Grand Villa Assisted Living at Winston

    2609 Old Salisbury Rd, Winston Salem, NC 27127
    • Assisted Living
    • Memory Care

    Clean, comfortable, attentive community, recommended

    I moved in recently and am impressed - the staff are genuinely loving, attentive, and treat residents like family. The facility is clean and refreshed, with great food, activities, and helpful caregivers; management's recent improvements are noticeable. It's a comfortable, safe community I'd recommend.

    Current/former resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.90·(51)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.9
    • Staff

      4.1
    • Meals

      3.2
    • Amenities

      3.4
    • Value

      3.9

    Pros

    • Compassionate, resident-focused staff
    • Attentive and helpful aides
    • Welcoming, home-like atmosphere
    • Clean, renovated interior and lobby
    • Comfortable, well-maintained living spaces
    • Attractive outdoor areas and grounds
    • Strong memory-care programming
    • Engaging activities and planned outings
    • Pleasant dining and enjoyable meals
    • Responsive maintenance and facilities support
    • Structured, peaceful daily routines
    • Positive caregiver teamwork and coordination

    Cons

    • Inconsistent sanitation and housekeeping standards
    • Incontinence-care management issues
    • Medication-administration and documentation gaps
    • Variable staff professionalism and conduct
    • Delays in attending to basic resident needs
    • Leadership instability and high staff turnover
    • Communication and family-notification shortcomings
    • Inconsistent meal-service continuity and quality
    • Pest-control concerns in some areas
    • Reputation and transparency concerns

    Summary of reviews

    Reviews for Grand Villa Assisted Living at Winston are highly polarized: many families describe warm, attentive caregivers, recent renovations, and active programming, while other accounts raise operational concerns that prospective families should evaluate closely.

    Care quality: Numerous reviews praise direct caregivers for compassion, patience, and individualized attention; several families credited staff with measurable improvements in residents’ mood and function. At the same time, other comments indicate lapses in basic care continuity — examples include missed assistance, delays in responding to needs, and at least one clinical event that required hospital transfer. Medication handling and recordkeeping appear uneven: reviewers referenced missing or unclear charts and questions about medication practices, suggesting gaps in medication-administration and documentation processes.

    Staff: Staff interactions are a prominent theme. Many reviewers emphasize respectful, loving, and engaged employees who treat residents like family. Contrasting entries describe instances of rude or unprofessional conduct and raise concerns about staff professionalism. Leadership changes were frequently mentioned; a named new administrator was associated with rapid improvements by some families, while others pointed to high turnover, internal conflict, and inconsistent management behavior. These mixed accounts indicate variability in supervisory stability and staff performance.

    Dining and activities: The community offers active programming, outings, and generally positive meal experiences according to several reviews. Conversely, a number of entries describe interruptions in meal service or dissatisfaction with meal continuity. Activity offerings and resident engagement are a commonly cited strength, but families should assess consistency of meal delivery and dietary accommodations during a visit.

    Facilities and maintenance: The facility receives praise for recent renovations, comfortable common areas, and attractive outdoor space. Maintenance responsiveness and a professional maintenance manager were singled out positively. However, other reviews describe cleanliness and sanitation concerns in both rooms and common areas and raise pest-control concerns. Prospective families should inspect housekeeping schedules, pest-control records, and the condition of furniture and dining areas as part of an in-person tour.

    Management and communication: Communication and responsiveness to family inquiries are recurring issues. Positive accounts note helpful administration and welcoming leadership, while negative accounts reference slow or unresponsive management, inconsistent family notification, and concerns about transparency. There are also mentions of rebranding or name changes and claims implying attempts to address reputation; such items contributed to overall reputation concerns for some reviewers.

    Notable patterns and guidance: The overall pattern is one of uneven consistency — strong, caring direct care and improved physical spaces coexist with operational weaknesses related to housekeeping, medication documentation, and leadership stability. For families considering this community, recommended due diligence includes asking about current staffing levels and turnover, medication-administration protocols and MAR/chart access, housekeeping schedules and pest-control measures, examples of recent quality-improvement actions, and opportunities to meet the current administrative team. An in-person visit at different times of day (including mealtimes and shift changes) will help verify whether the positive aspects described are persistent and whether the operational concerns have been addressed.

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    Location

    Map showing location of Grand Villa Assisted Living at Winston

    Grand Villa Assisted Living at Winston is located at 2609 Old Salisbury Rd, Winston Salem, NC, 27127.

    About Grand Villa Assisted Living at Winston

    Salem Terrace is a senior living community in Winston-Salem, North Carolina, offering a blend of assisted living and memory care services within a thoughtfully designed, supportive environment. With accommodations for up to 142 residents, Salem Terrace provides a spacious and comfortable setting for seniors who require varying levels of support. The community places a strong emphasis on personalized care, ensuring that daily support is tailored to meet the unique needs of each resident.

