Inspection Reports for Caswell House
535 US Highway 158 West Yanceyville, NC 27379, Yanceyville, NC, 27379
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
285% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
74% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 46
Capacity: 62
Deficiencies: 15
Date: Oct 3, 2025
Visit Reason
The Adult Care Licensure Section completed an annual and follow up survey and complaint investigation from 09/30/25 to 10/03/25.
Complaint Details
Complaint investigation was part of the visit, including issues with flooring, walls, medication administration, and fire safety.
Findings
The facility had multiple deficiencies including damaged flooring and walls, lack of proper housekeeping and furnishings, malfunctioning sprinkler and HVAC systems, medication administration errors, inadequate food supply and snack provision, failure to conduct fire watch, and incomplete staff training for the special care unit.
Deficiencies (15)
Floors were not kept in good repair with buckled and torn flooring in the assisted living and missing and chipped flooring in the special care unit day room.
Walls in a resident room in the special care unit were in disrepair with black marks, missing paint, and broken drywall.
A dresser in the special care unit was in poor repair with missing and askew drawers.
A closet door was leaning against the wall in a resident room in the special care unit, creating a hazard.
A broken paper towel dispenser was found in a resident bathroom in the special care unit.
The sprinkler system was malfunctioning and the fire alarm system was not functioning properly, and the facility failed to conduct a fire watch as instructed by the fire marshal.
The heating, ventilation, and air conditioning (HVAC) system was broken since June 2025 causing excessive heat in the dining and activity rooms, making the environment uncomfortable for residents.
The facility failed to ensure referral and follow-up to meet routine healthcare needs for 2 of 5 sampled residents related to mental health referral and nutritional supplement substitution.
The facility failed to ensure physicians' orders were implemented for 1 of 5 sampled residents related to finger stick blood sugar checks after a fall with hypoglycemia.
The facility failed to ensure therapeutic diets were served as ordered for 2 of 3 sampled residents including pureed diet and double portions.
The facility failed to ensure medication administration as ordered for 1 of 4 residents observed during medication pass and 3 of 5 sampled residents for record review including errors with dementia medication, iron supplement, pain relieving gel, gout prevention medication, and blood pressure medications.
The facility failed to ensure medications were stored safely and securely for 1 of 1 residents who had an unknown cream on the edge of the sink in her room in the special care unit.
The facility failed to ensure an expired controlled substance for 1 of 3 residents was destroyed or returned to the pharmacy within 90 days of expiration.
The facility failed to notify the local county Department of Social Services of an incident requiring emergency medical evaluation for 1 of 2 sampled residents who was sent to the hospital after two falls.
The facility failed to ensure that special care unit staff received required orientation and training within the first week and six months of employment for 2 of 6 and 4 of 6 sampled staff respectively.
Report Facts
Deficiencies cited: 15
Residents present: 46
Licensed capacity: 62
Medication error rate: 10
Fire watch log last date: Aug 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Did not complete required SCU orientation and training |
| Staff C | Medication Aide | Did not complete required SCU orientation and training |
| Staff E | Medication Aide | Did not complete required SCU orientation and training |
| Staff F | Medication Aide | Did not complete required SCU orientation and training |
| Maintenance Director | Responsible for maintenance, fire watch oversight, and reported sprinkler system issues | |
| Administrator | Facility administrator responsible for compliance and notifications | |
| Kitchen Manager | Responsible for food ordering and substitutions | |
| Special Care Unit Coordinator | Responsible for referrals, medication audits, and monitoring therapeutic diets | |
| Medication Aide | Observed medication administration errors and fire watch duties | |
| Personal Care Aide | Reported on flooring hazards and snack availability | |
| Activity Director | Reported on HVAC issues and snack complaints |
Inspection Report
Routine
Capacity: 100
Deficiencies: 11
Date: Aug 13, 2025
Visit Reason
Routine Construction Section Biennial Survey and Follow Up Survey conducted to assess compliance with licensure, building codes, and physical plant requirements for Caswell House, an adult care home licensed for 100 beds.
Findings
Multiple deficiencies were cited including failure to meet licensure and code requirements for physical plant, fire safety, housekeeping, maintenance of building equipment, and hot water temperature. Specific issues included non-functioning emergency release switches, lack of current fire safety inspection approval, missing wander alarms, unclean and damaged furnishings, fire safety equipment not maintained or operating properly, plumbing issues, and inadequate exhaust ventilation.
Deficiencies (11)
Emergency override switch at Nurses Station did not release electromagnetic locks.
Facility lacks approved current fire and building safety inspection report.
Exit doors not equipped with sounding devices to alert staff when opened.
Furnishings not kept clean and functional; broken toilet paper dispensers, mildew on shower mats, bathroom doors not closing properly, water damage and mildew stains.
Walls, ceilings, and floors not maintained in a clean, safe, and functional manner; moisture damage, cracked ceilings, grease buildup, mildew, and trip hazards observed.
Facility has persistent and recurring unpleasant odors including urine and sewer gas odors.
Means of egress obstructed or blocked; emergency release switches tied with heavy gauge twist ties; electrical panels blocked; oxygen bottles improperly stored without restraints.
