Aug 20, 2026
98 / 100
· 3 violations
#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 stained ceiling tile in activities room and mens 1st floor bathroom.
REPEAT.
#7 · Facilities provided, accessible, clean, good repair
.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 chair torn in room 316. Observed cleaning needed to 1st floor shower room.
#8 · Toilet rooms free of storage, handwash signs posted
.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 handwashing signs in mens 1st floor bathroom and bathroom next to shower room. Needs handwashing signage.
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Feb 4, 2026
97.5 / 100
· 2 violations
#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 throughout in need of repair (barbershop, shower rooms, dining room).
#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 large amounts of storage (non-bathing / shower) items stored inside shower / spa rooms in need of removal.
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Oct 15, 2025
97 / 100
· 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
General Comment:
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 stained carpet in 345.
#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 stained ceiling tiles in upstairs hallway and activity room downstairs. Observed build up on ceiling around vent in library. REPEAT.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust build up in a/c filters in multiple rooms and on ceiling vents in dining room.
#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 shower floors/seats/etc in need of cleaning in multiple rooms including shower rooms. Observed toilet in need of cleaning in 347. Observed toilet chair tearing and outside shower coping peeling in 316. Needs cleaning/repair. Observed caulking cracking around sinks in common area bathrooms. REPEAT.
#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.
Facility has parts of the backup water supply plan but is missing a few items. EHS emailed a template to fill out for full compliance.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated
General Comment:
.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 food in activity room refrigerator with no name or date labels.
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Apr 9, 2025
98 / 100
· 4 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 touch up paint needed to walling throughout building. Observed ceiling plaster peeling around ceiling vents in main lobby. Observed black build up to ceiling in main lobby area. Clean. Observed stained ceiling tiles in activity room. Repair.
#7 · Facilities provided, accessible, clean, good repair
.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 seat laminate peeling in room 308. -General comment.
#26 · Premises properly maintained −1
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed bag of trash and litter outside of dumpster area.
#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 removable AC vent with dust accumulation in room 308. Clean.
-General comment.
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Sep 26, 2024
99 / 100
· 1 violation
#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 several stained ceiling tiles throughout building. EHS advises facility to ensure no active leak is occurring and to have stained ceiling tiles replaced.
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Apr 23, 2024
98 / 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 several floor tiles missing and detailed cleaning needed to flooring in laundry room located on level 2.
#2 · Walls and ceilings clean, good 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. Observed ceiling peeling near vent closet to nurses station in main lobby. Observed black build up to ceiling creases in main lobby.
#3 · Ceiling attachments cleanable, clean, good repair −0.5
.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Observed removable vent to AC unit with heavy dust accumulation located in room 338.
#7 · Facilities provided, accessible, clean, good repair
.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 room 322.
#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 shared shower room located on level 2 being used as storage for furniture/wheelchairs. Per conversation with staff, the shared shower room is not used. EHS advises facility to adhere to notated rule.
#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete −1
.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. EHS emailed facility required template procedure. REPEAT VIOLATION.
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Sep 27, 2023
99 / 100
· 5 violations
#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 employee restrooms without handwash signs posted.
#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 facility template guidance for notated rule.
#25 · Containers and areas clean; sufficient capacity
.1316 (c) The designated rooms and containers described in rule .1316 (b) shall have the capacity to store the institution's refuse, recyclables, and returnables and shall be kept clean. Observed dumpster area with minor debris.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate −0.5
.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 activity room fridge without a thermometer.
#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. EHS emailed facility required written procedure.
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Apr 17, 2023
99 / 100
· 2 violations
#2 · Walls and ceilings clean, good repair −1
Observed stained ceiling in halls. Observed peeling paint around HVAC on ceiling in library. Observed missing ceiling tile in activity 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.
#7 · Facilities provided, accessible, clean, good repair
Observed toilet seat peeling in room 323.
.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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Nov 9, 2022
97 / 100
· 3 violations
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed dust build up on ac filters in rooms 336, 341, and in salon.
Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Re-caulk around hand sink in women’s restroom on 2nd floor and in room 341.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed stains in under couch cushions in library. Observed torn bedskirt in room 341.
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).
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May 18, 2022
96 / 100
· 4 violations
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
All walls shall be easily cleanable. 15A NCAC 18A .1310.
Walls shall be easily cleanable and shall have washable surfaces to the highest level reached by splash or spray in rooms or areas where such occur. 15A NCAC 18A .1310. Observed hand railings pulling from wall in residents room and in common bathrooms. .
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet in common area with red soil on toilet, observed toilet in common area soiled with brown accumulation on toilet. Observed multiple seats broken or damaged or scratched. Common restrooms, regrout where needed. Ensure toilet tank cover is correct for the toilet in men’s restroom on 1st floor.
#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 end table in bathroom with chips and cracks in finish. Observed tear in common area on chair.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a). Observed lint behind dryers in both laundry rooms. Observed puddles of water behind both wash machines. Leaks at both had been occurring long enough to pop up tiles in front of units.
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Jul 7, 2021
95.5 / 100
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Dec 9, 2020
95 / 100
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Feb 11, 2020
91.5 / 100
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Aug 6, 2019
91.5 / 100
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Jan 16, 2019
92 / 100
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Sep 21, 2018
95.5 / 100
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Jun 15, 2018
96 / 100
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Nov 27, 2017
96.5 / 100
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Jan 30, 2017
96 / 100
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Mar 23, 2016
95 / 100
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Dec 14, 2015
96.5 / 100
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Jun 17, 2015
96 / 100
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Nov 10, 2014
95 / 100
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May 16, 2014
94 / 100
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Jul 25, 2013
91.5 / 100
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