Inspection Reports for
Carolina Village
600 Carolina Village Road Hendersonville, NC 28792, Hendersonville, NC, 28792
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 5, 2025
Visit Reason
Report of a Construction Section Biennial Follow Up Survey conducted to verify correction of previous deficiencies.
Findings
Deficiencies have been corrected. No further action is necessary.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 25, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 02/25/25 to 02/26/25 to assess compliance with medication administration and self-administration regulations at Carolina Village.
Findings
The facility failed to ensure that medication aides observed residents taking their medications, resulting in medications being left unattended in a resident's room. Additionally, the electronic medication administration record (eMAR) was inaccurate for one resident, and the facility failed to have a physician's order for self-administration of certain oral and topical medications for the resident.
Deficiencies (3)
Failed to ensure medication aide observed resident taking all prepared medications, resulting in medications left unattended on the resident's nightstand.
Failed to ensure the electronic medication administration record (eMAR) was accurate for one resident.
Failed to ensure resident had a physician's order to self-administer two oral medications and a topical medication.
Report Facts
Dates of survey: 2
Number of residents sampled: 1
Medication administration time: 740
Calcium carbonate tablets: 75
Diclofenac sodium gel: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide (MA) | Named in relation to failure to observe medication administration and inaccurate eMAR documentation | |
| Resident Care Coordinator | Interviewed regarding medication administration training and observations | |
| Nurse Practitioner (NP) | Interviewed regarding resident's medication needs and self-administration | |
| Administrator | Interviewed regarding resident's medication self-administration status and facility policies | |
| Primary Care Provider (PCP) | Interviewed regarding medication orders and resident's self-administration |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with medication self-administration policies and food safety standards in the facility.
Findings
The facility failed to assess a resident's ability to self-administer medications and supplements, resulting in medications being left unattended. Additionally, the facility failed to remove expired food items from the walk-in refrigerator, posing a potential risk to residents.
Deficiencies (2)
Failed to assess the ability of a resident to self-administer medications and supplements, resulting in medications being left unattended on the resident's overbed table.
Failed to remove food items past the use-by date from the walk-in refrigerator, including sour cream, ham salad, pinto beans, and thawed raw chicken breast.
Report Facts
Medication pills observed: 9
Food items removed: 5
Resident #3 admission date: Resident #3 admitted on 12/12/24
Resident #3 blood pressure: 130/77 mmHg on 01/21/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Interviewed regarding medication administration to Resident #3 and acknowledged medication should have been removed from room | |
| Director of Nursing | Director of Nursing | Confirmed no residents had orders to self-administer medications and described facility policy for medication administration |
| Administrator | Administrator | Stated expectation that nursing staff follow facility policy for medication administration |
| Certified Dietary Manager | Certified Dietary Manager | Observed expired food items in walk-in refrigerator and removed them |
| Kitchen Supervisor | Kitchen Supervisor | Responsible for checking dates on food items and removing expired items; admitted failure to check refrigerator before observation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to complete discharge assessments within the regulatory timeframes for four sampled residents.
Complaint Details
The complaint investigation found that discharge assessments were not completed for Residents #38, #8, #24, and #22. The MDS Coordinator admitted missing the assessments and noted the need for a better tracking system. The Director of Nursing confirmed the assessments should have been completed at discharge.
Findings
The facility failed to complete discharge Minimum Data Set (MDS) assessments for four residents discharged between May and August 2023. Interviews with the MDS Coordinator and Director of Nursing confirmed the assessments were missed and should have been completed at discharge.
Deficiencies (1)
Failure to complete discharge MDS assessments within regulatory timeframes for 4 sampled residents.
Report Facts
Residents with missing discharge assessments: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding missing discharge MDS assessments for residents |
| MDS Coordinator | MDS Coordinator | Interviewed regarding missing discharge MDS assessments and tracking system |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 4, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident nutrition, food safety, medical record maintenance, restorative nursing documentation, and quality assurance processes at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to reweigh and notify dietician of significant weight loss for a resident, failure to label and date food items in walk-in cooler and freezer, failure to maintain accurate medical records for restorative nursing services, and failure to sustain an effective Quality Assessment and Assurance program.
Deficiencies (4)
Failed to reweigh a resident to determine if a change in weight status was accurate and notify the registered dietician of significant weight loss for 1 of 1 resident reviewed for nutrition (Resident #15).
Failed to label and date food items in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer, potentially affecting food served to residents.