Bedrooms lack towel bars or have broken towel bars.
Fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition; fire watch in place due to lack of fire sprinkler system approval; generator not functioning; fire safety equipment issues including turned off accelerators, low battery smoke detectors, missing detector covers, broken electrical outlet covers, non-working air handlers, doors not closing properly, cracked shower floors, gaps in fire resistant ceilings, overdue hood suppression inspection, doors wedged open, non-alarming screamer boxes, faulty call system, unsecured sinks, obstructed sprinkler heads, holes in resident room doors.
Hot water supply to resident fixtures not maintained between 100 and 116 degrees Fahrenheit.
Exhaust ventilation not maintained in specified spaces; exhaust fans not working in 100 Hall and SCU Spa.
Report Facts
Total licensed beds: 100
Special Care Unit beds: 42
Date of inspection: Aug 13, 2025
Date of last Fire Marshal inspection: Mar 25, 2024
Date of last hood suppression inspection: 2024-11
Water temperature: 90
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 1, 2025
Visit Reason
This is a complaint follow-up construction survey conducted to verify correction of previously cited deficiencies related to fire safety and building equipment maintenance.
Complaint Details
This survey was a complaint follow-up construction survey conducted on April 1, 2025.
Findings
The facility failed to maintain a current approved fire and building safety inspection report due to the fire sprinkler system being out of service. The fire sprinkler system had been intermittently out of service since August 2023, resulting in a fire watch status. Additional issues included fire alarm system troubles and electrical equipment not maintained in safe operating condition. The sprinkler system was repaired after the survey date.
Deficiencies (4)
Facility does not have an approved current fire and building safety inspection report due to fire sprinkler system being out of service.
Fire safety equipment, including the fire sprinkler system, was not maintained in a safe and operating condition, exposing occupants to risk in case of fire.
Fire alarm system has several troubles and does not automatically summon the fire department when activated.
Not all electrical equipment was maintained in a safe and operating condition; generator was not in automatic start mode.
Report Facts
Date of most recent Fire Marshal inspection: Mar 25, 2024
Date of Fire Marshal consultation inspection: May 30, 2024
Date sprinkler system repaired: Apr 4, 2025
Year sprinkler system out of service since: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Sluder | Conducted the complaint follow-up construction survey. | |
| Divisional Maintenance Director | Interviewed regarding sprinkler contractor and repair plans. | |
| Administrator | Interviewed regarding fire watch status due to sprinkler system being out of service. |
Inspection Report
Annual Inspection
Census: 58
Capacity: 100
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 06/18/24 to 06/20/24 to assess compliance with licensing and regulatory requirements.
Findings
The facility failed to meet required staffing aide hours in both the Assisted Living and Special Care Unit for multiple shifts, failed to ensure referral and follow-up for a resident's eye dilation appointment, lacked therapeutic diet menus for residents with special diet orders, and failed to administer medications as ordered for a resident including nebulizer treatments, nasal spray, and antacid tablets.
Deficiencies (5)
Failed to ensure required aide hours were met to meet the needs of residents in Assisted Living for 5 of 12 shifts sampled from 05/25/24 to 07/15/24.
Failed to ensure referral and follow-up were made for 1 of 5 residents related to an eye dilation appointment.
Failed to have a therapeutic diet menu for 2 of 2 sampled residents with pureed and mechanical soft diet orders.
Failed to ensure medications were administered as ordered for 1 of 5 residents including nebulizer treatment, nasal spray, and antacid.
Failed to ensure required aide hours were met to meet the needs of residents in the Special Care Unit for 14 of 25 shifts sampled from 05/24/24 to 06/16/24.
Report Facts
Resident census in Assisted Living: 58
Resident census in Special Care Unit: 42
Shifts sampled with staffing shortages in Assisted Living: 5
Shifts sampled with staffing shortages in Special Care Unit: 14
Medication administration opportunities: 60
Medication administration opportunities: 62
Medication administration opportunities: 35
Medication administration opportunities: 30
Medication administration opportunities: 31
Medication administration opportunities: 18
Medication administration opportunities: 14
Medication administration opportunities: 18
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 15, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify completion of deficiencies from the previous Biennial Survey and to identify any new deficiencies requiring correction.
Findings
The facility failed to maintain current annual sanitation and fire safety inspection reports, with the last report dated May 12, 2022, exceeding the annual requirement. Additionally, the building's sprinkler system was not maintained in safe operating condition, being shut off with fire watch in place since August 30, 2023, and the Fire Alarm Control Panel was indicating trouble.
Deficiencies (3)
Failure to maintain current annual sanitation and fire safety inspection reports.
Building sprinkler system was shut off and not maintained in safe operating condition.
Fire Alarm Control Panel was indicating trouble, failing to maintain fire system safety components in safe operating condition.
Report Facts
Date of last annual Building Sanitation Inspection Report: May 12, 2022
Fire watch start date: Aug 30, 2023
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 7, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on September 6-7, 2023 to verify correction of previously identified deficiencies.
Findings
The facility failed to serve a therapeutic mechanical soft diet as ordered for Resident #4, serving regular food items instead of chopped or softened meals. Additionally, the facility failed to discontinue Potassium Chloride medication for Resident #1 as ordered, resulting in continued administration of a discontinued supplement.
