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| Deficiency Category | Inspection Date: 11/22/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 11/8/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 7/14/22 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: | 11/22/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/22/24Read the full report (PDF) 10/24/24Read the full report (PDF) 6/27/24Read 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: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 6/27/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 10/24/24 | 7/20/24 | 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 enough food/fluids to maintain a resident's health. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
| 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. | 11/22/24 | 12/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 6/27/24 | 7/24/24 | 1 - Potential for minimal harm | Some |
| 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) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep residents' personal and medical records private and confidential. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service 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) |
|---|---|---|---|---|
Make sure that a working call system is available in each resident's bathroom and bathing area. | 11/22/24 | 12/18/24 | 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) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
| Date of last standard health inspection: | 11/8/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 6/29/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | 6/29/23Read the full report (PDF) |
| 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 feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 6/29/23 | 7/12/23 | 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. | 6/29/23 | 7/12/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| 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) |
|---|---|---|---|---|
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 11/8/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 7/14/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 12/15/22Read the full report (PDF) 8/31/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 1/23/23Read the full report (PDF) |
| 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. | 7/14/22 | 8/31/22 | 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. | 7/14/22 | 8/31/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/15/22 | 1/12/23 | 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. | 7/14/22 | 8/31/22 | 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) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 7/14/22 | 8/31/22 | 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) |
|---|---|---|---|---|
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 7/14/22 | 8/20/22 | 1 - Potential for minimal harm | Many |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 12/15/22 | 1/12/23 | 2 - Minimal harm or potential for actual harm | 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. | 8/31/22 | 9/9/22 | 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) |
|---|---|---|---|---|
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | 12/15/22 | 1/12/23 | 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. | 12/15/22 | 1/12/23 | 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 that residents are free from significant medication errors. | 12/15/22 | 1/12/23 | 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) |
|---|---|---|---|---|
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | 12/15/22 | 1/12/23 | 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) |
|---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 6/27/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 10/24/24 | 7/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 6/27/24 | 7/24/24 | 1 - Potential for minimal harm | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/22/24 | 12/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep residents' personal and medical records private and confidential. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 6/27/24 | 7/24/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 6/29/23 | 7/12/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 6/29/23 | 7/12/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/15/22 | 1/12/23 | 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. | 12/15/22 | 1/12/23 | 2 - Minimal harm or potential for actual harm | 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. | 8/31/22 | 9/9/22 | 1 - Potential for minimal harm | Some |
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | 12/15/22 | 1/12/23 | 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. | 12/15/22 | 1/12/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 12/15/22 | 1/12/23 | 2 - Minimal harm or potential for actual harm | Few |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | 12/15/22 | 1/12/23 | 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 that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 6/29/23 | 7/12/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 6/29/23 | 7/12/23 | 4 - Immediate jeopardy to resident health or safety | Some |