Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Feb 4, 2025 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Feb 6, 2024 | 99.5 | 3.5 | 4 | Annual Inspection | |
| Mar 2, 2022 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Sep 6, 2017 | 101.75 | 3.75 | 0 | Follow-Up Inspection | |
| Apr 6, 2017 | 98 | 5.5 | 7.5 | Annual Inspection | |
| Jun 17, 2015 | 92.75 | 11.25 | 0 | Follow-Up Inspection | |
| Mar 16, 2015 | 81.5 | 5.5 | 24 | Annual Inspection | |
| Nov 13, 2012 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Nov 18, 2010 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Apr 15, 2009 | 103.5 | 5.5 | 2 | Annual Inspection |
Inspection Report
Capacity: 152
Deficiencies: 3
Date: Apr 15, 2025
Visit Reason
The visit was a Construction Section Biennial Survey conducted to assess compliance with building, fire safety, plumbing, and hot water system regulations for the assisted living facility.
Findings
Deficiencies were cited related to unsafe plumbing equipment, failure to maintain fire safety equipment, and hot water temperatures exceeding regulatory limits. Specific issues included lack of a 2" air gap on the ice machine drain, a removed door closer in the Memory Care Laundry, and a spa hand sink water temperature of 131 degrees F.
Deficiencies (3)
Plumbing equipment not maintained in a safe operating condition; ice machine drain lacks a 2" air gap.
Fire safety equipment not maintained; door closer removed in Memory Care Laundry so door does not automatically close and latch.
Hot water temperature at spa hand sink near Room 30 was 131 degrees F, exceeding the maximum allowed 116 degrees F.
Report Facts
Total licensed beds: 152
Hot water temperature: 131
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 12/05/23 to 12/07/23 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in medication staff qualifications, medication administration, and infection control practices. Specifically, three medication aides lacked documentation of required state-approved training, one resident did not receive medications as ordered, and a medication aide failed to follow proper hand hygiene and glove use during medication administration.
Deficiencies (3)
Facility failed to ensure 3 of 6 medication aides completed the required state-approved medication aide training courses.
Facility failed to administer medications as ordered for 1 of 7 sampled residents who had two supplemental fiber medications.
Facility failed to ensure infection control measures during medication administration; a medication aide did not wash hands before and after glove use and handled medications with bare hands.
Report Facts
Medication aides lacking required training: 3
Sampled residents: 7
Fiber medication bottle size: 236
Fiber medication dispensed dates: 3
Metamucil packs dispensed: 30
Medication preparation: 11.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Named in deficiency for lacking documentation of required medication aide training. |
| Staff E | Medication Aide | Named in deficiency for lacking documentation of required medication aide training. |
| Staff F | Medication Aide | Named in deficiency for lacking documentation of required medication aide training. |
| Human Resources Director | Responsible for personnel records; interviewed regarding missing training certificates. | |
| Registered Nurse | Current and previous RNs interviewed regarding medication aide training and skills validation. | |
| Administrator | Interviewed regarding personnel records and medication administration concerns. | |
| Medication Aide | Observed and interviewed regarding improper hand hygiene and glove use during medication administration. | |
| Resident Care Director | Interviewed regarding medication administration and infection control practices. | |
| Supervisor | Interviewed regarding medication administration and audits. | |
| Pharmacy Technician | Interviewed regarding medication dispensing and supply. | |
| Pharmacist | Interviewed regarding medication supply and expected usage. |
Inspection Report
Capacity: 152
Deficiencies: 20
Date: Oct 9, 2019
Visit Reason
Biennial construction section survey to assess compliance with building codes, physical plant requirements, fire safety, and housekeeping standards for the assisted living and special care units.
Findings
The facility failed to meet multiple NC State Building Code and physical plant requirements including missing smoke detectors, inadequate separation of suites from corridors, missing exit signs, lack of sprinkler protection on combustible porches, compromised fire rated walls and ceilings, malfunctioning fire safety equipment, improper housekeeping, and electrical safety issues.
Deficiencies (20)
Space near laundry on AL side not equipped with smoke detectors.
Pass through opening and gaps in Administration suite walls not meeting corridor separation requirements.
Missing exit signs in corridors near nurse station and junctions between bedrooms.
Porch ceiling outside AL dining room lacks sprinkler protection despite combustible wood supports.
No radiation damper in a 10x10 inch supply register in beauty salon.
Corridor obstructed by lift near sprinkler riser room in Special Care.
Warning device ('screamer') at front exit from Special Care not working.
Excessive dust/lint accumulation on HVAC exhaust and return grills and radiation dampers in multiple locations.
Exit paths cluttered and obstructed, including difficult to open exit door in AL dining room and zippered porch exit portal.
Fire drill rehearsals not conducted quarterly on each shift; records lack descriptions of rehearsals.
GFCI receptacle on porch outside AL dining room failed to trip when tested.
Multiple holes and unsealed penetrations in one-hour fire rated walls and ceilings throughout facility.
Corridor doors fail to close and latch properly, some propped open, compromising fire and smoke barriers.
Exit signs throughout facility, including AL Activity room and connecting corridors, do not work on battery backup.
Duct mounted smoke detector sampling tube dirty and improperly oriented in Mechanical room.
Storage stacked too close to fire sprinkler heads in multiple storage rooms.
Range hood fire suppression system lacks documentation of required monthly inspections for July, August, and September.
Damaged post holding up pergola outside Dining room in Special Care presents laceration risk.
Electrical outlet expander in use in Activity room, not approved for Institutional Occupancies.
Exhaust ventilation not working in bathroom off room 107.
Report Facts
Licensed beds: 112
Special care beds added: 40
Total licensed capacity: 152
Porch depth: 16
Pass through opening size: 4
Lift obstruction: 6
Fire drill missing shifts: 3
Range hood inspection months missing: 3
Storage clearance: 8
Supply register size: 10
Inspection Report
Capacity: 152
Deficiencies: 6
Date: Sep 13, 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 North Carolina Building Code and licensing rules, as part of a Construction Section Biennial Survey.
Findings
The survey identified multiple deficiencies related to physical plant maintenance including failure to maintain building code compliance for special locking arrangements, ceilings not in good repair due to moisture damage and peeling finishes, fire safety equipment not maintained in safe operating condition with issues in door latching and gaps in fire resistant rated ceilings, failure to maintain electrical emergency lighting, and failure to maintain exhaust ventilation equipment in required areas.
Deficiencies (6)
Special Care Unit exit doors have magnetic locks with emergency release switches that re-lock after approximately 30 seconds, which may delay or impede exiting.
Building ceilings are not in good repair; ceiling finish peeling due to moisture damage at Assisted Living Resident Laundry exhaust fan and Nurses' Station #2 ceiling mounted light.
Fire safety equipment not maintained in safe operating condition; cross corridor doors and kitchen doors do not completely close and latch, and one door leaf missing hardware handle.
Gaps and holes in fire resistant rated ceilings at multiple locations including sprinkler head escutcheons, exhaust grilles, light fixture mounts, smoke detector mounts, and gypsum board wall hole.
Wall mounted emergency light in Special Care Unit did not illuminate on battery power during test.
Exhaust ventilation equipment not maintained; central exhaust system for North Hall is not operating.
Report Facts
Licensed beds: 152
Special Care Unit beds: 40
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 13, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey on March 8-10, 2017, and March 13, 2017 to assess compliance with health care, medication administration, and infection prevention regulations.
Findings
The facility failed to notify physicians of blood sugar results as ordered for residents, failed to assure proper documentation and administration of sliding scale insulin for multiple residents, and failed to implement infection control procedures regarding sharing and disinfection of glucometers between residents.
Deficiencies (4)
Failed to notify the physician for 2 of 5 sampled residents regarding blood sugar results as ordered.
Failed to assure documentation and administration of sliding scale insulin as ordered for 3 of 4 residents, including errors with administration and omissions.
Failed to assure electronic Medication Administration Records (eMAR) were accurate for 2 of 4 sampled residents regarding sliding scale insulin.
Failed to implement infection control procedures consistent with CDC guidelines regarding sharing and disinfection of glucometers for 4 of 6 sampled residents.