Deficiencies (2)
Failed to serve a therapeutic mechanical soft diet as ordered for Resident #4; meals were not chopped or softened as required.
Failed to discontinue Potassium Chloride 10mg for Resident #1 as ordered, resulting in continued administration of the medication.
Report Facts
Residents sampled: 5
Residents sampled: 2
Potassium Chloride dosage: 10
Dates of medication administration: 22
Dates of medication administration: 6
Date of medication discontinuation order: Aug 9, 2023
Inspection Report
Follow-Up
Deficiencies: 11
Date: Jun 8, 2023
Visit Reason
The Adult Care Licensure Section conducted a Follow-Up Survey on 06/05/23-06/08/23 to verify correction of previous deficiencies.
Findings
The facility failed to maintain a safe environment related to unsecured oxygen tanks and unclean air-conditioner units; failed to ensure medication aides passed required exams timely; failed to ensure referral and follow-up for acute health care needs resulting in serious injury; failed to implement physician's orders including oxygen administration and discontinued orders; failed to provide napkins at meals; failed to serve therapeutic diets as ordered; failed to treat residents with dignity during medication administration; failed to follow infection control measures during medication administration; failed to timely report injuries of unknown origin to the Health Care Personnel Registry; and failed to notify the county DSS of an incident requiring emergency medical evaluation.
Deficiencies (11)
Oxygen tanks were unsecured in a resident's room and there was build-up of dirt and debris inside wall air-conditioner/heater units and overhead bathroom exhaust vents.
Medication aide (Staff B) failed to pass the written medication aide examination within 60 days of clinical skills validation.
Facility failed to ensure referral and follow-up to meet acute health care needs for Resident #11, resulting in delayed hospital evaluation for dislocated shoulder and change in condition.
Facility failed to implement physician's orders for oxygen administration, discontinued anti-embolism stockings, and other medications for Residents #1, #3, and #7.
Facility failed to provide napkins at meals; residents were given paper towels instead.
Facility failed to serve therapeutic diet as ordered for Resident #2; bread and brownie were not moistened or cut into bite-sized pieces and corn was not substituted with soft vegetable.
Residents were not treated with dignity and respect during medication administration in the dining room; Resident #3 ate in her room due to staff not changing her portable oxygen tanks.
Facility failed to administer medications as ordered for multiple residents including errors with inhalers, eye drops, ointments, muscle relaxants, diuretics, and nebulizer treatments.
Medication aide failed to follow infection control measures during medication administration including popping pills into bare hand and failing to wash hands before and after glove use.
Facility failed to complete a Health Care Personnel Registry report within 24 hours of knowledge of resident injuries for Resident #11 with injuries of unknown origin and dislocated shoulder.
Facility failed to notify the County Department of Social Services of an incident requiring emergency medical evaluation for Resident #5 who fell and was hospitalized.
Report Facts
Medication error rate: 23
Medication doses administered: 17
Medication doses administered: 30
Medication doses administered: 5
Medication doses administered: 17
Medication doses administered: 7
Medication doses administered: 49
Medication doses remaining: 38
Medication doses remaining: 180
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 13, 2023
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation from 03/07/23 to 03/10/23 with an exit via telephone conference on 03/13/23.
Complaint Details
Complaint investigation conducted due to multiple resident safety and care concerns including environmental hazards, supervision failures, abuse allegations, medication errors, and reporting deficiencies.
Findings
The facility failed to maintain a clean and hazard-free environment, provide adequate supervision resulting in a resident fall with injury, ensure immediate response to accidents, provide appropriate health care follow-up, maintain residents' rights by preventing abuse, administer medications as ordered, and report injuries to the Health Care Personnel Registry and Department of Social Services in a timely manner.
Deficiencies (8)
Facility failed to maintain cleanliness and free of hazards related to wall air-conditioner/heater units, bathroom floors, commodes, and a broken shower floor.
Facility failed to provide supervision for a resident known to lean forward in her wheelchair, resulting in a fall with head injury requiring sutures.
Facility failed to ensure immediate response and intervention for residents with unwitnessed injury and falls, including lack of vitals checks, monitoring, and assessments.
Facility failed to ensure referral and follow-up to meet acute health care needs for residents related to failure to notify PCP of injury and delayed evaluation of change in condition.
Facility failed to maintain residents free of physical and mental abuse by not intervening and protecting a resident after verbal and physical abuse allegations.
Facility failed to ensure medications were administered as ordered for residents related to thyroid medication and blood pressure medication.
Facility failed to complete a Health Care Personnel Registry report within 24 hours of knowledge of resident injuries for residents with injuries of unknown origin and injury caused by staff.
Facility failed to notify the County Department of Social Services of an incident/accident requiring emergency medical evaluation for a resident with a fractured hip.
Report Facts
Deficiencies cited: 8
Severity counts: 3
Severity counts: 1
Medication dosage: 112
Medication dosage: 25
Medication dosage: 20
Medication dosage: 50
Medication dosage: 62.5
Medication dosage: 112
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 16, 2020
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on January 14, 2020 to January 16, 2020.
Findings
The facility was found deficient in multiple areas including failure to document tuberculosis test results for staff, inadequate provision of non-disposable place settings for residents, failure to serve a resident with a physician-ordered double portion diet, and failure to assist residents with eating in a timely and respectful manner.
Deficiencies (4)
Facility failed to assure 1 of 6 sampled staff was tested for tuberculosis disease using the two-step skin test in accordance with control measures.
Facility failed to ensure residents were provided with a non-disposable place setting including a fork, spoon, knife, and non-disposable plate.
Facility failed to assure 1 of 6 sampled residents with a physician order for double portions was served as ordered.
Facility failed to assist residents needing help with eating in a timely manner, including residents who were visionally impaired, fell asleep during meals, or required assistance with cutting meats and using silverware.
Report Facts
Residents in MCU dining room: 14
Residents in MCU dining room: 15
Residents in AL dining room: 29
Silverware sets prepared for MCU dinner meal: 28
Forks available: 91
Spoons available: 57
Knives available: 29
Order placed for silverware: 72
Residents served lunch in MCU: 14
Residents served lunch in MCU: 15
Residents served lunch in AL: 29
Inspection Report
Follow-Up
Deficiencies: 7
Date: Sep 19, 2019
Visit Reason
The Adult Care Licensure Section and the Caswell County Department of Social Services conducted a follow-up survey from 09/17/19 to 09/19/19 to verify correction of previous deficiencies.
Findings
The facility failed to provide personal care assistance for nail care for 2 of 7 sampled residents, failed to notify the endocrinologist and coordinate care for 2 of 6 residents with diabetes, failed to assure orders for finger stick blood sugar checks were completed, failed to maintain kitchen food safety and proper freezer temperatures, failed to serve therapeutic diets as ordered for 3 of 7 residents, and failed to administer medications as ordered for 5 of 9 residents observed during medication pass and 2 of 5 residents reviewed.
Deficiencies (7)
Failed to provide personal care assistance for nail care for 2 of 7 sampled residents (#1, #7).
Failed to notify the endocrinologist for 2 of 6 residents sampled related to coordinating care and missed doses of diabetes injection and elevated blood sugars outside ordered parameters.
Failed to assure orders for finger stick blood sugar checks were completed as ordered for 1 of 2 sampled residents (#6).
Failed to assure the kitchen was protected from contamination by missing dates and labels on food, uncovered food in refrigerators, no paper towels at handwashing sink, scoops stored inside bulk food containers, and buildup on hot food serving table.
Failed to assure the walk-in freezer was maintained at proper temperature range (-10°F to 0°F) with temperatures documented between 17°F and 22°F and soft ice cream observed.
Failed to clarify orders and serve therapeutic diets as ordered for 3 of 7 residents (#7 pureed diet, #4 mechanical soft with nectar thick liquids, #3 mechanical soft diet).
Failed to administer medications as ordered and in accordance with facility policy for 5 of 9 residents observed during medication pass and 2 of 5 residents reviewed, including errors with pancreatic enzyme replacement, insulin, antiemetic, oral antidiabetic medication, eye drops, and antidepressant.
Report Facts
Medication error rate: 19
Trulicity administration: 2
Walk-in freezer temperature: 20
Walk-in freezer temperature range: 17
Walk-in freezer temperature range: 22
Walk-in freezer temperature range: -10
Walk-in freezer temperature range: 0
Trulicity pens: 2
Effexor not administered: 29
Effexor refills: 9
Effexor refills: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed regarding medication administration errors, order approvals, and care coordination | |
| Memory Care Manager | Interviewed regarding medication administration and order approvals | |
| Resident Care Coordinator | Interviewed regarding medication administration and order approvals | |
| Medication Aide | Observed administering medications and interviewed about medication administration practices | |
| Kitchen Manager | Interviewed regarding food preparation, diet orders, and kitchen sanitation | |
| Cook | Interviewed regarding food preparation and kitchen sanitation | |
| Personal Care Aide | Interviewed regarding resident care and observations of resident vomiting | |
| Pharmacist | Interviewed regarding medication orders and pharmacy practices | |
| Business Office Manager | Interviewed regarding medication order approvals and facility contacts | |
| Resident Care Coordinator | Interviewed regarding medication administration timing and order approvals |
Inspection Report
Follow-Up
Deficiencies: 5
Date: May 17, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on May 15-17, 2019 to assess compliance with previously identified deficiencies.
Findings
The facility failed to provide personal care assistance with nailcare to one resident, failed to assure a podiatry consult was completed for one resident, and failed to administer medications as ordered for two residents. Additional findings included unclean kitchen and food storage areas and failure to serve nutritional shakes as ordered.
Deficiencies (5)
Failed to provide personal care assistance with nailcare to 1 of 5 sampled residents (#5).
Failed to assure a podiatry consult was completed for 1 of 5 sampled residents (#5) with calluses and long toenails.
Failed to assure medications were administered as ordered by a licensed prescribing practitioner for 2 of 5 sampled residents (Resident #4 and #3).
Failed to assure the kitchen and food storage areas were clean and free of contamination including floors in walk-in refrigerator and freezer, can opener, and ice machine.
