Nursing Home Inspector

Alamance County
Phone: 336-585-2400
Provider Number: 345545
Last Inspection: 12/14/2016

About the Nursing Home

Number of Beds: 16
Number of Residents: 14
Beds Available: 2
Percent Occupancy: 88%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Family
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.

Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better







Deficiency Ratings
By Year

Lower Numbers Are Better






Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating


Details by Inspection Date

12/16/2015 Inspection

Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 1/16/2016
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 1/16/2016

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 14 97.50 84.96
Registered Nurses 1.54 0.82 0.72
Licensed Practical / Vocational Nurses 0.39 0.74 0.87
Certified Nursing Assistants 3.34 2.60 2.33
Total Staff Hours 5.26 4.16 3.91


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 5 4 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 95 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 96 93
of long-stay residents experiencing one or more falls with major injury 8 3 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 8 9 8
of long-stay residents who received an antianxiety or hypnotic medication 30 28 29
of long-stay residents who received an antipsychotic medication 8 18 13
of long-stay residents who self-report moderate to severe pain 2 6 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 13 22 23
of long-stay residents whose need for help with daily activities has increased 9 20 18
of long-stay residents with a catheter inserted and left in their bladder 0 1 1
of long-stay residents with a urinary tract infection 0 4 4