    The physical environment at Salem Terrace has been carefully curated to enhance quality of life. Residents have access to well-maintained gardens and patios, which offer peaceful spaces for relaxation and social interaction outdoors. Inside, there is an on-site beauty and barber shop to make personal grooming convenient and accessible without leaving the community. Housekeeping and maid services, as well as laundry for linens and personal clothing, are included, so residents can enjoy a consistently clean and comfortable home.

    A vibrant array of activities is available to promote engagement and enrichment among residents. Salem Terrace regularly organizes music sessions, games, book clubs, fitness programs, gardening activities, and arts and crafts. These activities are designed to support an active social environment and stimulate both mind and body. For dining, residents can share meals in the community dining room, and room service is available for those who prefer privacy or require it for health reasons. Guests are always invited to join at mealtime, contributing to a warm, family-like atmosphere.

    Salem Terrace also makes resident transportation a priority, providing services that help seniors access offsite activities and excursions with ease. The peaceful, tree-bordered location offers a serene backdrop while retaining proximity to the cultural and recreational attractions of Winston-Salem. All amenities and activities are thoughtfully developed to foster independence, well-being, and a sense of community among those who call Salem Terrace home. The approach at Salem Terrace centers on treating each individual with dignity and respect, helping seniors live fulfilling and enjoyable lives in a nurturing atmosphere.

    People often ask...

    Grand Villa Assisted Living at Winston offers competitive pricing, with rates starting at a cost of $5,311 per month.

    Grand Villa Assisted Living at Winston offers assisted living and memory care.

    There are 7 photos of Grand Villa Assisted Living at Winston on Mirador.

    The full address for this community is 2609 Old Salisbury Rd, Winston Salem, NC 27127.

    No, Grand Villa Assisted Living at Winston does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In North Carolina, the Division of Health Service Regulation licenses adult care and assisted living facilities, posting annual, complaint, and follow-up inspection results.

    License number920768
    Facility typeAdult Care Home
    Capacity142 residents
    View the official license record

