetic locks, delayed egress door failures, lack of current fire safety inspection reports, failure to submit construction documents for remodeling, unsafe and unclean premises, fire safety equipment and alarm system failures, missing or damaged fire safety components, and inadequate exhaust ventilation in resident bathrooms.
Deficiencies (15)
| Description |
|---|
| Electromagnetic locks lacked proper emergency release access for all staff responsible for evacuation. |
| Delayed egress doors did not initiate release process when pressure was applied to the door latch. |
| Facility did not maintain all building safety inspection reports; most recent fire sprinkler inspection was from December 15, 2022. |
| Construction or remodeling documents and specifications were not submitted to the Division for review and approval as required. |
| Outside premises were not maintained in a clean and safe condition; recessed can light was falling out of the ceiling. |
| Ceilings and floors were not kept clean and in good repair; cracks in ceiling and stained carpet observed. |
| Furnishings were not kept in good repair; door trims pulling away and broken toilet paper dispenser. |
| Facility was not maintained free from hazards; furnishings stored in front of electrical breaker panels obstructing access. |
| Facility did not maintain records of quarterly fire rehearsals for each shift; missing records for several shifts in 2023. |
| Fire safety systems had holes or gaps at penetrations through fire resistant ceilings, missing sprinkler escutcheon rings, unsealed cable penetrations, and doors that did not latch properly. |
| Emergency fire alarm system devices and equipment were not maintained in safe operating condition; smoke detectors missing or unsecured. |
| Resident room doors had holes through the face of the door, compromising smoke resistance. |
| Use of non-fire resistant materials (yellow foam) to seal penetrations in cable/phone room. |
| Missing or broken cover plates on electrical outlets, posing safety hazards. |
| Facility failed to provide required exhaust ventilation equipment in resident bathrooms; exhaust fans not working in Memory Care. |
Report Facts
Total licensed capacity: 85
Special Care Unit beds: 33
Date of inspection: Jan 10, 2024
Date of most recent fire sprinkler inspection: Dec 15, 2022
Scheduled fire sprinkler inspection: Jan 15, 2024
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 11, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from March 9 to March 11, 2022.
Findings
The facility failed to administer medications as ordered and in accordance with facility policies for 3 of 5 residents observed during medication passes, resulting in medication errors including crushing a medication labeled 'Do Not Crush', underdosing a nasal spray, and under-measuring a fiber powder medication.
Deficiencies (3)
| Description |
|---|
| Medication aide crushed Enteric Coated Aspirin labeled 'Do Not Crush' for Resident #8, contrary to physician's orders and medication label instructions. |
| Medication aide administered only 1 spray into each nostril instead of 2 sprays as ordered for Resident #7's Flonase nasal spray. |
| Medication aide measured 1 teaspoon of Citrucel fiber powder instead of the ordered 1 tablespoon for Resident #6, resulting in underdosing. |
Report Facts
Medication error rate: 10
Medication errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Involved in medication administration errors for Residents #6, #7, and #8 | |
| Wellness Coordinator | Interviewed regarding medication administration policies and procedures | |
| Associate Executive Director | Interviewed regarding expectations for medication administration and DNC list |
Inspection Report
Capacity: 85
Deficiencies: 3
May 16, 2018
Visit Reason
This facility was surveyed for conformance with the applicable portions of the 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Deficiencies were cited related to failure to meet building code requirements for special locking systems, failure to maintain building equipment and components in a safe and operating condition, and failure to provide required exhaust ventilation in specified areas.
Deficiencies (3)
| Description |
|---|
| Facility failed to meet building code requirement regarding Special Locking Systems; momentary switches that depend on electronics to interrupt power were found on magnetically locked doors in the Special Care Unit (Fitness Center Room, Salon, Housekeeping). |
| Facility failed to maintain building components in a safe and operating condition including: main kitchen entry door not latching properly due to door frame damage; attic access metal door assembly not secured to provide fire resistance; return-air grilles in the Assisted Living Dining Hall with excessive particulate build-up; escutcheons not flush to ceiling in the Assisted Living Dining Hall; ceiling penetration not fire protected due to cable installation in Room C-127. |
| Facility failed to provide exhaust ventilation at the required rate of two cubic feet per minute per square foot; mechanical ventilation system was not operational in the Laundry/Room 1039. |
Report Facts
Licensed beds: 85
Special Care Unit beds: 33
Inspection Report
Follow-Up
Deficiencies: 1
Sep 21, 2016
Visit Reason
Follow-up Survey conducted to verify correction of previously cited deficiencies, specifically related to fire safety equipment and special locking systems.
Findings
All deficiencies were verified as corrected except for the deficiency related to the special locking system not meeting building code requirements, specifically that four manual override switches for magnetically locked exit doors are not an 'on/off' type and the doors relock automatically after a time delay.
Deficiencies (1)
| Description |
|---|
| Facility is not maintaining fire safety equipment in safe operating condition by not complying with building code requirements for special locking systems; four manual override switches for magnetically locked exit doors are not 'on/off' type and doors relock automatically after a time delay. |
Report Facts
Date of finding: Jun 22, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Strickland | Conducted the Follow-up Survey | |
| Billy S. Bryant | Conducted the Follow-up Survey |
Inspection Report
Annual Inspection
Capacity: 85
Deficiencies: 7
Jun 22, 2016
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2009 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a biennial survey.
Findings
The inspection identified multiple deficiencies including unsafe dryer exhaust duct materials, fire safety equipment not maintained in safe operating condition, failure of cross corridor doors to latch properly, open penetrations in fire resistant ceilings, lack of monthly fire extinguisher inspections, and non-functioning central exhaust ventilation system.
Deficiencies (7)
| Description |
|---|
| Resident Laundry dryer exhaust duct constructed of flexible foil type material not listed for use as clothes dryer exhaust. |
| Special Care Unit Laundry dryer exhaust transition duct product not verified for UL listing compliance. |
| Four manual override switches for magnetically locked exit doors are not 'on/off' type, doors relock automatically after time delay. |
| One leaf of cross corridor doors adjacent to Rooms 1026 and 1038 did not completely close and latch. |
| Open ended pipe sleeve for data cabling penetrating fire resistant ceiling in S.C.U. Room C171 Furnace Room. |
| Monthly checks and inspections of portable fire extinguishers not being conducted. |
| Central exhaust ventilation system in North Hall Assisted Living is not working. |
Report Facts
Licensed bed capacity: 85
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 1, 2015
Visit Reason
The Adult Care Licensure Section conducted an Annual Survey on 9/29/15, 9/30/15, and 10/1/15 to assess compliance with regulations for the facility.
Findings
The facility was found to have deficiencies including improper food storage with mesh bags of onions stored directly on the floor, and failure to ensure that 2 of 3 medication aides completed their state approved Annual Infection Control training.
Deficiencies (2)
| Description |
|---|
| Foods were stored in a manner to prevent contamination; mesh bags of onions were stored directly on the floor. |
| Two of three medication aides failed to complete their state approved Annual Infection Control training as required. |
Report Facts
Number of medication aides not compliant with infection control training: 2
Number of large bags of onions observed on floor: 3
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