Failed to maintain an accurate medical record for restorative nursing services for 1 of 1 sampled resident (Resident #27).
Failed to maintain implemented procedures and monitor interventions previously put in place following prior survey, showing inability to sustain an effective Quality Assessment and Assurance program.
Report Facts
Resident weight records: 110.4
Resident weight records: 109.2
Resident weight records: 109
Resident weight records: 100.2
Resident weight records: 100
Resident weight records: 106.4
Physician order frequency: 3
Survey completion date: Aug 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Noticed weight loss of Resident #15 and reported it to MDS Nurse; responsible for reviewing weights and entering into medical record | |
| MDS Nurse | Aware of Resident #15's weight changes but did not request reweigh; communicated with Registered Dietician | |
| Nurse Aide #2 | Responsible for obtaining resident weights and reported weight to nurse; observed Resident #15's meal consumption | |
| Registered Dietician | RD | Notified of weight loss through nurses; had not seen Resident #15 since 3/5/22; part-time, 2 days per week |
| Medical Director | Indicated Resident #15's weight loss was unplanned but not unexpected; no adverse outcome | |
| Director of Nursing | DON | Reviewed resident weights weekly; aware of weight loss; stated resident should have been reweighed |
| Dietary Manager | DM | Observed unlabeled and undated food items; responsible for monitoring labeling and dating of food |
| Administrator | Headed Quality Assessment and Assurance committee; stated dietary deficiencies were addressed | |
| RCA #1 | Trained by occupational therapy on restorative program; documented restorative notes on notepad but not in electronic medical record | |
| Staff Development Coordinator #1 | Oversees restorative nursing program; unable to locate restorative documentation in medical record |
Inspection Report
Capacity: 60
Deficiencies: 4
Date: Mar 7, 2019
Visit Reason
The survey was a Construction Section Biennial Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for the Licensing of Adult Care Homes and the 1996 North Carolina State Building Code.
Findings
The survey identified deficiencies related to fire safety rehearsals lacking complete documentation, corridor doors failing to close and latch properly to resist fire and smoke, compromised fire-rated walls and ceilings due to unsealed penetrations, and plumbing equipment drain lines not maintained safely. Some deficiencies were corrected during the survey.
Deficiencies (4)
Records of fire safety rehearsals failed to include the time of the rehearsal, the shift when the rehearsal was done, and included little to no description of what the rehearsal involved.
Corridor doors prevented from closing quickly and latching, including smoke barrier doors in the basement failing to latch, a door obstructed by a decorative hanger, and a fire rated door wedged open.
Unsealed penetrations and sleeves in fire rated walls and ceilings compromising fire resistance.
Ice machine drain line laying directly on the floor drain, not maintained at least 2 inches above the floor or drain as required.
Report Facts
Total licensed capacity: 60
Unsealed penetrations: 2
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 31, 2018
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services conducted an annual survey on 10/30/18 and 10/31/18.
Findings
The facility failed to ensure that each staff person had a criminal background check completed prior to hire for 1 of 3 sampled staff (Staff A). Review of Staff A's personnel record revealed no documentation of a criminal background check despite being hired in 2007.
Deficiencies (1)
Facility failed to ensure that each staff person had a criminal background check completed prior to hire for 1 of 3 sampled staff (Staff A).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Assistant | Named in deficiency for lack of criminal background check documentation. |
| Director of Human Resources | Interviewed regarding staff hiring and background check procedures. | |
| Administrator | Interviewed regarding staff hiring and background check procedures. |
Inspection Report
Capacity: 60
Deficiencies: 5
Date: Jan 22, 2015
Visit Reason
This report is of a Biennial Construction Survey conducted to assess compliance with the 1996 and applicable 2005 Rules for Licensing of Adult Care Homes and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were noted including improper storage of oxygen cylinders, unprotected penetrations compromising fire-resistance ratings, fire rated doors not closing properly, missing electrical junction box covers, and fire protection equipment failures.
Deficiencies (5)
Oxygen cylinders were stored in drink crates instead of proper storage crates to prevent falling over.
Unprotected ceiling and wall penetrations by pipes and conduits in multiple locations compromising fire-resistance ratings.
Fire rated doors near the 1st floor portico entrance did not latch and close completely to contain smoke and fire.
Missing cover on a junction box in the ceiling of the janitor's closet on the 2nd floor near the D stairwell.
Smoke dampers in the attic failed to close when the fire alarm was activated.
Report Facts
Licensed capacity: 60
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