    Inspection Reports

    65

    Reports

    35

    Type A Citations

    41

    Type B Citations

    36

    Complaints

    11

    Years

    18 Dec 2025Inspection
    Investigated deficiencies found in medication ordering and administration, including unclear insulin sliding-scale orders, mismatched beta-blocker and insomnia med records, and inconsistent administration of hydralazine.
    • 10A NCAC 13F .1002(a)Medication Orders
    • 10A NCAC 13F .1004(a)Medication Administration
    06 Mar 2025Construction
    Identified numerous physical plant and safety deficiencies, including inadequate exits for the SCU dining area, lack of privacy in bathrooms, unsecured storage rooms, and multiple fire safety and electrical system concerns.
    • 10A NCAC 13F .0301APPLICATION OF PHYSICAL PLANT REQUIREMENTS
    • 10A NCAC 13F .0305PHYSICAL ENVIRONMENT
    • 10A NCAC 13F .0305PHYSICAL ENVIRONMENT
    • 10A NCAC 13F .0305PHYSICAL ENVIRONMENT
    • 10A NCAC 13F .0306HOUSEKEEPING AND FURNISHINGS
    • 10A NCAC 13F .0306HOUSEKEEPING AND FURNISHINGS
    • 10A NCAC 13F .0306BEDROOM FURNISHINGS-CLEAN
    • 10A NCAC 13F .0309FIRE SAFETY-REHEARSALS ON EACH SHIFT
    • 10A NCAC 13F .0311BUILDING EQUIPMENT MAINTAINED SAFE, OPERATING
    • 10A NCAC 13F .0311EXHAUST VENTILATION
    06 Mar 2025Construction
    Identified multiple deficiencies in construction safety, privacy in rooms, equipment accessibility, and housekeeping requiring corrective actions.
    • Type ANC State Building CodeTwo exit means required
    • 10A NCAC 13F .0305Privacy Curtains in Showers
    • 10A NCAC 13F .0305Hand Grips in Bathrooms and Showers
    • 10A NCAC 13F .0300 / 10A NCAC 13F .0305Physical environment improvements
    • 10A NCAC 13F .0300 / 10A NCAC 13F .0305Oxygen storage hazards
    15 Nov 2024Follow-Up
    Investigated a complaint and found deficiencies in personal care, dietary therapy, medication administration and documentation, insulin management, and residents' funds access.
    • 10A NCAC 13F .0901(a)Personal Care and Supervision
    • 10A NCAC 13F .0904(e)(4)Nutrition and Food Service
    • 10A NCAC 13F .1004(a)Medication Administration
    • 10A NCAC 13F .1004(j)Medication Administration
    • 10A NCAC 13F .1104(e)Accounting For Resident's Personal Funds
    15 Nov 2024Follow-Up
    Investigated reported concerns and identified multiple deficiencies in personal care, nutrition, medication administration, and handling of residents' funds.
    • Type A10A NCAC 13F .0901(a)Personal Care and Supervision
    • Type A10A NCAC 13F .0904(e)(4)Nutrition and Food Service - Therapeutic Diets
    • Type A10A NCAC 13F .1004(a)Medication Administration
    • 10A NCAC 13F .1004(j)Medication Administration
    • Type B10A NCAC 13F .1104(e)Accounting For Resident's Personal Funds
    23 Aug 2024Complaint
    Investigated multiple deficiencies across care areas, including emergency response, health care referrals, LHPS oversight, nutrition, and medication administration.
    • Type A10A NCAC 13F .0901(c)Personal Care and Supervision
    • Type B10A NCAC 13F .0902(b)Health Care
    • Type A10A NCAC 13F .0902(c)(3-4)Health Care
    • Type B10A NCAC 13F .0903(c)Licensed Health Professional Support
    • Type A10A NCAC 13F .0904(c)(7)Nutrition and Food Service
    • Type A10A NCAC 13F .0904(d)(3)Nutrition and Food Service
    • Type A10A NCAC 13F .0904(e)(4)Nutrition and Food Service
    • Type B10A NCAC 13F .1002(a)Medication Orders
    • Type B10A NCAC 13F .1004(a)Medication Administration
    23 Aug 2024Complaint
    Investigated multiple deficiencies across resident care, health referrals, nutrition, and medication management, uncovering failures in emergency response, follow-up on physician orders, diet accuracy, and proper medication administration.
    • Type A10A NCAC 13F .0901(c)Personal Care and Supervision
    • Type A10A NCAC 13F .0902 Health CareHealth Care
    • Type A10A NCAC 13F .0903(c)(3-4)Licensed Health Professional Support
    • Type A10A NCAC 13F .0903(c)Licensed Health Professional Support
    • Type A10A NCAC 13F .0904(d)(3)Nutrition And Food Service
    • Type A10A NCAC 13F .0904(d)(3)Nutrition And Food Service
    • Type A10A NCAC 13F .0904(e)(4)Therapeutic Diets in Adult Care Homes
    • Type A10A NCAC 13F .1002Medication Orders
    • Type A10A NCAC 13F .1004(a)Medication Administration
    03 May 2023Follow-Up
    Investigated deficiencies in nutrition, hydration, supplements, and medication administration, including unsafe feeding practices, missing beverages and supplements, and incomplete medication orders.
    • 10A NCAC 13F .0904(a)(2)Nutrition and Food Service
    • 10A NCAC 13F .0904(d)(3)Nutrition and Food Service
    • 10A NCAC 13F .0904(d)(4)Nutrition and Food Service
    • 10A NCAC 13F .0904(e)(4)Nutrition and Food Service
    • 10A NCAC 13F .1004(a)Medication Administration
    03 May 2023Follow-Up
