Swipe or scroll to see the entire table
Deficiency Category | Inspection Date: 1/10/25 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/27/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 7/21/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
---|---|---|---|
Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
Quality of Life and Care Deficiencies | |||
Infection Control Deficiencies | |||
Resident Assessment and Care Planning Deficiencies | |||
Nursing and Physician Services Deficiencies | |||
Resident Rights Deficiencies | |||
Nutrition and Dietary Deficiencies | |||
Pharmacy Service Deficiencies | |||
Environmental Deficiencies | |||
Administration Deficiencies |
Date of last standard health inspection: | 1/10/25Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 1/10/25Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in North Carolina: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Prepare residents for a safe transfer or discharge from the nursing home. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 10/27/23Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | No complaint inspections |
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in North Carolina: | |
Average number of Health Deficiencies in the United States: |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/27/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Quality of Life and Care Deficiencies were found during this inspection period. |
No Infection Control Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure each resident receives an accurate assessment. | 10/27/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 10/27/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 10/27/23 | 10/27/23 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 10/27/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Date of last standard health inspection: | 7/21/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 10/27/22Read the full report (PDF) 7/21/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in North Carolina: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 7/21/22 | 8/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/27/22 | 10/17/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/2/23 | 2/7/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Many |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 2/2/23 | 2/7/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 7/21/22 | 8/18/22 | 1 - Potential for minimal harm | Some |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 2/2/23 | 2/4/23 | 1 - Potential for minimal harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure medication error rates are not 5 percent or greater. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 2/2/23 | 2/7/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Prepare residents for a safe transfer or discharge from the nursing home. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 1/10/25 | 2/4/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 7/21/22 | 8/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/27/22 | 10/17/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/2/23 | 2/7/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure services provided by the nursing facility meet professional standards of quality. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 2/2/23 | 2/7/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 7/21/22 | 8/18/22 | 1 - Potential for minimal harm | Some |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 2/2/23 | 2/4/23 | 1 - Potential for minimal harm | Some |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 7/21/22 | 8/18/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure medication error rates are not 5 percent or greater. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 7/21/22 | 8/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 2/2/23 | 2/7/23 | 2 - Minimal harm or potential for actual harm | Some |
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |