Dec 31, 2025
96 / 100
· 4 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
Observed floor tile in need of repair in the restroom adjacent to room 208 and in the nourishment room on 200 hall.
**.1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.
#2 · Walls and ceilings clean, good repair −1
Observed touch up paint needed in soiled utility room on 200 hall, restroom in 208, room 214, room 118 and the soiled room on 100 hall. Observed ceiling peeling in the spa on 100 hall.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#5 · Ventilation equipment clean, good repair
Observed vent cover with dust build up in the restroom next to room 208.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed shower bed torn in the spa on 100 hall.
**.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
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Feb 19, 2025
93.5 / 100
· 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged floor in 100 hall. Observed. Floor next to tub in 100 bathing room in need of cleaning. Observed floors in 102 room and bathroom in need of cleaning. Observed floors in need of cleaning in 112 and 117 bathroom. Observed damaged floor in dining room. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed damaged window sills in 110 and 117. Observed damaged wall in 100 hall. Observed chips and scuffs on walls throughout. Needs repair. REPEAT.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed stained shower curtain in 100 bathing room. Observed shower bed in both 100 and 200 bathing rooms with torn Matt’s. Observed worn toilet seat in 110. Observed cracks on toilet chair in 217. Needs repair.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed 100 hall bathing room tub in need of cleaning. Needs cleaning. REPEAT. Points not escalated due to difference between violation item on last inspection compared to this inspection.
#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled
General Comment:
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed over stacked single-use cups on medication carts. Needs to be stored to protect cups to maintain cleanliness.
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Aug 19, 2024
93.5 / 100
· 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
REPEAT
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed flooring in bathrooms and resident rooms having damaged floor and/or peeing floor tiles in need of repair.
#2 · Walls and ceilings clean, good repair −2
REPEAT
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed walls scuffed in resident rooms throughout in need of repair / touch-up painting.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed PTAC units having dirty filters in need of general cleaning.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed spa’s used without disinfectant used for disinfecting. CDI disinfectant provided
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed linen having holes and tears in need of replacing inside resident room #204.
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Apr 22, 2024
90 / 100
· 9 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged flooring in dining room. Observed glue on floor in 126 bathroom. Observed bathroom floors need cleaning in 111 and 104. Observed damaged tile in 100 hall. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed broken tile on wall in 200 bathroom. Observed paint peeling in 200 housekeeping, in 200 activity, bathroom of 203 and bathroom 212. Observed paint chipping in several doorways throughout. Observed damaged window sill in 126. REPEAT.
#7 · Facilities provided, accessible, clean, good repair −2
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed shower floor needing cleaning in 100 shower. Observed toilet needing cleaning in room 111 and room 229. Observed toilet seat peeling in PT bathroom. Observed toilet chair rusting in 200 shower and in room 212. Observed hair washing sink nozzle in need of cleaning in salon. Needs cleaning/ repair. REPEAT.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed shower chair in shower rooms 200 and 100 with build up under seats. Observed shower beds with torn mats that are in need of cleaning in both shower rooms. Observed tubs in both shower rooms in need of cleaning.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice machines, buckets, and scoops shall be kept clean and in good repair. Observed build up in ice machines in both nourishment rooms. Needs cleaning.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed water damage to cabinets under sink in Nourishment room 100. Observed torn mat table, trampoline cover, and chair on hand pedal equipment in PT room. Observed damaged counter top in salon. Observed bed laminate peeling in 229 and 126. REPEAT.
#38 · Food service equipment and utensils clean, good repair
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed build up in refrigerators in nourishment stations and activity kitchens. Observed build up in microwave in Nourishment 200. Needs cleaning.
#44 · Time/Temperature Control for Safety (TCS) foods maintained as required −2
.1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed liquid food served with medicine that requires refrigeration after opening on med carts at 53F. Drink is kept in ice in coolers. Ice had melted and was not filled enough to maintain temperature. Needs to be kept at required temperatures.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. Observed not thermometer in physical therapy room fridge and in 100 hall activity room fridge. Needs thermometer.