    Observed multiple deficiencies in nutrition, feeding sanitation, beverage service, and medication administration that posed safety risks to residents.
    • 10A NCAC 13F .0904(a)(2)Nutrition and Food Service - Food Procurement and Safety
    • 10A NCAC 13F .0904(d)(3)Nutrition and Food Service - Food Requirements (d)(3)
    • 10A NCAC 13F .0904(d)(4)Nutrition and Food Service - Water Service at Meals
    • 10A NCAC 13F .0904(e)(4)Therapeutic Diets in Adult Care Homes - Vitamin, Mineral Supplements and Wound Healing
    • 10A NCAC 13F .1004(a)Medication Administration - Administration of Medications and Treatments
    09 Nov 2022Follow-Up
    Identified deficiencies in medication administration and order processing.
    • 10A NCAC 13F .1004(a) Medication AdministrationMedication Administration
    09 Nov 2022Follow-Up
    Identified medication administration deficiencies, including failing to hold medications as ordered and not administering prescribed eye drops.
    • Type A10A NCAC 13F .1004(a) Medication AdministrationMedication Administration
    05 Aug 2022Follow-Up
    Identified deficiencies related to staff background checks and related personnel records, with documentation gaps and incomplete checks for several employees.
    • Type BContinued From page 1
    • Type B10A NCAC 13F .0407(a)(5)Other Staff Qualifications
    • Type B10A NCAC 13F .0407(a)(7)Other Staff Qualifications
    05 Aug 2022Follow-Up
    Investigated multiple deficiencies across staffing, training, supervision, health care referrals, and medication administration, leading to several cited violations.
    • Type B10A NCAC 13F .0406(a)Test For Tuberculosis
    • Type B10A NCAC 13F .0407(a)(5)Other Staff Qualifications
    • Type B10A NCAC 13F .0407(a)(7)Other Staff Qualifications – Criminal Background Check
    • Type B10A NCAC 13F .0504Competency Validation For LHPS Tasks
    • 10A NCAC 13F .0505Training On Care Of Diabetic Resident
    • Type B10A NCAC 13F .0901(b)Personal Care and Supervision
    • Type B10A NCAC 13F .0902(b)Health Care
    • 10A NCAC 13F .0904(e)(4)Nutrition and Food Service
    • Type B10A NCAC 13F .1004Medication Administration
    • 10A NCAC 13F .1004(j)Medication Administration – MAR Accuracy
    • Type B10A NCAC 13F .1409Special Care Unit Orientation And Training
    • Type BG.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    • Type BG.S. 131D-4.5B(b)ACH Medication Aides; Training and Competency Evaluation Requirements
    • G.S. 131D-45(a)Examination and screening for controlled substances
    06 May 2022Follow-Up
    Investigated multiple failures in supervising residents, health care follow-up, medication administration, infection control, and treatment of residents' rights. Documented numerous deficiencies, including lack of supervision for a wandering resident, inadequate health care referrals, repeated medication errors, improper infection control practices, and disrespectful staff behavior toward residents.
    • 10A NCAC 13F .0901(b)Personal Care and Supervision
    • Type B10A NCAC 13F .0902(b)Health Care
    • Type B10A NCAC 13F .1004(a)Medication Administration
    • Type B10A NCAC 13F .1004(n)Medication Administration
    • 10A NCAC 13F .1801(c)Infection Prevention & Control Program
    • G.S. 131D-21(1)Declaration of Residents' Rights
    • G.S. 131D-21(2)Declaration of Residents' Rights
    06 May 2022Follow-Up
    Found deficiencies related to inadequate supervision, incomplete incident documentation, and medication administration issues affecting a resident with behavioral concerns.
    • Supervision and incident follow-up
    • Documentation and monitoring of safety behavior
    • Medication administration and pharmacy accountability
    25 Jan 2022Follow-Up
    Investigated complaints found multiple deficiencies in supervision, health care referrals, private telephone access, medication administration, and infection prevention during the on-site and desk review followed by an exit conference.
    • Type B10A NCAC 13F .0901(b)Personal Care and Supervision
    • Type B10A NCAC 13F .0902(b)Health Care
    • 10A NCAC 13F .0906 (d)Other Resident Care And Services
    • 10A NCAC 13F .1004(a)Medication Administration
    • Type B10A NCAC 13F .1801(c)Infection Prevention & Control Program (temp)
    25 Jan 2022Follow-Up
    Found repeated resident falls with injuries and insufficient supervision and documentation, indicating ongoing safety and oversight concerns.
    • Deficiency related to inadequate supervision and monitoring of residents, including falls
    23 Aug 2021Follow-Up
    Found multiple deficiencies in dietary management and medication administration, including missing diet menus and inconsistent diet orders, as well as unsafe medication handling practices.
    • Type A10A NCAC 13F .0904(c)(7)Nutrition and Food Service – Diets and Menu
    • 10A NCAC 13F .0904(d)(3)(A)Nutrition and Food Service – Diets and Menu
