Inspection Reports for Oak Hill Assisted Living Community

The Adult Care Licensure Section conducted a follow-up survey on 08/27/25 and 08/28/25 to verify correction of a previous Type B violation related to healthcare referral and follow-up.

The facility failed to ensure referral and follow-up to meet the routine healthcare needs of 1 of 5 sampled residents due to not notifying the provider about a seizure medication (Valtoco nasal spray) that was not available for administration. The medication was not delivered due to high co-pay costs, and communication failures occurred between the facility, pharmacy, providers, and family.

Annual survey conducted by the Adult Care Licensure Section from 05/28/25 to 05/30/25 to assess compliance with regulations including physical environment, health care, medication administration, and medication storage.

The facility failed to ensure exit doors had audible alarms at all times for residents with wandering behavior, resulting in a resident exiting unnoticed and sustaining injuries. The facility also failed to ensure timely health care referrals and follow-up for three residents, including failure to notify PCPs of incidents and arrange podiatry and cardiology care. Additionally, medication administration errors were found with missed doses of Warfarin, and medication carts were observed unlocked when unattended.

The Adult Care Licensure Section conducted a follow-up survey from 02/02/22 to 02/07/22 to verify correction of previous deficiencies.

The facility failed to meet minimum staffing requirements on multiple shifts, failed to ensure hot foods were served hot to quarantined residents, failed to administer medications as ordered and on time for multiple residents, had inaccurate medication administration records with multiple omissions, failed to secure medication storage properly, and failed to ensure staff wore appropriate PPE when caring for COVID-19 positive residents. Additionally, a medication aide was found administering medications without completing required state training and competency validation.

The Adult Care Licensure Section conducted an annual survey of Oak Hill Living Center from November 16, 2021 through November 17, 2021 to assess compliance with health care and medication administration regulations.

The facility failed to meet health care needs of residents, including failure to notify the primary care provider or call 911 for a resident with irregular breathing and lethargy, and failure to schedule a urology appointment for another resident. Medication administration errors were observed in 3 of 5 residents, including failure to ensure residents swallowed all medications and improper insulin pen priming. Additionally, the facility failed to secure crushed medications properly, posing a safety risk.

The Adult Care Licensure Section conducted a complaint investigation and a COVID-19 focused Infection Control survey with an onsite visit on 12/10/20 to 12/11/20.

The facility failed to ensure implementation of CDC, North Carolina Department of Health and Human Services, and local health department guidance regarding designating staff to work only with residents diagnosed with COVID-19 and proper use of full PPE including gowns, gloves, face masks, and face shields. Staff were observed not following PPE protocols, and staff were not designated to work exclusively with COVID-19 positive residents, increasing risk of transmission.

The visit was complaint-related, focusing on infection control practices during the COVID-19 pandemic. The complaint investigation found failures in staff PPE use and cohorting practices.

The Adult Care Licensure Section conducted an annual survey and complaint investigation on 10/18/17 - 10/20/17 and 10/23/17-10/26/17. The complaint investigation was initiated on 09/20/17 by Harnett County Department of Social Services.

The facility had multiple deficiencies including failure to maintain cleanliness and repair in dining and kitchen areas, failure to replace damaged blinds compromising resident privacy, incomplete tuberculosis testing for residents, failure to meet health care needs including medication administration and follow-up appointments, failure to treat residents with dignity and respect, and failure to ensure medication aides completed required training.

Complaint investigation initiated on 09/20/17 by Harnett County Department of Social Services related to multiple resident care and facility maintenance issues.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure. This was a Construction Section Biennial Survey.

Multiple deficiencies were found including damaged interior doors and walls, improperly stored oxygen bottles presenting hazards, fire safety equipment and doors not maintained in safe operating condition, gaps in fire resistant ceilings, electrical receptacles not providing shock protection, and non-functioning exhaust fans in specified areas.

The inspection was conducted as a complaint investigation to assess the facility's conformance with applicable licensing rules and building codes.

The facility was found to have multiple deficiencies including damaged and unclean walls, floors, and furnishings; failure to maintain electrical emergency and safety equipment in safe operating condition; fire safety doors that do not close and latch properly; and plumbing issues such as inadequate gap between the ice machine drain and floor drain.

This was a complaint investigation conducted by Billy S. Bryant and Frank Stricland on 10/16/2015. The report does not state substantiation status.