Failed to assure 1 of 5 sampled residents (#5) was served nutritional shakes as ordered by the physician.
Report Facts
Deficiencies cited: 5
Missed medication administrations: 10
Missed medication administrations: 4
Inspection Report
Annual Inspection
Deficiencies: 25
Date: Jan 16, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation on January 9-11;14-16, 2019.
Findings
The facility failed to assure the walls, ceilings, and floors were kept clean and in good repair in multiple resident rooms, bathrooms, hallways, and the Assisted Living dining room ceiling. The call light system was not fully operational in the Assisted Living unit, resulting in delayed staff response to residents' calls. The facility was short staffed on multiple shifts in the Special Care Unit and Assisted Living unit, impacting resident care and supervision. Several residents did not have required assessments, care plans, or Licensed Health Professional Support evaluations completed timely. The facility failed to provide adequate supervision for residents with dementia and history of falls, resulting in multiple injuries. There were failures in health care follow-up, medication administration, and notification of responsible parties. Nutrition and food service deficiencies included lack of therapeutic diet menus, improper meal substitutions, and failure to serve milk as ordered. The facility also failed to respond to resident requests related to smoking breaks, ice for beverages, and salad dressing. The Administrator failed to ensure implementation of policies and procedures, resulting in widespread noncompliance and resident risk.
Deficiencies (25)
Failed to assure all components of the call light system were operating as designed to assure residents' calls were received by staff and responded to in a timely manner in the Assisted Living unit for residents with special care needs including blindness, paralysis, and colostomy care.
Failed to assure the minimum requirements for aide hours were met on multiple shifts for 13 days from December 2018 - January 2019.
Failed to provide supervision for residents with dementia and history of repeated falls resulting in fractures.
Failed to assure physician notification and referrals related to transportation to medical appointments and medication refusals; failed to schedule dermatology follow-up appointments for residents with rash; failed to contact oxygen medical supplier for oxygen tank refills.
Failed to implement physician's orders related to colostomy care and oxygen administration.
Failed to serve residents with physician ordered mechanical soft diets and food allergies as ordered.
Failed to assure minimum number of staff were present at all times to meet the needs of residents residing in the Special Care Unit for multiple shifts.
Failed to assure all components of the call light system were operable for all residents in the assisted living including those with special needs.
Failed to implement physician's orders for colostomy bags and oxygen tanks resulting in resident risk.
Failed to assure medication aide completed required continuing education annually related to medication administration.
Failed to assure resident was tested upon admission for tuberculosis disease.
Failed to complete assessments and care plans for residents to determine levels of assistance required.
Failed to assure staff provided personal care assistance for residents regarding colostomy care, incontinence care, and toileting assistance.
Failed to assure Licensed Health Professional Support evaluations were completed timely by a Registered Nurse for residents with specific care tasks.
Failed to ensure kitchen area was clean and free of contamination including dirty walk-in refrigerator, dirty stove, expired food, improperly stored food, and unlabeled food.
Failed to serve appropriately substituted meal items and maintain documentation to indicate foods actually served.
Failed to assure 8 ounces of milk was served twice daily to residents on the Special Care Unit.
Failed to ensure matching therapeutic diet menus for residents with mechanical soft diet orders.
Failed to provide reasonable response to residents' requests for smoking breaks, ice in beverages, timely meal service, and salad dressing.
Failed to assure long acting insulin was administered as ordered by a licensed prescribing practitioner.
Failed to notify responsible party for resident transported to emergency department for behavioral health evaluation.
Failed to respond to resident's request to be moved to another room due to odor of roommate's colostomy.
Failed to assure medication aides had completed state-mandated infection control training annually.
Failed to assure medication aide had employment verification or completed required medication administration training and competency evaluation prior to administering medications.
Administrator failed to assure management, operations, and policies of the facility were implemented and rules maintained for multiple regulatory areas, placing residents at substantial risk of harm and neglect.
Report Facts
Deficiencies cited: 23
Residents with call light issues: 4
Shifts short staffed: 14
Days short staffed: 13
Residents with missing assessments/care plans: 4
Residents with missing LHPS evaluations: 4
Residents with mechanical soft diet issues: 2
Residents with food allergy diet issues: 3
Residents with missing pre-admission screening: 3
Residents with missing resident profile: 2
Residents with missing care plan: 3
Residents waiting for smoking breaks: 5
Residents refusing long acting insulin: 1
Residents missing notification of hospital transfer: 1
Residents requesting room change due to odor: 1
Medication aides missing annual infection control training: 2
Medication aide missing required training: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Missing annual infection control training |
| Staff B | Medication Aide | Missing annual infection control training and required medication training |
| Staff F | Medication Aide | Missing required medication training and competency validation |
| Business Office Manager | Responsible for personnel records and training tracking | |
| Administrator | Facility Administrator | Responsible for overall facility operations and compliance |
| Care Manager | Responsible for resident care plans and LHPS evaluations | |
| Medication Aide | Involved in resident care and medication administration | |
| Dietary Manager | Responsible for dietary menus and staff guidance | |
| Cook | Responsible for meal preparation | |
| Personal Care Aide | Responsible for resident assistance and meal service | |
| Physician Assistant | Primary care provider involved in resident care | |
| Regional Director of Operations | Oversight of facility operations | |
| Medication Aide Supervisor | Supervises medication aides and resident care | |
| Activity Director | Assists with resident transportation and activities | |
| Housekeeper | Responsible for cleanliness and reporting maintenance issues | |
| Physician Assistant from Primary Care Physician's office | Provided medical care and orders for residents | |
| Nurse from home care agency | Provided colostomy care training and services | |
| Distributor of ileostomy bags | Supplies colostomy bags to residents | |
| County representative | Responsible party for resident under guardianship | |
| Local law enforcement officer | Involved in missing resident investigation |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Nov 29, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies from the Biennial Construction Survey.