    • 10A NCAC 13F .0904(d)(3)(H)Nutrition and Food Service – Diets and Menu
    • 10A NCAC 13F .0904(e)(4)Nutrition and Food Service – Diets and Menu
    • 10A NCAC 13F .1004(a)Medication Administration
    23 Aug 2021Follow-Up
    Identified deficiencies in nutrition/food service and medication administration, including missing diet menus and incomplete documentation of resident diets and medications.
    • 10A NCAC 13F .0904(c)(7) Nutrition And Food ServiceNutrition and Food Service
    • 10A NCAC 13F .0904(d)(3)(A) Nutrition And Food ServiceNutrition and Food Service
    • 10A NCAC 13F .0904(d)(4)(H) Nutrition And Food ServiceNutrition and Food Service
    • 10A NCAC 13F .0904(e)(4) Nutrition And Food ServiceNutrition and Food Service
    • 10A NCAC 13F .1004(a) Medication AdministrationMedication Administration
    23 Aug 2021Follow-Up
    Investigated deficiencies in nutrition, medication administration, resident rights, and staff competency. Found mismatched diet menus, incomplete beverage service, meals served without tables in the SCU, multiple medication administration errors, and gaps in medication aide training.
    • 10A NCAC 13F .0904(c)(7)Nutrition And Food Service - Matching therapeutic diet menus
    • 10A NCAC 13F .0904(d)(3)(A)Nutrition And Food Service - Milk served as required
    • 10A NCAC 13F .0904(d)(3)(H)Nutrition And Food Service - Water and beverages at meals
    • 10A NCAC 13F .0904(e)(4)Therapeutic Diets in Adult Care Homes - Diets served as ordered
    • 10A NCAC 13F .1004(a)Medication Administration - Administer medications as ordered
    • G.S. 131D-21(1)Declaration of Residents' Rights
    • G.S. 131D-4.5B(b)Adult Care Home Medication Aides; Training and Competency
    06 Feb 2020Follow-Up
    Identified deficiencies related to TB testing for new staff, LHPS competency validation, and clarification of a medication order.
    • 10A NCAC 13F .0406(a) Test For TuberculosisTest For Tuberculosis
    • 10A NCAC 13F .0504 Competency Validation For LHPS TasksCompetency Validation For LHPS Tasks
    • 10A NCAC 13F .1002(a) Medication OrdersMedication Orders
    06 Feb 2020Follow-Up
    Investigated TB skin testing and staff competency processes; found TB tests not completed timely for new staff and no documented competency validation for LHPS tasks.
    • 10A NCAC 13F .0406(a) Test For TuberculosisTest For Tuberculosis
    • 10A NCAC 13F .0504(a) Competency Validation For LHPS TasksCompetency Validation For LHPS Tasks
    05 Dec 2019Follow-Up
    Found deficiencies related to physical plant requirements and exit-door safety; exit doors remained equipped with double-cylinder dead bolts.
    • 10A NCAC 13F .0301; SECTION .0300 - PHYSICAL PLANT REQUIREMENTSPHYSICAL PLANT REQUIREMENTS
    05 Dec 2019Follow-Up
    Identified deficiencies in physical plant and egress, including an insufficient number of exits for the 62-bed unit and locked doors that could hinder evacuation.
    • 10A NCAC 13F .0301APPLICATION OF PHYSICAL PLANT REQUIREMENTS
    18 Oct 2019Follow-Up
    Investigated a complaint and follow-up visit found deficiencies in resident supervision, insulin administration documentation, and adherence to residents' rights and care standards.
    • 10A NCAC 13F .0901(b)Personal Care and Supervision
    • 10A NCAC 13F .1004Medication Administration
    • G.S. 131D-21(2)Declaration of Residents' Rights
    18 Oct 2019Follow-Up
    Found deficiencies in personal care and supervision, including missing orientation documentation and incomplete post-fall reporting after a resident fall.
    • Type A10A NCAC 13F .0901(b)Personal Care and Supervision
    18 Oct 2019Follow-Up
    Investigated supervision failures for a resident with dementia who had multiple falls, along with medication documentation issues and concerns regarding residents' rights.
    • Type A10A NCAC 13F .0901(b) Personal Care and SupervisionPersonal Care and Supervision
    • 10A NCAC 13F .1004(a) Medication AdministrationMedication Administration
    • G.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    18 Oct 2019Follow-Up
    investigators found supervision failures for a resident with dementia and multiple falls, along with medication administration documentation gaps related to insulin sliding scale, and a broader rights-related care deficiency.
    • Type A10A NCAC 13F .0901(b)Personal Care and Supervision
    • 10A NCAC 13F .1004(a)Medication Administration
    • G.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    06 Aug 2019Follow-Up
    Found multiple deficiencies in the facility's physical plant and environment, including exit compliance, outside premises safety, housekeeping and furnishings, electrical safety, and ventilation.
    • 10A NCAC 13F .0301Physical Plant
    • 10A NCAC 13F .0306Outside Premises-Clean, Safe
    • 10A NCAC 13F .0306Housekeeping and Furnishings-Clean, Repaired
    • 10A NCAC 13F .0309 / .0310Building Equipment Maintained Safe, Operating
