| License Number: | HAL-034-093 |
| Site Address: |
3150 Burke Mill Road Winston-Salem, NC 27103-6431 |
| County: | Forsyth |
| Capacity: | 100 Beds |
Statements of Deficiencies (form used by the state to document inspections) are posted for adult care facilities with survey dates beginning November 1, 2014 and deficiencies or violations were identified.
Note:Â A Yes under the column, IDR Pending, indicates the facility has requested Informal Dispute Resolution (IDR), a process that gives a facility the opportunity to dispute all or some of the findings of a state inspection. If the Statement of Deficiency is changed as a result of IDR, the web page will be updated.
| Inspection Type | Document Type | Inspection Date | Pages | IDR Pending |
|---|---|---|---|---|
| Other | No Deficiencies Cited | 9/29/2020 | No | |
| ACLS Follow-up | Statement of Deficiency with Plan of Correction | 4/16/2020 | 20 | No |
| ACLS Follow-up | Statement of Deficiency | 4/16/2020 | 19 | No |
| ACLS Complaint | Statement of Deficiency with Plan of Correction | 1/17/2020 | 60 | No |
| ACLS Complaint | Statement of Deficiency | 1/17/2020 | 60 | No |
| ACLS Complaint and Follow-up | Statement of Deficiency | 11/15/2019 | 339 | No |
| ACLS Annual and Complaint | Statement of Deficiency with Plan of Correction | 7/26/2019 | 82 | No |
| ACLS Annual and Complaint | Statement of Deficiency | 7/26/2019 | 82 | No |
| ACLS Annual | No Deficiencies Cited | 8/23/2017 | No | |
| ACLS Annual and Complaint | No Deficiencies Cited | 3/3/2016 | No | |
| ACLS Annual | Statement of Deficiency with Plan of Correction | 10/29/2015 | 10 | No |
| ACLS Annual | Statement of Deficiency | 10/29/2015 | 10 | No |
| Constr Biennial Follow-up | No Deficiencies Cited | 10/3/2019 | 0 | No |
| Constr Biennial Follow-up | Statement of Deficiency | 9/12/2019 | 2 | No |
| Constr Biennial | Statement of Deficiency with Plan of Correction | 7/18/2019 | 11 | No |
| Constr Biennial | Statement of Deficiency | 7/18/2019 | 11 | No |
| Constr Biennial Follow-up | No Deficiencies Cited | 8/21/2017 | 0 | No |
| Constr Biennial Follow-up | Statement of Deficiency with Plan of Correction | 7/13/2017 | 3 | No |
| Constr Biennial Follow-up | Statement of Deficiency | 7/13/2017 | 1 | No |
| Constr Biennial | Statement of Deficiency with Plan of Correction | 6/2/2017 | 10 | No |
| Constr Biennial | Statement of Deficiency | 6/2/2017 | 10 | No |
| Constr Biennial Follow-up | No Deficiencies Cited | 9/25/2015 | 0 | No |
| Constr Biennial Follow-up | Statement of Deficiency | 7/29/2015 | 2 | No |
| Constr Biennial Follow-up | Statement of Deficiency with Plan of Correction | 7/29/2015 | 2 | No |
| Constr Biennial Follow-up | Statement of Deficiency with Plan of Correction | 6/25/2015 | 2 | No |
| Constr Biennial | Statement of Deficiency | 6/18/2015 | 2 | No |
| Constr Biennial | Statement of Deficiency | 4/9/2015 | 7 | No |
| Constr Biennial | Statement of Deficiency with Plan of Correction | 4/9/2015 | 7 | No |
Star Ratings are based on the results of DHSR inspections and some inspections by the County Department of Social Services (DSS).
