Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamance Health Care Center during CMS and state inspections, most recent first.
A deficiency was identified when multiple rooms were found with dead and active bugs, including roaches, despite ongoing pest control treatments. Staff interviews revealed that pest issues had persisted for months, with some staff using personal sprays due to ineffective pest control services. Clutter and improper food storage in resident rooms contributed to the problem, and repeated reports to management did not result in effective resolution.
Surveyors observed multiple resident rooms with sticky, dirty floors, old food and paper debris, detached or broken baseboards, and air conditioning units filled with dust, debris, and broken parts. The Housekeeping Director, Maintenance Director, and DON confirmed that cleaning and maintenance were not performed according to facility protocols, resulting in unaddressed environmental concerns throughout the facility.
A resident with impaired vision and a diagnosis of cataracts did not receive a timely ophthalmologist consultation for cataract extraction surgery as ordered. The optometrist's recommendation and physician order were not communicated to the staff responsible for scheduling, resulting in a delay until the resident repeatedly requested assistance and a new order was placed. Staff interviews confirmed a lack of awareness and a breakdown in the process for managing outside consultant recommendations.
Surveyors found that nourishment refrigerators were not properly cleaned, temperature logs were incomplete, and residents' food items were not consistently labeled or dated. Staff interviews revealed unclear responsibilities among dietary, nursing, and housekeeping teams regarding food labeling, temperature monitoring, and cleaning of the refrigerators.
A resident with limited mobility and cognitive intactness was pulled backwards in a geriatric wheelchair by a nurse aide, despite expressing discomfort and feeling undignified. The aide cited misaligned wheels as the reason but had not reported the issue, and facility leadership was unaware of the problem. This action was recognized by leadership as not respecting the resident's dignity.
A resident with severe cognitive impairment and parkinsonism, dependent on staff for ADL care, was found with excessively long and dirty fingernails despite care plans requiring staff assistance. Staff interviews revealed confusion over responsibility for nail care, and the DON confirmed that nails should have been trimmed and cleaned as needed.
A blind resident with a history of aggression threw a can of peaches at another resident, causing a laceration. The incident occurred after the blind resident believed his food was eaten by the other resident. The injured resident refused hospital treatment, and the facility classified the event as abuse.
The facility's QA process failed to implement, monitor, and revise action plans for multiple surveys, resulting in repeated deficiencies in areas such as Quality of Care, Bowel/Bladder Incontinence, Catheter, UTI, and medication management. Specific incidents included inadequate communication among staff, improper assessment and monitoring of residents, and failures in wound and catheter care.
The facility failed to store medications according to manufacturer's instructions, label medications with required information, and date an opened vial of injectable medication. Observations revealed improper storage of eye drops, loose tablets in a med cart, unlabeled Linzess capsules and inhalation solution, and an undated vial of Tuberculin PPD.
A resident with chronic diarrhea and a complex medical history experienced multiple episodes of nausea and vomiting. The facility staff failed to ensure effective communication among themselves and with providers, leading to a lack of timely intervention and the resident's eventual hospitalization for severe sepsis and a small bowel obstruction.
The facility failed to document the Advance Directives (code status) for a resident who was readmitted and assessed as cognitively intact. Despite the resident's care plan indicating a Full Code status, there was no active order in the EHR. Staff interviews confirmed that the admitting nurse missed entering the code status during the readmission process.
The facility failed to prevent a urinary catheter bag from touching the floor for a resident with a history of UTIs and pressure ulcers. Despite staff education on proper catheter bag positioning, multiple observations showed the bag either touching or partially lying on the floor, increasing the risk of infection.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in 7 out of 94 resident rooms, with pest activity observed across all four halls. Monthly and special pest control service reports from August 2024 through March 2025 documented repeated treatments for roach, ant, and fly activity in resident rooms and common areas, but no changes to the service were recommended despite ongoing pest issues. There was no pest control visit in January 2025, and subsequent reports continued to note pest activity, particularly in specific rooms. Direct observations on April 28, 2025, revealed dead and active bugs, including roaches, in multiple resident rooms, particularly in areas such as bathrooms, under air conditioning units, behind nightstands, and around closets and baseboards. In one room, clutter and improperly stored food and personal items were noted to contribute to the pest problem. Staff interviews confirmed that the pest issue had been ongoing since 2024, with some staff resorting to using their own sprays due to the ineffectiveness of the contracted pest control services. Staff also reported that clutter and food storage practices by residents exacerbated the problem, and that these issues had been repeatedly reported to management without resolution. Housekeeping and maintenance staff acknowledged the presence of pests and described challenges in cleaning and pest control due to resident behaviors and limited staffing. The Housekeeping Director and Maintenance Director both confirmed that pest control companies had been contacted regularly, and that certain rooms required special attention due to hoarding and clutter. Despite these efforts, the visibility of pests persisted, and the Director of Nursing confirmed that environmental concerns in resident rooms remained unaddressed at the time of the survey.