    • 10A NCAC 13F .0310 / .0311Exhaust Ventilation
    06 Aug 2019Follow-Up
    Identified multiple deficiencies related to physical plant, safety systems, and maintenance, including inadequate exits, damaged exterior and interior surfaces, and unaddressed fire/safety equipment issues.
    • 10A NCAC 13F .0301Physical Plant Requirements
    • 10A NCAC 13F .0305(m)Outside Premises - Physical Environment
    • 10A NCAC 13F .0306Housekeeping and Furnishings
    • 10A NCAC 13F .0311Building Equipment Maintained Safe, Operating
    • 10A NCAC 13F .0311(g)Exhaust Ventilation
    19 Jul 2019Follow-Up
    Investigated a complaint and identified multiple deficiencies in medication administration, resident care, and documentation.
    • Type AMedication administration and recording deficiencies
    19 Jul 2019Follow-Up
    Investigated a complaint and found failures in physician referrals, medication orders/administration, and special care unit staffing, affecting multiple residents.
    • Type B10A NCAC 13F .0902(b)Health Care
    • 10A NCAC 13F .1002 Medication OrdersMedication Orders
    • Type A10A NCAC 13F .1004(a)Medication Administration
    • Type B10A NCAC 13F .1308(a)Special Care Unit Staff
    • Type BG.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    19 Jul 2019Follow-Up
    Investigated a complaint about medical referrals and medication practices; identified multiple deficiencies in how orders were verified, medications were administered, MARs were maintained, and SCU staffing met needs.
    • Type B10A NCAC 13F .0902(b) Health CareHealth Care
    • Type A10A NCAC 13F .1002(a) Medication OrdersMedication Orders
    • Type A10A NCAC 13F .1004(a) Medication AdministrationMedication Administration
    • Type A10A NCAC 13F .1004(j) Medication AdministrationMedication Administration
    • Type B10A NCAC 13F .1308(a) Special Care Unit StaffSpecial Care Unit Staff
    • G.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    08 Mar 2019Follow-Up
    Investigated findings showed multiple deficiencies including unsafe hot water temperatures, incomplete TB testing, inadequate health care follow-up, and numerous medication administration and record-keeping failures, including missed or refused meds and lack of physician notification.
    • 10A NCAC 13F .0311(d)Other Requirements
    • 10A NCAC 13F .0703(a)Tuberculosis Test, Medical Exam & Immunization
    • Type B10A NCAC 13F .0902(b)Health Care - Referral and Follow-up
    • 10A NCAC 13F .1002(a); 10A NCAC 13F .1004(a)Medication Orders; Medication Administration
    • 10A NCAC 13F .1004(a)Medication Administration
    • 10A NCAC 13F .1004(j)Medication Administration
    • G.S. 131D-21(2)Declaration of Residents' Rights
    • G.S. 131D-45(a)Examination and Screening for Controlled Substances
    08 Mar 2019Complaint
    The site had deficiencies in medication management and in notifying physicians about residents' health events, including high FSBS readings and verification of insulin orders.
    • Type B10A NCAC 13F .0311(d)Other Requirements
    31 Oct 2018Follow-Up
    Identified multiple deficiencies in the physical plant, outside premises, housekeeping, and safety systems.
    • 10A NCAC 13F .0301Application of Physical Plant Requirements
    • 10A NCAC 13F .0305Physical Environment
    • 10A NCAC 13F .0306Housekeeping and Furnishings
    • 10A NCAC 13F .0306Housekeeping and Furnishings
    • 10A NCAC 13F .0311Other Requirements
    • 10A NCAC 13F .0311Other Requirements
    • 10A NCAC 13F .0311Other Requirements
    26 Oct 2018Follow-Up
    Investigated a complaint and found numerous deficiencies, including unsanitary conditions and damaged fixtures, inadequate resident supervision, missing licensed health professional assessments, inaccurate medication documentation, and improper discharge practices.
    • Type B10A NCAC 13F .0306(a)(1)Housekeeping And Furnishings
    • 10A NCAC 13F .0702 (d)Discharge Of Residents
    • Type A10A NCAC 13F .0901 Personal Care and SupervisionPersonal Care and Supervision
    • 10A NCAC 13F .0903(a)Licensed Health Professional Support
    • 10A NCAC 13F .1004(j)Medication Administration
    • G.S. 131D-21(2)Declaration of Residents' Rights
    26 Oct 2018Follow-Up
    Cited multiple deficiencies in operations including housekeeping, resident discharge, safety of windows, medication management, and residents’ rights, with ongoing corrective actions noted across several pages.
    • Type B10A NCAC 13F .0306(a)(1)Housekeeping And Furnishings
    • Discharge Or Transfer Of Residents
    • Resident Missing From The SCU
    • Resident Discharge/Transfer (Additional)
    • G.S. 131D-21(2)Declaration Of Residents' Rights
    • G.S. 131D-21(2)Declaration Of Residents' Rights
    23 Aug 2018Construction
    Identified extensive deficiencies in physical plant, safety systems, and maintenance across multiple areas requiring correction.
    • 10A NCAC 13F .0301Application of Physical Plant Requirements