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Oct 26, 2023
94 / 100
· 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed floor in 100 hall bath shower with debris. Observed build up on floors behind toilet in room 103, 204, and 110. Observed stained carpet in 224 and 229. Observed dust and debris build up in house keeping, linen, and other storage closets. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed window sill damaged in 103 and 110. Observed ceiling stain in central supply closet. Observed ceiling stain in 100 hall. Observed scuffs and small wall damage throughout facility. Observed water damage on wall under vanity in room 122. Needs repair. REPEAT
#7 · Facilities provided, accessible, clean, good repair −2
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed toilet seats loose in 103 and 125. Observed shower floor cracking and shower head cracked in 122. Observed liquid spill in shower room 100 tub and debris in shower room 200 tub. REPEAT.
#18 · Drinking fountains clean, good repair
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed build up on water fountains. Needs cleaning. REPEAT.
Points not escalated due to water fountain being repaired and is motion sensor with no handle.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed tear in cushion for wheel chair in 100 hall bathing room. Observed build up and water damage under vanity in beauty shop sink. Observed tears in beauty shop chair.
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May 11, 2023
95.5 / 100
· 9 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed severely water stain/damaged on floor tiles in bathroom 200, little minor here and there throughout the facility floor. PIC stated there was water damaged because of bursted pipes when cold weather hit last winter.
#2 · Walls and ceilings clean, good repair −1
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed stain on ceiling in some rooms, conference room, 100 hallway. PIC stated it was not an active leak. It was old stain from previous management. Need repair and paint touch up and keep in good repair. Observed damaged wall where a soap dispenser fell off in 200 hallway bath, wall possibly cut or scratched from wheelchair in bathroom 123. Observed one room in 100 hallway, missing a based board on bottom floor. Need repair and keep in good repair.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dusts on the air conditioner filter in residents room. Need cleaning and keep clean.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed loose toilet seat in most of the rooms throughout the facility. Observed loose faucet handle in some room. Need repair and keep in good repair. Observed some toilets throughout the facility with pink/black line in toilet bowl, Need cleaning and keep clean.
#16 · Hot water between 105°F and 116°F −1.5
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water throughout the facility range from 117F-120F. PIC stated they just changed a system about two days ago. PIC will call the company to come out and adjust the water temperature to be between 105F and 116F to prevent burning hazard. VERIFICATION NEEDED ON 5/16/2023.
#18 · Drinking fountains clean, good repair
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed broken on around handle on water fountain in 100 hallway. Need repair or replace
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice machines, buckets, and scoops shall be kept clean and in good repair. Observed mildew on wall,ceiling, splash guard in the ice machine in 200 hallway. Need cleaning and keep clean.
#51 · Proper use of restriction, exclusion, and reporting
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. NEW RULES. No point deduction. Discuss the topic with staff and provided Employee Health Policy poster at the time of inspection.
#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete
.1324 (d) The institution shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on institution surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guests, food, and additional surfaces to vomitus or fecal matter. NEW RULE. No point deduction. Discuss the topic with staff and provided Vomitus and diarrhea poster at the time of inspection, The facility need obtain the actual kits ready for such an event.
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Nov 7, 2022
96 / 100
· 3 violations
#3 · Walls and ceilings cleanable, clean, good repair −2
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed numerous walls throughout resident rooms scuffed in need of touch-painting / repair.
#14 · Disinfectant accessible, properly used −1
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed disinfectant not accessible inside spa rooms during inspection; CDI disinfectant provided.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
REPEAT
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no documentation that linen is being sanitized during washing cycle. (Note) points taken at half due to varying violation rule.
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Jun 13, 2022
95 / 100
· 4 violations
#2 · Floors clean, carpet clean, dry, odor free −1
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed carpet inside resident room (#225) stained in need of detailed cleaning.
#3 · Walls and ceilings cleanable, clean, good repair −2
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls damaged behind trash cans within facility that have lids that open and come in contact with surfaces of walls; walls in these areas are in need of touch-up painting.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
REPEAT
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed broken cabinet doors inside nourishment room on 200 hall in need of repair.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no proof that linen is being disinfected on site; facility washes sheets and linen together on site and will work with company (Eco-Lab) to provide documentation.
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