Failure to Maintain Cleanliness and Environmental Safety in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of unclean and poorly maintained resident rooms across all facility halls. Surveyors found sticky floors with brown substances, old food, and paper products under nightstands and beds, stained and dirty surfaces, and strong urine odors in several rooms. Additionally, baseboards were found to be detached, broken, or with holes exposing sheetrock, and air conditioning units in numerous rooms had significant dust and debris buildup, with some units containing food, paper products, and broken slats with sharp edges. These conditions were directly observed by surveyors during their inspection of 13 resident rooms. Interviews with the Housekeeping Director and Maintenance Director confirmed that cleaning and maintenance tasks were not performed according to the facility's established checklists and responsibilities. The Housekeeping Director acknowledged that some rooms had not been cleaned as required, and the Maintenance Director confirmed the presence of dirty air conditioning units and unrepaired baseboards. The DON also confirmed awareness of the environmental concerns and the lack of proper cleaning and maintenance in resident rooms at the time of the survey.
Failure to Schedule Ophthalmologist Consultation for Cataract Surgery
Penalty
Summary
A deficiency occurred when the facility failed to schedule an ophthalmologist consultation for cataract extraction surgery as ordered for a resident with impaired vision. The resident, who was cognitively intact and used glasses, had a diagnosis of age-related cataracts in both eyes, with the right eye causing blurred vision and increasing fall risk. An optometrist recommended in November that the facility select a local ophthalmologist for cataract extraction, and the Medical Director initialed the consultation. However, there was no documented appointment with an ophthalmologist or follow-up on the recommendation until a new order was placed in March of the following year. Interviews with staff revealed that the optometrist's recommendation was not communicated to the appropriate personnel responsible for scheduling appointments. The Unit Manager, Unit Secretary, and Director of Nursing were all unaware of the initial referral, and the new Social Worker stated that the system for managing outside consultant recommendations was still being developed. The resident reported having to repeatedly request assistance before finally being seen by an ophthalmologist. The deficiency was attributed to a breakdown in communication and follow-up regarding the optometrist's recommendation and physician order.
Failure to Maintain Cleanliness and Proper Food Labeling in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain proper food storage and sanitation practices in two of three nourishment refrigerators located on the Teal and Mauve 1 hallways. Observations revealed that temperature logs for the refrigerators and freezers were not documented for several days, and the interiors of the refrigerators contained water, yellowish-red stains, and light yellowish stains. Additionally, there were multiple instances of unlabeled and undated food items, including a protein shake bottle, a bag of raw seafood mix, and an open fast-food milkshake container. The raw seafood mix was identified as belonging to a resident who had ordered it from a grocery store, but it was not labeled or dated as required. Interviews with staff indicated confusion and lack of clarity regarding responsibilities for labeling food, recording temperatures, and cleaning the refrigerators. The Dietary Manager stated that nursing staff were responsible for labeling residents' food, while dietary staff were to record temperatures. Housekeeping staff were reported to clean the nourishment refrigerators weekly, but the Housekeeping Manager clarified that their staff only cleaned the exterior and not the inside of the refrigerators. The Administrator confirmed that all three departments—Dietary, Nursing, and Housekeeping—were responsible for keeping the refrigerators clean and ensuring that no raw food was stored in them, and that all residents' foods should be labeled with names and dates.
Resident Dignity Compromised by Improper Wheelchair Handling
Penalty
Summary
A deficiency occurred when a nurse aide (NA) pulled a resident's geriatric wheelchair backwards down the hall from the nurses' station to the dining room, a distance of approximately 50 yards. The resident, who had a history of cerebral infarction resulting in limited range of motion on one side and was dependent on staff for wheelchair locomotion, was cognitively intact and reported feeling undignified and as if she was being treated like a 'crazy person.' The resident expressed that she did not want to go to the dining room and specifically disliked being pulled backwards, noting that this NA was the only staff member who moved her in this manner. The NA stated that she pulled the wheelchair backwards because the wheels were misaligned, making it difficult to push the chair forward as trained. However, she had not reported the issue to maintenance, and there were no work orders on file to repair the wheelchair. Facility leadership, including the Nurse Consultant and Administrator, were unaware of the wheelchair's condition and confirmed that staff were expected to push, not pull, wheelchairs. The act of pulling the wheelchair backwards was acknowledged by facility leadership as undignified treatment.
