Adult Care Home Rating Worksheet
Facility Name:
Alpha Care One Assisted Living
County: Pitt
License #: HAL-074-046
FID: 990707
This facility is rated: * Facilities must obtain two |
Star Rating Score Key | ||
|---|---|---|---|
| Four Stars | = 100 points or greater | ||
| Three Stars | = 90.9 - 99.9 points | ||
| Two Stars | = 80.0 - 89.9 points | ||
| One Star | = 70.00 - 79.9 points | ||
| Zero Stars | = 69.9 and lower | ||
| Total Merit Points | Total Demerit Points | Base Points | Facility Rating Score |
|---|---|---|---|
| Base Points - Total Demerits + Total Merits = Rating Score | |||
| 2.50 | 3.50 | 100.00 | 99.00 |
Reason for Rating Issuance:
| Annual Inspection Date: 04/20/2023 |
| Merit Points Earned | Demerit Points Issued | Statute or Rule Category | Measurement Evaluated |
|---|---|---|---|
| 13F/G.0300 - Physical Plant Requirements | For each citation of noncompliance with the rules related to physical plant, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) | ||
| 13F/G.0700 - Admission & Discharge Requirements | For each citation of noncompliance with the rules related to admission and discharge, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F/G.0800 - Resident Assessment & Care Plan | For each citation of noncompliance with the rules related to resident assessment & care plan, the facility will receive a demerit of 2 points. (citiation(s): _ x 2.0 = _ ) |
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| 13F/G.0900 - Resident Care & Services | For each citation of noncompliance with the rules related to resident care & services, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F/G.1000 - Medication Management | For each citation of noncompliance with the rules related to medication management, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F.1300 - Special Care Units for Alzheimer's & Related Disorders (ACH Only) | For each citation of noncompliance with the rules related to special care units for Alzheimer's & related disorders, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F.1400 - Special Care Units for Mental Health Disorders (ACH Only) | For each citation of noncompliance with the rules related to special care units for mental health disorders, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F/G.1500 - Use of Physical Restraints & Alternatives | For each citation of noncompliance with the rules related to physical restraints and alternatives, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| G.S.131D-21 - Residents' Rights | For each citation of noncompliance with the statutes related to residents' rights, the facility will receive a demerit of 2 points. (citation(s): _ x 2.0 = _ ) |
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| 13F/G.0215 - Type A Violation | For each citation of noncompliance, which results in a Type A violation, the facility will receive a demerit of 10 points. (citation(s): _ x 10.0 = _ ) |
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| 3.50 | 13F/G.0215 - Type B Violation | For each citation of noncompliance, which results in a Type B violation, the facility will receive a demerit of 3.5 points. (citation(s): 1 x 3.5 = 3.50) |
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| 13F/G.0215 - Type B Violation Uncorrected | For each Type B violation that is uncorrected, the facility will receive a demerit of 3.5 points. (Type B violations uncorrected: _ x 3.5 = _ ) |
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| 13F/G.0214 Suspension of Admissions | If the facility's admissions are suspended, the facility will receive a demerit of 10 points. | ||
| 13F/G.0212 Notice of Revocation of License Issued | If a notice of revocation of license is issued, the facility will receive a demerit of 31 points. | ||
| 13F/G.1603 - Citation of noncompliance corrected or Type B Violation correction | For each citation of non-compliance of Type B Violation correction with rules related to 10A NCAC 13F .1603, which is corrected, the facility will receive a merit of 1.25 points. (citation(s): _ x 1.25 = _ ) |
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| 13F/G.0215 - Type A Violation corrected | For each citation, which is corrected, which previously resulted in a Type A violation, the facility will receive a merit of 2.5 points. (citation(s): _ x 2.5 = _ ) |
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| 13F/G.0215 - Uncorrected Type B Violation corrected | For each uncorrected Type B violation that is corrected, the facility will receive a merit of 1.25 points. (Type B violations corrected: _ x 1.25 = _ ) |