Report Facts
Insulin administration documentation omissions: 81
Insulin administration documentation omissions: 84
Insulin administration documentation omissions: 22
Insulin administration documentation omissions: 4
Insulin administration documentation omissions: 22
Insulin administration documentation omissions: 27
Insulin administration documentation omissions: 28
Insulin administration documentation omissions: 8
Insulin administration documentation omissions: 102
Glucometers stored: 17
Glucometers stored: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding insulin administration, documentation, and infection control procedures. |
| Administrator | Administrator | Interviewed regarding expectations for following doctors' orders and documentation. |
| Medication Aide | Medication Aide | Interviewed regarding insulin administration and glucometer use. |
| Registered Nurse | Registered Nurse | Interviewed at resident's primary care physician's office regarding blood sugar reporting. |
| Pharmacy Consultant | Contracted Pharmacy Consultant | Interviewed regarding eMAR order entry and documentation issues. |
Inspection Report
Capacity: 112
Deficiencies: 7
Date: Nov 6, 2015
Visit Reason
Biennial survey conducted to assess conformance with applicable licensing rules and building codes for an adult care home with 112 licensed beds including a 40 bed Special Care Unit.
Findings
The facility was found to have multiple deficiencies including failure to maintain clear emergency egress pathways, improper storage of oxygen bottles, gaps and penetrations in fire resistant ceilings, fire doors that did not close or latch properly, inoperable self-closing door hardware, lack of vacuum breaker devices on plumbing fixtures, and absence of required exhaust ventilation in resident bathrooms of the Special Care Unit.
Deficiencies (7)
Failure to maintain emergency egress pathways free of obstructions; stored med carts reduced path width.
Oxygen bottles not stored in racks or restrained, presenting hazard.
Gaps and open penetrations in fire resistant rated ceilings allowing potential spread of fire and smoke.
Doors that did not completely close and latch, including laundry door and Special Care Unit entrance doors.
Inoperable automatic self-closing hardware on doors, including disabled closer on Special Care Unit mechanical room door.
Absence of vacuum breaker/anti-siphon devices on hand held rinse wands in salon sinks.
Widespread absence of exhaust ventilation in required spaces, including resident bathrooms in Special Care Unit lacking mechanical exhaust fans or windows.
Report Facts
Licensed beds: 112
Special Care Unit beds: 40
Inspection Report
Annual Inspection
Census: 84
Capacity: 112
Deficiencies: 8
Date: Feb 10, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on February 10 - 12, 2015 with an exit conference on February 16, 2015.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing compliance, failure to notify physicians regarding resident health changes, failure to implement physician orders for fluid restrictions and stool monitoring, failure to maintain and serve appropriate therapeutic diet menus, failure to serve milk twice daily in the Special Care Unit, failure to administer medications within prescribed timeframes, and failure to administer prescribed medications as ordered.
Deficiencies (8)
Failure to ensure tuberculosis testing compliance for residents upon admission.
Failure to notify physicians for residents regarding excess weight gain, medication refusals, timely lab draws, and improper thickened liquids.
Failure to implement physician orders for fluid restrictions and stool monitoring.
Failure to maintain accurate and current listing of residents with physician-ordered therapeutic diets.
Failure to serve therapeutic diets as ordered for nectar thickened liquids and regular/chopped diets.
Failure to serve eight ounces of pasteurized milk at least twice a day to Special Care Unit residents.
Failure to administer medications within one hour before or after scheduled time for two residents.
Failure to administer prescribed Kayexalate medication as ordered for one resident.
Report Facts
Residents present: 84
Total licensed capacity: 112
Deficiencies cited: 8
Medication administration delay: 148
Medication administration delay: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Responsible for monitoring medication administration and physician orders |
| Director of Nursing | Director of Nursing (DON) | Responsible for overseeing resident care and medication administration |
| Medication Aide | Medication Aide (MA) | Administered medications and involved in medication pass delays |
| Dietary Manager | Dietary Manager | Responsible for dietary menus and therapeutic diet guidance |
| Executive Director | Executive Director | Facility leadership overseeing compliance and operations |
| Physician's Assistant | Physician's Assistant | Provided medical orders and clarifications for resident care |
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