Failure to Trim and Clean Dependent Resident's Fingernails
Penalty
Summary
A deficiency was identified when a resident, admitted with adult failure to thrive and parkinsonism and assessed as severely cognitively impaired, was observed to have fingernails that were excessively long, measuring approximately three-fourths to one inch. The resident was dependent on staff for activities of daily living (ADL) care, including personal hygiene, and required substantial to maximum assistance. During observations, the resident's fingernails were noted to have black debris and food particles underneath, particularly after eating with her hands. The care plan indicated the need for staff assistance with ADLs due to the resident's cognitive and physical limitations. Interviews with staff revealed that nurse aides were responsible for trimming fingernails unless the resident had diabetes, in which case the nurse would perform the task. The assigned nurse aide acknowledged noticing the long fingernails and reported it to the nurse, but the nurse had not observed the issue. The Director of Nursing confirmed that fingernails should be checked and trimmed as needed during showers or bed baths, and that the resident's nails should have been trimmed and cleaned by staff. The failure to provide this care resulted in the resident having untrimmed and unclean fingernails despite being dependent on staff for hygiene.
Resident-to-Resident Abuse Involving a Blind Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident struck another with a can of peaches. The incident involved two residents, one of whom was blind and had a history of verbal behavioral symptoms and aggression. The blind resident, believing that his food had been eaten by his roommate, threw a can of peaches in frustration, which resulted in the can striking the other resident on the head, causing a laceration. The resident who was struck had a recent admission to the facility and was cognitively intact with no behaviors noted. The incident occurred when the blind resident, who was unable to see where he was throwing the object, acted out of frustration after suspecting his food had been taken. The altercation led to the injured resident sustaining a laceration above the right eye, which was treated on-site after the resident refused to go to the hospital. Interviews with staff and residents revealed that the blind resident had a history of being easily angered and verbally aggressive, with a care plan that noted behaviors related to past substance abuse. The incident was classified as resident abuse, and the facility's response included separating the residents and notifying relevant authorities. However, the deficiency highlights a failure to prevent resident-to-resident abuse, particularly given the known behavioral history of the blind resident.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's quality assurance (QA) process failed to implement, monitor, and revise action plans developed for multiple recertification and complaint investigation surveys. This resulted in repeated deficiencies in areas such as Quality of Care, Bowel/Bladder Incontinence, Catheter, UTI, and the labeling and storage of drugs and biologicals. Specific incidents included a resident with chronic diarrhea who experienced multiple episodes of nausea and vomiting without effective communication among staff and providers, and a diabetic resident whose need for daily bedside blood sugar monitoring was not assessed properly. Additionally, a resident with a seizure disorder had their medication dosage decreased without proper communication, leading to a seizure, hospitalization, and intubation. In another incident, the facility failed to identify the seriousness of third-degree facial burns in a resident, resulting in inadequate monitoring and medical intervention until emergency services arrived. The resident suffered severe burns, cardiac arrest, and ultimately expired. There were also failures in conducting full body skin assessments, leading to a resident being sent to the emergency department with significant swelling, excoriations, pressure ulcers, and an embedded identification band. Another resident did not receive consistent wound care and treatment order changes after a podiatry visit. The facility also failed to manage urinary catheter care properly, including preventing a catheter bag from touching the floor and addressing a resident's use of a condom catheter without a physician's order. Medication management issues were also noted, such as improper storage, labeling, and disposal of medications. These deficiencies were observed across multiple surveys, indicating a pattern of the facility's inability to sustain an effective quality assurance program.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications in accordance with the manufacturer's storage instructions on two of four medication carts. Specifically, neomycin, polymyxin B, and 0.1% dexamethasone ophthalmic suspension eye drops were stored lying on their side instead of upright on the Teal South Med Cart. Additionally, two bottles of 1% prednisone acetate ophthalmic suspension eye drops were stored lying on their side in the Mauve 2 South Med Cart. Staff interviews revealed that the nurses were unaware of the proper storage requirements for these medications. Furthermore, five loose, unidentified tablets were found in the drawer of the Teal South Med Cart, which were not discarded as required by the facility's protocol for cleaning medication carts after each shift. The facility also failed to label medications with the minimum required information, including the resident's name, on two of four medication carts. Two opened bottles of Linzess capsules on the Teal South Med Cart were not labeled with the resident's name, and one of these bottles was expired. Similarly, a vial of ipratropium bromide/albuterol inhalation solution on the Mauve 2 South Med Cart was not labeled with the resident's name. Staff interviews confirmed that the nurses were aware of the labeling requirements but had not adhered to them in these instances. Additionally, the facility did not date a vial of injectable medication to determine its shortened expiration date in one of two medication storage rooms. An opened multi-dose vial of Tuberculin PPD injectable medication in the Teal Med Room was not labeled with the date it was opened, contrary to the manufacturer's instructions that it should be discarded after 30 days. The Unit Manager confirmed that the vial should have been dated when opened and discarded after 30 days if not used.