    • 10A NCAC 13F .0305Physical Environment
    • 10A NCAC 13F .0306Housekeeping and Furnishings
    • 10A NCAC 13F .0306Housekeeping and Furnishings
    • 10A NCAC 13F .0309Plan for Evacuation
    • 10A NCAC 13F .0311Other Requirements
    • 10A NCAC 13F .0311Other Requirements
    • 10A NCAC 13F .0311Other Requirements
    • 10A NCAC 13F .0311Other Requirements
    23 Aug 2018Construction
    An inspection identified multiple deficiencies related to maintenance, safety, and equipment, including broken fixtures, unsealed gaps, and improper heating devices.
    18 Jul 2018Follow-Up
    Found that fire safety was not maintained; penetrations in the kitchen were sealed with an unapproved firestop material, which could allow fire or smoke to spread.
    • 10A NCAC 13F .0311PHYSICAL PLANT
    18 Jul 2018Follow-Up
    Identified deficiencies related to fire safety and physical plant, including unapproved firestop material in the kitchen.
    • Type A10A NCAC 13F .0311Initial Comments
    • 10A NCAC 13F .0311PHYSICAL PLANT - OTHER REQUIREMENTS
    16 Jul 2018Follow-Up
    Investigated found failures to arrange health care referrals and wound care follow-up for a resident, and to manage residents' funds properly.
    • Type B10A NCAC 13F .0902(b)Health Care
    • Type B10A NCAC 13F .1104(c)Accounting For Resident's Personal Funds
    • Type BG.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    • Type BG.S. 131D-21(4) Declaration of Residents' RightsDeclaration of Residents' Rights
    16 Jul 2018Follow-Up
    Investigated concerns about the handling of residents' funds and adherence to residents' rights. Multiple deficiencies were cited regarding how money and rights were managed and protected.
    15 May 2018Construction
    Investigated a construction complaint about a ceiling leak affecting the kitchen and related building systems; found deficiencies in the kitchen’s roof/HVAC area and overall building maintenance.
    • Kitchen area affected by roof leak and HVAC issues
    • Physical Plant and safety equipment
    15 May 2018Construction
    Investigated a complaint about a ceiling leak affecting the kitchen; observed roof leaks causing holes in the ceiling over the food prep area and related safety concerns, including water intrusion and deteriorated building components.
    • 10A NCAC 13F .0302 DESIGN AND CONSTRUCTIONDESIGN AND CONSTRUCTION
    • 10A NCAC 13F .0311 OTHER REQUIREMENTSBUILDING EQUIPMENT MAINTAINED SAFE, OPERATING
    16 Feb 2018Follow-Up
    Investigated multiple deficiencies across outside environment, resident contracts, personal care, health care follow-up, resident rights, medication control, and resident funds.
    • 10A NCAC 13F .0305(m)Physical Environment (outside grounds) and related conditions
    • 10A NCAC 13F .0704Resident Contract, Information on Home and Resident Register
    • 10A NCAC 13F .0901(a)Personal Care and Supervision
    • Type A10A NCAC 13F .0902(b)Health Care - Physician notification (aggressive behaviors)
    • 10A NCAC 13F .0909Resident Rights - Safe environment related to aggressive behavior
    • 10A NCAC 13F .1008(a)Controlled Substances
    • 10A NCAC 13F .1104(c)Accounting For Resident's Personal Funds
    • G.S. 131D-21(4)Declaration of Residents' Rights - Exploitation
    • G.S. 131D-21(11)Declaration of Residents' Rights - Voice complaints and retaliation
    16 Feb 2018Follow-Up
    Investigated a complaint and found multiple deficiencies related to rate notices, resident rights, and the facility’s physical environment.
    16 Nov 2017Complaint
    Investigated deficiencies found in resident supervision and personal care, including insufficient monitoring during meals and routine checks.
    • Type B10A NCAC 13F .0901(b)Personal Care and Supervision
    16 Nov 2017Complaint
    Investigated concerns found failures in supervision during night shifts, diet compliance, and accounting for residents' personal funds. A death occurred due to supervision lapse, and multiple deficiencies were documented in diet handling and fund management.
    • Type B10A NCAC 13F .0901(b)Personal Care and Supervision
    • Type B10A NCAC 13F .0904(e)(4)Nutrition and Food Service
    • Type B10A NCAC 13F .1104(c)Accounting For Residents' Personal Funds
    15 Mar 2017Follow-Up
    Investigated deficiencies from a prior biennial follow-up construction survey related to sanitation and the physical plant; deficiencies remained unresolved and require a new Plan of Correction.
    • Type A10A NCAC 13F .0306Housekeeping and Furnishings-Sanitation Grade
    15 Mar 2017Follow-Up
    Identified that sanitation scores were not consistently maintained at the required level. A past sanitation score of 81 was documented.
    • 10A NCAC 13F .0306Housekeeping and Furnishings - Sanitation
    02 Dec 2016Follow-Up
