Adult Care Home Rating Worksheet

Facility Name: Forsyth Village
County: Forsyth
License #: HAL-034-084
FID: 920396

This facility is rated:

2

* Facilities must obtain two
consecutive 100 point or
greater annual surveys to
earn a Four Star Rating.

 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 15.50 100.00 87.00

Reason for Rating Issuance:

Annual Inspection    Date: 12-Aug-16
Merit Points Earned Demerit Points Issued Statute or Rule Category Measurement Evaluated
  2.00 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): 1 x 2.0 = 2.00)
    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 = _ )
    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 = _ )
  8.00 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): 4 x 2.0 = 8.00)
  2.00 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): 1 x 2.0 = 2.00)
    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 = _ )
    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 = _ )
    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 = _ )
    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 = _ )
    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 = _ )
  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)
    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 = _ )
    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 = _ )
    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 = _ )
    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 = _ )
    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.