Failure to Ensure Effective Communication Among Staff and Providers
Penalty
Summary
The facility failed to ensure effective communication among staff and providers when a resident with chronic diarrhea began experiencing multiple episodes of nausea and vomiting. Despite the resident's complex medical history, including chronic osteomyelitis, heart conditions, and gastrointestinal issues, the staff did not adequately communicate these acute changes. The resident's care plan noted the risk for gastrointestinal problems and dehydration, but the staff did not take timely action to address the new symptoms or adjust the resident's medications accordingly. The resident was prescribed multiple medications, including antibiotics and digestive aids, which could have contributed to her symptoms. The staff administered the antibiotics Daptomycin and Ertapenem, despite a flagged allergy to carbapenems, without thoroughly investigating the potential risks. The resident's bowel log indicated frequent loose stools, but this information was not effectively communicated to the nurse practitioners or physicians, leading to a lack of timely intervention. Interviews with staff revealed that the resident's symptoms of nausea and vomiting were not consistently reported or addressed. The resident's condition deteriorated over several days, culminating in a hospital transfer where she was diagnosed with severe sepsis and a small bowel obstruction. The lack of effective communication and timely intervention contributed to the resident's worsening condition and eventual hospitalization.
Failure to Document Advance Directives in Resident's Record
Penalty
Summary
The facility failed to have Advance Directives (code status) documented in the resident's record for one resident reviewed for Advance Directives. Resident #44, who was cognitively intact, was readmitted to the facility and had a care plan indicating a Full Code status. However, there was no active order for code status in the resident's Electronic Health Record (EHR). Interviews with various staff members, including a nurse, social worker, RN supervisor, Nurse Practitioner, and the Director of Nursing (DON), confirmed that the code status was not documented in the EHR as required. The RN supervisor and DON indicated that the admitting nurse missed entering the code status during the readmission process, resulting in the absence of a physician's order for the resident's code status. The social worker mentioned that the Advance Directives were discussed with the resident during the baseline care plan meeting at readmission, and there was no change in the resident's code status. However, the social worker did not notify the nursing staff since there was no change. The RN supervisor and Nurse Practitioner both stated that the admitting nurse should review and enter the code status in the EHR, but this step was missed. The DON confirmed that the code status should have been entered in the resident's medical record at admission or readmission, but it was overlooked during the recent hospitalization readmission process.
Failure to Prevent Urinary Catheter Bag from Touching the Floor
Penalty
Summary
The facility failed to keep a urinary catheter bag from touching the floor, which increases the risk of infection for a resident with a history of urinary tract infections (UTIs). Resident #129, who has Stage 4 pressure ulcers and a history of repeated UTIs, was observed multiple times with her urinary catheter bag either touching or partially lying on the floor. These observations occurred on several occasions, including when the resident was lying in bed. The resident's care plan indicated the need for a urinary catheter due to her wounds, and her most recent Minimum Data Set (MDS) assessment confirmed she was cognitively intact but dependent on staff for most Activities of Daily Living (ADLs). Despite this, the catheter bag was repeatedly found in an improper position, increasing the risk of infection. During an interview, Nurse #5 acknowledged that the catheter bag should not be on the floor and attributed the issue to the resident lowering her electric bed, which she could control independently. The resident herself was unaware that lowering her bed could cause the catheter bag to touch the floor. The facility's Registered Nurse (RN) Supervisor confirmed that staff were educated to ensure catheter bags were not on the floor and that beds should be raised to prevent this. However, the repeated observations of the catheter bag on the floor indicate a failure to consistently follow these guidelines, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oak Manor - Burlington | 1 mi | — | 3 | 0 |
| Peak Resources - Alamance, Inc | 1.6 mi | — | 3 | 0 |
| Edgewood Place At The Village At Brookwood | 3.4 mi | — | 0 | 0 |
| Liberty Commons Nursing & Rehabilitation Center Of | 5.9 mi | — | 2 | 0 |
| Compass Healthcare And Rehab Hawfields, Inc. | 6.6 mi | — | 2 | 0 |
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