| Stars | Score | Issue Date | Merits | Demerits | Inspection Type | ||
|---|---|---|---|---|---|---|---|
| (ZERO STARS) | (0) | 27 | 5/29/2020 | 10 | 0 | Follow-up | View Worksheet |
| (ZERO STARS) | (0) | 17 | 3/5/2020 | 0 | 15.5 | Complaint | View Worksheet |
| (ZERO STARS) | (0) | 32.5 | 3/5/2020 | 5 | 47 | Follow-up | View Worksheet |
|
(1) | 74.5 | 10/15/2019 | 0 | 25.5 | Annual | View Worksheet |
|
(4) | 102.5 | 10/20/2017 | 2.5 | 0 | Annual | View Worksheet |
|
(3) | 100.25 | 3/8/2016 | 1.25 | 0 | Follow-up | View Worksheet |
|
|
(3) | 99 | 11/24/2015 | 2.5 | 3.5 | Annual | View Worksheet |
|
|
(4) | 104.5 | 6/26/2013 | 4.5 | 0 | Annual | View Worksheet |
|
|
(3) | 102.25 | 9/12/2012 | 1.25 | 0 | Follow-up | View Worksheet |
|
|
(3) | 101 | 6/7/2012 | 4.5 | 3.5 | Annual | View Worksheet |
|
|
(3) | 93.5 | 4/25/2011 | 10 | 0 | Follow-up | View Worksheet |
|
(2) | 83.5 | 2/28/2011 | 2.5 | 19 | Annual | View Worksheet |
|
|
(3) | 102.5 | 10/26/2009 | 4.5 | 2 | Annual | View Worksheet |
Penalties imposed during the last 36 months are listed.
| Penalty Issued Date | Penalty Amount | Penalty Type | Reason for Issuance | Current Status | Amount Paid | Date of Payment | |
|---|---|---|---|---|---|---|---|
| Rule Cited | Nature of Violation | ||||||
| 10/1/2020 | $14,000.00 | A1 | 10A NCAC 13F .0901 (b) Personal Care and Supervision; G.S. 131D-21(4) Declaration of Residents' Rights | Facility failed to provide supervision according to residents' assessed needs and current symptoms for 5 of 9 sampled residents (#1, #4, #10, #11 and #13) including a resident who eloped from the Special Care Unit (SCU) without staff's knowledge, resulting in a fractured hip (#13), a confused resident who consumed an unknown substance (#11), two residents who displayed agitation and aggressive behaviors and physically abused other residents (#4 and #10), and a resident with altercations and falls (#1). | Appealed 10/30/2020 | ||
| 10/1/2020 | $3,500.00 | A1 | G.S. 131D-25 Declaration of Residents' Rights; G.S. 131D-21(4) Declaration of Residents' Rights | Administrator failed to assure the management, operations, and policies of Facility were implemented and rules were maintained for personal and other staffing, Special Care Unit staff, personal care and supervision, health care, resident rights, medication administration, reporting of accidents and incidents, settlement of cost of care, Ach infection prevention requirements and Ach medication aides; training and competency. | Appealed 10/30/2020 | ||
| 10/1/2020 | $1,000.00 | A2 | 10A NCAC 13F .0909 Residents' Rights; G.S. 131D-21(4) Declaration of Residents' Rights | Facility failed to assure residents' rights for 10 of 15 residents (Residents #1, #2 #11, #12, #14, #15, #16, #17, #18, and #20) regarding staff yelling at a resident (#12), a staff (Staff G, personal care aide (PCA)) hitting a resident (#1), a resident being forced to sit in the hallway all day due to not having portable oxygen (#2) and residents receiving injuries and bruises after being hit by other residents (#11, #14, #15, #16, #17, #18, and #20). | Appealed 10/30/2020 | ||
| 10/1/2020 | $4,000.00 | A1 | 10A NCAC 13F .0901 (b) Personal Care and Supervision; G.S. 131D-21(4) Declaration of Residents' Rights | Facility failed to provide supervision according to residents' assessed needs and current symptoms for 5 of 9 sampled residents (#1, #4, #10, #11 and #13) including a resident who eloped from the Special Care Unit (SCU) without staff's knowledge, resulting in a fractured hip (#13), a confused resident who consumed an unknown substance (#11), two residents who displayed agitation and aggressive behaviors and physically abused other residents (#4 and #10), and a resident with altercations and falls (#1). | Appealed 10/30/2020 | ||
| 10/1/2020 | $2,000.00 | A1 | 10A NCAC 13F .0909 Residents' Rights; G.S. 131D-21(4) Declaration of Residents' Rights | Facility failed to assure 3 of 6 sampled residents (Residents #8, #9 and #10) in the Special Care Unit (SCU) were free of physical abuse and neglect by three staff (Staff A, Staff B, and Staff C) encouraging the residents to fight each other, resulting in one resident being strangled with her face turning red (Resident #8) while staff recorded and shared the video through social media; a staff (Staff A) pushed a resident into a room, turned off the light and yelled to the resident to go to sleep, and then closed the door leaving the resident in the dark room (Resident #8); and a resident being left on the floor while staff recorded a second video and shared the video through social media (Resident #10). [Refer to Tag 338, 10A NCAC 13F .0909 of Residents' Rights (Type A1 Violation). | Appealed 10/30/2020 | ||