    Identified multiple deficiencies in safety access, housekeeping, and sanitation. Observed issues included missing hand grips, obstructed exits, water-damaged ceilings, a broken countertop, and a substandard sanitation score.
    • 10A NCAC 13F .0305 PHYSICAL ENVIRONMENTBathrooms-Hand Grips
    • 10A NCAC 13F .0305 PHYSICAL ENVIRONMENT (m)Outside Premises-Clean, Safe
    • 10A NCAC 13F .0306 HOUSEKEEPING AND FURNISHINGSHousekeeping and Furnishings-Clean, Repaired
    • 10A NCAC 13F .0306 HOUSEKEEPING AND FURNISHINGSHousekeeping and Furnishings-Sanitation Grade
    02 Dec 2016Follow-Up
    Found deficiencies in safety equipment and fixtures; observed no hand grip at a handicap tub and a damaged countertop.
    • Bathrooms-Hand Grips
    • Countertops - Broken/Damaged
    01 Sept 2016Construction
    The facility had multiple deficiencies including accessibility hazards, damaged finishes, unsafe premises, housekeeping issues, and problems with fire safety and equipment storage.
    01 Sept 2016Complaint
    Investigated a complaint and identified deficiencies in personal care and medication management, including failure to provide adequate personal care to memory care residents and poor recordkeeping for outside medications.
    • 10A NCAC 13F .0901(a)Personal Care and Supervision
    • 10A NCAC 13F .1010 (d) (e)Pharmaceutical Services
    01 Sept 2016Construction
    Identified multiple safety and maintenance deficiencies, including missing hand grips, obstructed exits, damaged surfaces, excessive combustible storage, improper oxygen cylinder storage, and inadequate fire safety and evacuation measures.
    • 10A NCAC 13F .0302Current sanitation and fire safety inspection reports
    • 10A NCAC 13F .0305PHYSICAL ENVIRONMENT - Hand Grips
    • 10A NCAC 13F .0305PHYSICAL ENVIRONMENT - Outside Premises
    • 10A NCAC 13F .0306HOUSEKEEPING AND FURNISHINGS - Clean and Repaired
    • 10A NCAC 13F .0306HOUSEKEEPING AND FURNISHINGS - Sanitation Grade
    • 10A NCAC 13F .0306HOUSEKEEPING AND FURNISHINGS - Maintained Free of Hazards
    • 10A NCAC 13F .0309PLAN FOR EVACUATION
    • 10A NCAC 13F .0311BUILDING EQUIPMENT MAINTAINED SAFE, OPERATING
    01 Sept 2016Complaint
    Identified deficiencies in care planning and documentation for residents, including missing assessment dates and inadequate recording of care needs and continence. Evidence showed incomplete continence observations and gaps in staff interviews.
    • Care plan documentation and continence deficiencies
    22 Jul 2016Follow-Up
    Found multiple deficiencies including roof-related ceiling damage, sanitation scoring below required levels, and unsafe air conditioning covers.
    • 10A NCAC 13F .0306(a)(1)Housekeeping And Furnishings
    • 10A NCAC 13F .0306(a)(4)Housekeeping And Furnishings
    • 10A NCAC 13F .0311(a)Other Requirements
    22 Jul 2016Follow-Up
    Observed roof and ceiling problems with water damage, including stained ceilings and tarps used to cover leaks, with ongoing repairs noted.
    • Maintenance/condition of building envelope and interior ceilings
    07 Apr 2016Complaint
    Investigated multiple deficiencies across outside grounds, indoor environment, sanitation, furnishings, medication documentation, and infection control related to diabetic care.
    • 10A NCAC 13F .0305(m)Physical Environment (m) Outside premises
    • 10A NCAC 13F .0306(a)(1)Housekeeping And Furnishings (a)(1) Clean and repair
    • 10A NCAC 13F .0306(a)(3)Housekeeping And Furnishings (a)(3) Furniture in good repair
    • 10A NCAC 13F .0306(a)(4)Housekeeping And Furnishings (a)(4) Sanitation score
    • 10A NCAC 13F .1002(b)Medication Orders (b)
    • G.S. 131D-21(2) Declaration of Residents' RightsDeclaration of Residents' Rights
    • G.S. 131D-4.4A(b) ACH Infection Prevention RequirementsInfection Prevention Requirements
    07 Apr 2016Complaint
    Inspected the site for deficiencies and identified multiple maintenance and safety issues requiring corrective action.
    24 Jun 2015Follow-Up
    Investigated found sanitation classification below required level and multiple cleanliness and repair issues remained, including damaged flooring and sticky residue.
    • 10A NCAC 13F .0306(a)(4)Housekeeping And Furnishings
    24 Feb 2015Complaint
    Investigated a complaint about inadequate supervision and safety for a resident with dementia, which contributed to violent incidents and a death of another resident. Findings cited deficiencies in supervision, medical notification/referral, and protection of residents.
    • Type A10A NCAC 13F .0901(b)Personal Care and Supervision
    • Type A10A NCAC 13F .0902(b)Health Care
    • Type A10A NCAC 13F .0909Resident Rights
    24 Feb 2015Complaint
    Investigated an incident involving a resident's aggressive behavior and staff safety concerns; documented multiple episodes of swinging, wandering, and physical threats with insufficient supervision and follow-up actions.

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