Findings
The facility had multiple deficiencies related to housekeeping and furnishings, building equipment safety and operation, fire safety including fire-rated doors and fire alarm system, electrical system maintenance, handrail repairs, and exhaust ventilation system failures. Some doors were propped open or removed, compromising fire safety, and some exhaust fans were not working, causing odor issues.
Deficiencies (10)
Building floors are not kept clean and in good repair; seamless floor separating at the joint in Beauty Shop/Vending/Laundry area.
Fire rated doors of hazardous or incidental areas not maintained in safe and operating condition; corridor doors held open improperly or propped open.
Missing escutcheon plate from sprinkler head near door leaving hole in fire-resistance-rated ceiling assembly.
Housekeeping carts and buckets stored in front of electrical panels limiting required clearance.
Corridor doors do not latch properly due to doorframe issues, preventing containment of smoke/fire.
Corridor door held open with wedge preventing rapid release and proper closing.
Handrails near bedrooms 603 and 606 missing end returns exposing rough edges.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel indicating trouble unknown to staff.
Med Room door completely removed from door frame, leaving room open to corridor.
Exhaust ventilation system not maintained in proper working order; some exhaust fans not working causing odor issues.
Report Facts
Fire-resistance rating: 45
Minimum clearance: 36
Exhaust ventilation rate: 2
Exhaust fans working: 2
Exhaust fans tested: 4
Inspection Report
Follow-Up
Deficiencies: 11
Date: Sep 26, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies related to building maintenance, housekeeping, fire safety, and ventilation systems.
Findings
The facility had multiple deficiencies including doors not functioning properly, floors not kept clean and in good repair, plumbing equipment hazards, improperly maintained fire extinguishers, fire safety doors not maintained, electrical system hazards, corridor doors not latching properly, missing handrail parts, failure to maintain emergency fire alarm system, and ventilation system failures.
Deficiencies (11)
Building doors failed to function as originally intended or were missing, including a closet bi-fold door off and propped against the wall.
Building floors were not kept clean and in good repair, including seamless floor separating at joints.
Plumbing equipment not maintained free of hazards, including broken fiberglass shower floor and loose commode connections.
Building not maintained free of hazards due to incomplete general maintenance, risking injury from broken or partially removed items.
Fire extinguishers not properly maintained; last annual maintenance checks were over a year old and some extinguishers were not mounted as required.
Fire rated doors of hazardous or incidental areas not maintained in safe and operating condition; doors held open improperly and propped open with a table.
Building fire safety not maintained; corridor doors did not resist passage of smoke and did not latch properly, including doors hitting doorframes and wedges holding doors open.
Electrical system not maintained safe; housekeeping carts and buckets stored in front of electrical panels limiting required clearance.
Handrails missing end returns exposing rough edges in corridors near bedrooms 603 and 606.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel indicated trouble unknown to staff.
Exhaust ventilation system failed to maintain proper working order in multiple areas, preventing exhausting of odors.
Report Facts
Date of last fire extinguisher maintenance: 2017
Fire extinguisher coverage requirement: 2500
Fire door rating: 45
Minimum clearance in front of electrical panels: 36
Exhaust ventilation rate: 2
Inspection Report
Routine
Capacity: 100
Deficiencies: 15
Date: Jun 20, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and other regulatory requirements for Caswell House, a licensed adult care home.
Findings
Multiple deficiencies were cited including failure to maintain exits and emergency release systems, lack of current fire and safety inspection reports, inadequate privacy in bathrooms, missing wanderer alarms, housekeeping and maintenance issues, improperly maintained fire extinguishers, electrical safety violations, fire safety and sprinkler system deficiencies, unsafe hot water temperatures, and non-functioning exhaust ventilation systems.
Deficiencies (15)
Exits not operable by all staff due to special locking system with secured emergency release switch.
Paths to exits not marked with signs.
Facility failed to maintain current sanitation and fire safety inspection reports.
Bathrooms and showers lacked privacy partitions or curtains.
Exit doors accessible by residents lacked sounding devices activated when opened.
Building not kept in good repair; doors malfunctioning or missing, floors separating.
Building not maintained free of hazards; unsecured oxygen cylinders, broken shower floor, loose commode, sharp edges on mounting bracket.
Fire extinguishers not properly maintained; last maintenance in 2017, some not mounted.
Electrical outlets in wet locations lacked ground fault interrupters.
