Jun 10, 2026
97 / 100
· 6 violations
#2 · Walls and ceilings clean, good repair −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 some floor tiles damage in laundry room.
.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 minor wall damage throughout facility and touch up paint needed. Major improvement has been made since previous inspection report. Observed wall damage in shower room on 100 hallway.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheelchairs stored in shared spa room on 100 hallway. Improvement from previous inspection report.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no disposable towels at handsink in shared spa room on 100 hallway. Disposable towels were supplied to handsink during time of inspection. -General comment.
#17 · Back-up water supply plan available and complete
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees.
Observed incomplete back up water supply plan. EHS emailed administrator template for creating back up water supply plan that is in accordance with notated rule. -General comment.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean.
.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
Observed ice chests throughout facility left unattended and unlocked. EHS advises center to adhere to notate rule.
REPEAT VIOLATION.
#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 vinyl pillow case with tears in room 103. Discard. Observed debris on mattress in room 406. Clean.
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Nov 21, 2025
96 / 100
· 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
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 minor floor damage in laundry room. -General comment.
#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 walling damage behind beds in rooms 201 and 402. Observed touch up paint needed to door frames and walling throughout. REPEAT VIOLATION.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust accumulation to removable vents in rooms 111 and 311. Clean. REPEAT VIOLATION.
#8 · Toilet rooms free of storage, handwash signs posted −1
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed all shower rooms within facility containing storage not used for toileting to include clothing, wheelchairs, and rolling bins for soiled linen/trash. REPEAT VIOLATION.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice chest on 300 hallway stored unlocked and unattended. -General comment.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated −0.5
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Observed nourishment room refrigerators containing outside food not properly labeled according to notated rule on hallways 300 and 400.
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Jun 25, 2025
96.5 / 100
· 6 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage in the laundry room. Observed touch up paint needed in room 407. Observed ceiling leaking on the 400 hall. Observed wall in the shower rooms 100 and 200 in need of repair.
**.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 −0.5
Observed vent filter in need of cleaning in rooms 407 and 402.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair
Observed shower curtain in need of cleaning in the shower room on 400 hall. Needs to be cleaned.
**.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.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
Observed wheelchairs stored in the shower room on 200 hallway.
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected
Observed bedside commode in need of cleaning in room 206. Room is currently unoccupied. Bedside commode was emptied.
**.1312 (c) Institutions where bedpans, bedside commodes, urinals, or emesis basins are used shall provide facilities for emptying, cleaning, and disinfecting bedpans, bedside commodes, urinals, and emesis basins.
#38 · Food service equipment and utensils clean, good repair −0.5
Observed refrigerator gasket in need of repair and crisper drawer full of water on 400 hall.
**.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.
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Dec 10, 2024
97.5 / 100
· 2 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage in the laundry room, activity room, bathing spa on 400, 300 and 100 hall, rooms 410 and 403.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
Observed stained divider curtain in room 402. Observed cushion stained in room 410.
**.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.
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Jun 5, 2024
97 / 100
· 4 violations
#2 · Walls and ceilings clean, good repair −2
Observed touch up paint needed in laundry room. Observed baseboard tile in need of repair in the spa on 300 and 100 hall. Observed wall damage in room 110. Observed ceiling damage in room 303.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#16 · Hot water between 105°F and 116°F
Observed water temperature at 118F in the spa on 300 hall and 119F in activity room.
**.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.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
Observed ice chest on the main hallway left unattended and accessible.
**.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed torn pillow in room 306. Removed.
**.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.
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Dec 14, 2023
96 / 100
· 4 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage throughout facility. Observed ceiling in need of painting in the main living room. Observed ceiling damage in memory care. Observed door frame in need of repair in room 410.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed tile in need of repair near the shower in the bathing suite.
**.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.
#8 · Toilet rooms free of storage, handwash signs posted
Observed wheel chair foot rails stored in the bathing suite. Foot rails were removed during the inspection.
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
Observed ice chest on the 100 hallway left unattended and accessible.
**.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
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May 12, 2023
94 / 100
· 10 violations
#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 major damaged ceiling from a big leaks in the activity room in Main hall, ceiling was covered with a big plastic to prevent the residue from falling. Staining and peeling popcorn ceiling throughout hallways. Repair, repaint needed and keep all in good repair. Observed scraping walls and doors, possibly need repair, repaint as it fits.
#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 or damaged toilet seat in room 308, 200 and 300 hall bath, Need repair or replace. Observed toilet in rooms on 300 and 100 hallway can receive better cleaning. And keep clean. Observed in all baths, shower floor trim need caulking, damaged tiles along the base in 200 hall bath. Need repair.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. Observed no hand washing sign posted in therapy and 100 hall restrooms, any other restrooms have the sign posted. Hand washing signs need to be posted. Hand washing signs provided at the time of inspection.
#11 · EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used −1
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed housekeeper cleaning a room and when asked how to clean effectively using chemical (contact time and what type of chemicals use), a housekeeper doesn’t seems to have knowledge on how to effectively clean surfaces per manufacturer’s instruction. The facility need to ensure that all staff/cleaning staff have a knowledge of how to use chemical and clean effectively according to manufacturer's instructions.
#18 · Drinking fountains clean, good repair −0.5
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed water fountains throughout the facility are in need of deep cleaning and keep clean. The facility is not using the fountains currently, however they shall be kept clean.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice chest on every hall left unattended and not protected. There is a nourishment room in every hall. ICE SHALL BE PROTECTED AT ALL TIME.
#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 frayed mattress at the corners, damaged, stain mattresses in some rooms throughout the facility. Observed damaged sink cabinets/trim in Main hall nourishment room. Need repair or replace.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed heavy food debris in microwaves in nourishment room in Main, 400 hall. Need deep 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 RULE. NO POINTS DEDUCTION. Employee Health Policy discuss with staff and EHP poster provided 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. The facility need to obtain the vomiting and diarrhea kit along with instructional plan how to clean up in such an event. Vomit or diarrhea clean up procedures poster provided at the time of inspection.
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Nov 30, 2022
95 / 100
· 5 violations
#3 · Walls and ceilings cleanable, clean, good repair −2
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed popcorn ceiling peeling sporadically throughout building. Observed wall tiles and floor tiles damaged in shared spa rooms. Observed touch up paint needed to wall joints and baseboards throughout building.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage in shared spa rooms to include furniture and large rolling bins.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). Observed unused medication cups stored not inverted or covered on medication cart stored on 200 hallway.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
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 flooring to cabinet in activity room with brown staining and laminate peeling.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). Observed no cleaning/disinfectant solution in rehab therapy room to be used on patient contact items after patients rehab session. Housekeeping manager supplied rehab employee’s with approved disinfectant cleaner during time of inspection.
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