Jan 12, 2026
97 / 100
· 3 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 scuffed walls in various areas throughout facility. Repair.
#5 · Ventilation equipment clean, good repair −1
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed heavy dust buildup in a/c vents in room 113. Keep clean. 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 loose toilet seat in room 104. Tighten. REPEAT *Points not escalated due to improvements in toilets and bathing facilities from previous inspection*
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Jul 16, 2025
95.5 / 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 cracked/damaged floor tiles in laundry room in memory care. Repair.
#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 peeling/chipping wall in memory care laundry room with multiple holes in wall. Repair.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed several bathroom vents in resident rooms with dust buildup. Keep ventilation equipment clean. 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 shower seat in need of cleaning in room 117 MC. Observed loose toilet seats in rooms 117 MC and 127 AL. Observed peeling shower seat in need of replacement and shower floor in need of cleaning in room 127.
#16 · Hot water between 105°F and 116°F −3
.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 at 119F in room 117, and 117F in room 121 and 120. Ensure hot water is between 105-116 at handwashing and bathing facilities. REPEAT
#28 · No pest presence; effective pest control measures
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed live roach-like bug in room 120. Observed silverfish bug on 2nd floor ceiling. Observed a 1-2 gnats/flies throughout building.
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Jan 7, 2025
98 / 100
· 5 violations
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed filters missing on A/C unit in 126. Needs repair.
#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 papertowels at handsink in memory care activity area. Needs papertowels.
#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 at handsinks over 116F in 113, 230, and 231. Hot water for handwashing and bathing shall be 105-116F.
#17 · Back-up water supply plan available and complete
General Comment:
.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 facility had parts of the backup water supply plan for food service and cleaning. Facility needs complete plan. Facilty has county backup water supply check list and handout information. EHS advised facility to fill out check list.
#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 spill in memory care activity area freezer needs cleaning.
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Jul 8, 2024
96.5 / 100
· 3 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 holes and damaged areas in wall inside common area in need of repair; Observed hole being created by door knob of bathroom door in need of repair inside resident room #208
#7 · Facilities provided, accessible, clean, good repair −1
REPEAT
.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 several toilet seats very loose in need of repair / tightening throughout facility.
#28 · No pest presence; effective pest control measures −0.5
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed numerous I’ve ants inside resident room #216 in need of immediate attention.
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Apr 11, 2024
95.5 / 100
· 8 violations
#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 multiple walls throughout the facility, such as memory care common area, room 128, damaged or scuffed in need of repair and/or repainting.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed air vent in memory care common area with heavy debris buildup, as well as multiple private resident bathrooms in memory care with dusty bathroom vent fans.
#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 toilets in multiple private resident bathrooms soiled and in need of cleaning. Observed a handful of toilets with loose seat cover in need of repair. Repeat.
#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed medication cart in memory care area with patient cups over stacked, exposing the lips to possible contamination. Informed PIC to either keep smaller stacks of cups or keep covered from contamination.
#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 chair, pillow, and mattress in room 126 soiled or stained. Observed stained box spring in 125.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed chair, pillow, and mattress cover in room 126 soiled or stained. Observed more stained sheets in room 121, soiled mattress cover in 127, and soiled linens in 210.
#38 · Food service equipment and utensils clean, good repair −1
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed refrigerators in rooms 109, 210, 208, second floor common room, and memory care common room with food debris buildup and in need of cleaning. Observed microwave in room 210 and second floor common room soiled with food debris and in need of cleaning. Repeat.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate −1
.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 refrigerator in room 227 and second floor common room without thermometers. Observed refrigerators in rooms 210 and 208 with ambient temperature of 60 degrees. Repeat.
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Sep 21, 2023
97 / 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 flooring need to be cleaned in memory care unit closet, room 218, 212, 121, kitchen closet upstairs.
#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 tub needs to be cleaned in room 211, loose toilet seat needs to be repaired in room 206, damaged toilet seat needs to be replaced in room 230, toilet and or hand sink need cleaning in room 218, 212, AL restroom. Observed slow draining at the common area sink in room 218, need repair.
#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 men’s restroom main hallway, memory care restroom, AL restroom need hand washing sign posted. Hand washing signs provided at the time of inspection.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed salon is missing soap for hand washing. Ensure to provide all hand washing supplies at all hand sinks at all time.
#16 · Hot water between 105°F and 116°F
.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 water temperature at the hand sink at some part of the building where it is closed to hot water heater, the temperature was above the required range from 2-3 degrees. The maintenance will adjust the water temperature and keep within the range of 105F to 116F.
#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 facilities with incomplete water back up supply plan. EHS emailed administrator the checklist of the plan, and discussed what required at the time of inspection. The administrator will put the plan ready by next inspection.
#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 microwave in memory care dining room need to be cleaned and keep clean.
#42 · Food and food supplies from approved sources; properly stored and handled
.1321 (a) All food and food supplies provided by an institution for consumption by residents shall be from approved sources, stored, and handled as set forth in 15A NCAC 18A .2600. Observed boxes of can foods and boxes of single service articles stored on the floor in the kitchen storage upstairs. Maintenance and staff is currently working on getting items up and get rid of some items. Ensure to keep all items off the floor at least 6 inches or above to prevent cross contamination.
#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 refrigerator in memory care unit need the thermometer for temperature indication.
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Dec 12, 2022
98 / 100
· 2 violations
#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 stains on toilets in rooms 202, 205, and 227.
#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 trash bags and trash on ground near dumpsters.
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