Building equipment including fire sprinkler system not maintained in safe and operating condition; accelerators out of service, fire doors held open, gaps in fire-resistance-rated assemblies, holes in corridor doors, blocked electrical panels.
Corridor doors did not latch properly or were held open with wedges or cardboard, compromising smoke/fire containment.
Hot water temperature exceeded maximum allowed, ranging 120-128°F at sinks in bedrooms.
Exhaust ventilation systems in multiple areas not working, causing odors.
Egress impeded by hasp devices on closets that could trap individuals.
Handrails missing end returns exposing rough edges.
Report Facts
Licensed capacity: 100
Special Care Unit beds: 42
Date of inspection: Jun 20, 2018
Fire Sprinkler Inspection Date: May 25, 2018
Hot water temperature range (°F): 120-128
Fire extinguisher last maintenance: 201702
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 11, 2018
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on April 11, 2018 - April 13, 2018.
Complaint Details
The visit included a complaint investigation as well as a follow-up survey.
Findings
The facility failed to maintain floors, walls, and furnishings in good repair, with multiple doors scratched, damaged paint in resident rooms, missing caulking around commodes, and a damaged shower floor that was unusable. Additionally, the facility failed to serve eight ounce glasses of milk at least twice daily to residents in the Assisted Living dining room as required.
Deficiencies (2)
Failed to maintain floors and walls that were clean and in good repair, including scratched doors, damaged paint, missing caulking around commodes, stained floors, missing toilet paper holder, and missing countertop molding.
Failed to serve eight ounce glasses of milk at least twice daily to residents in the Assisted Living dining room.
Report Facts
Damaged doors: 18
Resident bathrooms without caulking: 8
Damaged paint areas: 4
Residents in AL dining room: 36
Tables with milk served: 1
Tables in AL dining room: 15
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 9
Date: Dec 21, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow-up survey, and complaint investigation on December 13, 2017 through December 15, 2017 and December 18, 2017 through December 21, 2017.
Findings
The facility failed to maintain clean and well-repaired housekeeping and furnishings, failed to meet staffing requirements resulting in inadequate supervision and care, failed to notify primary care providers of significant incidents, failed to protect residents from abuse and neglect, and failed to maintain food preparation and storage areas in a clean and sanitary condition.
Deficiencies (9)
Facility failed to maintain floors and walls clean and in good repair with dirt and dust accumulation, damaged paint, missing toilet paper holders, and damaged doors in multiple resident rooms and common areas.
Facility failed to assure aide hours met minimum staffing requirements on multiple shifts resulting in inadequate staff available to provide personal care and supervision for residents on the Assisted Living and Special Care Units.
Facility failed to notify primary care providers for residents related to sexual assault and sexually expressive behaviors, resulting in lack of follow-up care and medical intervention.
Facility failed to keep food preparation and storage areas, including food cart, coolers, freezer, ice machine, beverage machines, kitchen walls, stove/oven, and doors clean and free of contamination.
Facility failed to assure food that was unwrapped was passed out to residents following sanitation and safety guidelines, including passing out cookies with bare hands without gloves or utensils.
Facility failed to assure 8 ounces of milk was served to residents on the Special Care Unit twice daily.
Facility failed to complete quarterly resident profiles for 7 of 10 residents sampled in the Special Care Unit.
Facility failed to assure adequate staffing to meet the needs of residents on the Special Care Unit on 34 of 45 shifts sampled, resulting in an undocumented fall with a lip injury and incidents of resident to resident assault.
Facility failed to notify the county Department of Social Services of five incidents of physical and sexual abuse of residents.
Report Facts
Residents present: 87
Staffing shortfall: 7.86
Staffing shortfall: 8.82
Staffing shortfall: 15
Milk served: 6
Milk served: 4
Milk served: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Manager | Memory Care Manager | Responsible for overseeing SCU and AL, completing quarterly profiles, and assisting staff |
| Administrator | Responsible for staffing, incident report review, and communication with DSS and PCP | |
| Maintenance Technician | Responsible for maintenance and cleaning of kitchen equipment | |
| Personal Care Aide | PCA | Mentioned in relation to resident supervision and incident reporting |
| Medication Aide | MA | Responsible for documenting incidents and notifying PCP |
| Dietary Aide | Responsible for cleaning kitchen and food service areas | |
| Cook | Responsible for kitchen cleaning and food safety |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 27, 2016
Visit Reason
The visit was a follow-up survey conducted to verify correction of deficiencies noted during a previous follow-up survey on 2016-08-09.
Findings
The facility had unresolved deficiencies related to fire resistance rated components of doors at the main nurse station not latching properly, and the electrically operated nurse call system failed to notify staff when activated.
Deficiencies (3)
The corridor dutch door's top leaf did not latch into the bottom leaf when the bottom leaf was latched to its doorframe at the main nurse station.
The bottom half of the dutch door at the main nurses' station does not latch to the door frame when pulled closed.
The electrically operated nurse call system did not provide the ability to call for assistance when activated; nurse call pull stations did not notify staff.
Inspection Report
Follow-Up
Deficiencies: 10
Date: Aug 9, 2016
Visit Reason
This is a follow-up construction survey conducted to verify correction of deficiencies cited during the Biennial Construction Survey that had not been satisfactorily corrected.