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| Removal of Suspension of Admissions | If the facility has a Suspension of Admissions removed, the facility will receive a merit of 5 points. | ||
| 2.50 | G.S.131D-10(d)(2) - Participation in a Quality Improvement Program | If the facility participates in a quality improvement program approved by DHHS, it will receive a merit of 2.5 points. | |
| G.S.131E - NC NOVA designation awarded | If the facility has been awarded NC NOVA designation, it will receive a merit of 2.5 points. | ||
| Emergency power back-up | The facility will receive 2 merit point for new (On or after 07/03/2008) emergency power arrangements and 1 point for existing power arrangements. | ||
| Automatic sprinklers | The facility will receive 3 merit points for newly (On or after 07/03/2008) installed sprinklers and 2 points for existing sprinklers. | ||
| 13F/G .0400 Staff Qualifications | For each citation of noncompliance with the rules related to physical plant, the facility shall receive a demerit of 2 points. (citation(s):______x 2.0 =_________) | ||
| 13F .1800/13G .1700 Infection Prevention and Control | For each citation of noncompliance with the rules related to physical plant, the facility shall receive a demerit of 2 points. (citation(s):______x 2.0 =_________) | ||
| G.S. 131D-34 Type A1 Violation | For each citation of noncompliance, which results in a Type A1 violation, the facility will receive a demerit of 10 points. (citation(s):______x 10 =_________) | ||
| G.S. 131D-34 Type A2 Violation | For each citation of noncompliance, which results in a Type A2 violation, the facility will receive a demerit of 10 points. (citation(s):______x 10 =_________) | ||
| G.S. 131D-34 Uncorrected (Unabated) Type A1 Violation | For each citation of noncompliance, which results in a Type A1 violation that is uncorrected, the facility will receive a demerit of 10 points. (citation(s):______x 10 =_________) | ||
| G.S. 131D-34 Uncorrected (Unabated) Type A2 Violation | For each citation of noncompliance, which results in a Type A2 violation that is uncorrected, the facility will receive a demerit of 10 points. (citation(s):______x 10 =_________) | ||
| G.S. 131D-2.7 Provisional License issued - 10.0 demerit points. | If the facilities license is downgraded to a Provisional License, the facility will receive a demerit of 10 points. | ||
| G.S. 131D-2.7 Summary Suspension issued - 31.0 demerit points. | If a notice of summary suspension of license is issued, the facility will receive a demerit of 31 points. | ||
| Corrected citation(s) of non-compliance in statute and rule areas of 10A NCAC 13F/G .1603 | For each citation of non-compliance correction with rules related to 10A NCAC 13F/G .1603, which is corrected, the facility will receive a merit of 1.25 points. (citation(s):______x 1.25 =_________) | ||
| G.S. 131D-34 Corrected Type B Violation(s) in statute and rule areas of 10A NCAC 13F/G .1603 | For each Type B Violation correction with rules related to 10A NCAC 13F/G .1603, which is corrected, the facility will receive a merit of 1.75 points. (citation(s):______x 1.75 =_________) | ||
| G.S. 131D-34 Correction of previously Uncorrected (Unabated) Type A1 Violation(s) | For each uncorrected Type A1 violation that is corrected, the facility will receive a merit of 5.0 points. (citation(s):______x 5.0 =_________) | ||
| G.S. 131D-34 Correction of previously Uncorrected (Unabated) Type A2 Violation(s) | For each uncorrected Type A2 violation that is corrected, the facility will receive a merit of 5.0 points. (citation(s):______x 5.0 =_________) | ||
| G.S. 131D-2.7 Provisional License lifted (full license restored) + 5.0 merit points. | If the facility has a Provisional License restored to a full license, the facility will receive a merit of 5 points. | ||
| Resident Council + 0.5 merit points. | If the facility has an ongoing resident council which meets at least quarterly, it will receive a merit of 0.5 points. | ||
| Family Council + 0.5 merit points. | If the facility has an ongoing family council which meets at least quarterly, it will receive a merit of 0.5 points. | ||
| Infection Control in Long Term Care Course (UNC SPICE) + 0.5 merit points. | If the facility's designated on-site staff member who directs the facility's infection control activities in accordance with G.S. 131D-4.4A every two years, the facility shall receive a merit of 0.5 points. | ||
| Resident and Family Satisfaction Surveys + 1.0 merit points. | If the facility engages the services of a third-party company to conduct resident and family satisfaction surveys at least annually for the purpose of of improving resident care, the facility shall receive a merit of 1.0 points. |