Findings
The facility was found to have multiple unresolved deficiencies including unstable handrails in corridors, lack of functioning wanderer alarms on exit doors, unclean and unrepaired furnishings, presence of hazards such as obstructed HVAC dampers, fire safety equipment not maintained properly, malfunctioning exhaust ventilation, and a non-functional nurse call system.
Deficiencies (10)
Unstable handrails in corridor between Bedrooms 314 and Sitting Room.
Exit doors accessible by residents lacked functioning sounding devices; exterior exit near Bedroom 104 had a non-working alarmed protective cover over emergency release switch.
Furniture not kept clean and in good repair; wardrobe missing door in Bedroom 515.
Facility not maintained free of hazards; HVAC dampers and ventilation grilles obstructed with dust/lint.
Chronic unpleasant odors present; strong urine odor in Bedroom 101.
Fire sprinkler heads debris-loaded with lint/dust causing delayed fire response.
Smoke barrier doors near Bedroom 410 did not close completely or latch to restrict smoke.
Fire resistance rated components not maintained; corridor dutch-door at Main Nurse Station did not latch properly.
Exhaust ventilation system failed to work in Bedroom 513 Bathroom, allowing odor buildup.
Electrically operated nurse call system did not notify staff when activated; nurse call pull stations failed to notify staff.
Inspection Report
Capacity: 100
Deficiencies: 15
Date: Jun 16, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant and safety regulations applicable to the licensed adult care home.
Findings
Multiple deficiencies were identified related to physical plant safety, fire safety equipment maintenance, housekeeping, hazardous conditions, and call system functionality. These included unsecured oxygen cylinders, non-functioning nurse call stations, fire sprinkler system issues, unstable handrails, and inadequate exit door alarms.
Deficiencies (15)
Nurse Station special locking system lacks wiring diagram and system components location map at fire alarm panel.
Corridor handrails were loose and unstable, affecting safety for residents, staff, and visitors.
Exit doors accessible by residents lacked functioning sounding devices and had unalarmed or non-working protective covers over emergency release switches.
Walls, ceilings, floors, and furniture were not kept clean or in good repair; e.g., incomplete ceiling finish and missing wardrobe door.
HVAC dampers and ventilation grilles were obstructed with dust/lint, potentially impairing fire containment.
Strong urine odor present in Bedroom 101 indicating failure to prevent chronic unpleasant odors.
Portable medical oxygen cylinders were stored unsecured, posing projectile hazard risk.
Fire extinguishers lacked documentation of monthly inspections since last annual maintenance.
Fire sprinkler system compromised by bypassed accelerator, debris-loaded sprinkler heads, and fire doors failing to latch properly.
Commercial kitchen hood fire extinguishing system lacked required inspections and maintenance documentation.
Fire-resistance-rated ceiling penetrations and escutcheon plates were missing or improperly sealed, compromising smoke/fire containment.
Doors protecting smoke barriers and corridors did not close or latch properly, risking smoke spread.
Egress from some areas required keys or special knowledge due to locked doors without override devices.
Exhaust ventilation system failed to operate properly in Bedroom 513 Bathroom, allowing odor buildup.
Electrically operated nurse call system failed to notify staff; some pull stations missing.
Report Facts
Total licensed beds: 100
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 15, 2015
Visit Reason
The Adult Care Licensure Section conducted an Annual, Follow-up and Complaint Investigation survey on June 10, 2015, June 12, 2015 and June 15, 2015.
Findings
The facility failed to comply with staff qualifications, training on care of diabetic residents, special care unit staff orientation and training, infection prevention requirements, and medication aide training and competency evaluation requirements.
Deficiencies (5)
Failed to assure 1 of 6 staff persons sampled had a criminal background check in accordance with G.S. 114-19.10 and 131D-40.
Failed to assure 4 of 4 medication aides sampled had completed training on the care of the diabetic resident prior to the administration of insulin.
Failed to assure special care unit staff received 6 hours orientation within the first week of employment and/or 20 hours of training within 6 months related to the population served for 4 of 5 sampled special care unit staff.
Failed to assure the state mandatory, annual in-service training program for adult care home medication aides on infection control had been completed for 2 of 4 sampled medication aides.
Failed to assure 2 of 4 sampled medication staff completed medication administration training and competency requirements before performing unsupervised medication aide duties.
Report Facts
Staff persons sampled: 6
Medication aides sampled: 4
Special care unit staff sampled: 5
Medication aides sampled: 4
Medication staff sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide and Personal Care Aide | Failed to have nationwide criminal background check; lacked diabetic care training; lacked medication administration training and competency. |
| Staff C | Medication Aide and Personal Care Aide | Lacked diabetic care training; lacked state medication administration training and competency. |
| Staff E | Medication Aide | Lacked diabetic care training; lacked special care unit orientation and training; lacked state mandatory infection prevention training. |
| Staff F | Medication Aide | Lacked diabetic care training; lacked state mandatory infection prevention training. |
| Staff B | Nursing Assistant | Lacked special care unit training beyond initial orientation. |
| Staff D | Nursing Assistant | Lacked special care unit training within 6 months of employment. |
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