Inspection Reports for Faith Assisted Living Facility
3032 N.C. Highway 16 South Taylorsville, NC 28681, Taylorsville, NC, 28681
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
21.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
319% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 32
Deficiencies: 14
Date: May 14, 2025
Visit Reason
The facility was surveyed as part of a Construction Section Biennial Survey to assess compliance with the 2005 Rules for Adult Care Homes of Seven or More Beds and the 1971 Minimum and Desired Standards and Regulations for Homes for the Aged and Infirm.
Findings
Multiple deficiencies were cited including unsecured storage of hazardous cleaning agents, unsafe and unmaintained outside premises, poor housekeeping and maintenance issues such as broken floor tiles and unsecured oxygen bottles, lack of clean towels for hand drying, failure to conduct required fire safety rehearsals, unsafe electrical and plumbing equipment, fire safety equipment not maintained or inspected properly, and hot water temperatures exceeding regulatory limits.
Deficiencies (14)
Storage rooms and closets containing hazardous cleaning agents were not kept locked.
Outside premises were not maintained in a clean and safe condition with broken rail spindles, exterior soffit damage allowing pest entry, broken chairs, and other hazards.
Ceilings and floors were not kept clean and in good repair; kitchen had approximately twenty-two missing, chipped or broken floor tiles.
Oxygen bottles were improperly stored without restraint, posing a hazard.
Facility did not provide a supply of clean towels for hand drying at bathroom sinks; paper towel dispensers were removed.
Facility was not conducting quarterly fire rehearsals on each shift and did not provide descriptions of rehearsals.
Electrical equipment was not maintained in a safe and operating condition; open light sockets and unsecured plumbing fixtures were observed.
Emergency/safety lighting and exit signs were not maintained in safe operating condition; some exit signs did not illuminate on test.
Fire doors did not close or latch properly, and door hardware was loose or missing screws.
Openings in exterior walls allowed pests and elements to enter the facility.
Fire safety equipment, including fire extinguishers and kitchen hood suppression system, was not inspected or maintained properly.
Hot water system was not maintained between 100 and 116 degrees Fahrenheit at all resident fixtures; temperatures measured at 125 degrees Fahrenheit.
Plumbing equipment was not maintained in safe and operating condition; sinks were clogged or not securely mounted, and water heater relief valve was not properly piped.
Sprinkler heads were obstructed by dust, potentially affecting fire suppression.
Report Facts
Total licensed capacity: 32
Missing floor tiles: 22
Unsecured small oxygen bottles: 19
Unsecured tall oxygen bottles: 4
Water temperature: 125
Inspection Report
Annual Inspection
Census: 16
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The Adult Home Licensure Section conducted an annual survey from January 8 through January 9, 2025, to assess compliance with regulations including reporting and notification of communicable disease outbreaks.
Findings
The facility failed to report a confirmed influenza outbreak to the local health department that began on December 31, 2024, involving multiple residents and hospitalizations. Observations and interviews confirmed residents with flu were isolated, masks were required, and staff were trained, but the administrator was unaware of the reporting requirement.
Deficiencies (1)
Failure to report a confirmed influenza outbreak to the local health department as required by regulation.
Report Facts
Census: 16
Residents tested positive for flu: 5
Residents hospitalized: 2
Staff tested positive for flu: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding infection control training and outbreak management | |
| Personal Care Assistant | Interviewed about infection control and resident isolation practices | |
| Activities Director | Interviewed about infection control and activity modifications during outbreak | |
| Administrator | Interviewed and found unaware of flu outbreak reporting requirements | |
| Registered Nurse from Local Health Department | Interviewed about reporting requirements and outbreak notification | |
| Primary Care Provider | Interviewed regarding resident monitoring and treatment during outbreak |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 9, 2017
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted a follow-up survey and complaint investigation initiated on September 23, 2017.
Complaint Details
The complaint investigation was initiated by Alexander County Department of Social Services on September 23, 2017, and the follow-up survey was conducted October 9-11, 2017.
Findings
The facility failed to protect food from contamination, ensure adequate food supply for therapeutic diets, serve therapeutic diets as ordered for 6 sampled residents, administer medications as ordered for 2 sampled residents, maintain accurate medication administration records, implement proper infection control procedures for blood glucose monitoring, and report a known drug diversion to law enforcement. These failures resulted in physical harm to Resident #5, risk of aspiration pneumonia, risk of bloodborne pathogen transmission, and medication errors.
Deficiencies (7)
Failed to protect all food being stored, prepared, and served by the facility from contamination.
Failed to ensure at least a three-day supply of perishable food and a five-day supply of non-perishable food was in the facility based on the menus for regular, no concentrated sweets, and vegetarian therapeutic diets.
Failed to ensure all therapeutic diets for 6 sampled residents were served as ordered related to puree, honey thick liquids, no concentrated sweets, vegetarian, lactose free, and chopped meat diet orders.
Failed to ensure medications were administered as ordered for 2 sampled residents related to errors in medication administration of oral inhalers, hydrocortisone cream, lisinopril, and potassium chloride.
Failed to assure the accuracy of the electronic Medication Administration Records (eMARs) for 2 sampled residents related to documenting PRN administration for Percocet.
Failed to assure that a known drug diversion was reported to the local law enforcement as required by state law.
Failed to assure adequate and appropriate infection control procedures were implemented for blood glucose monitoring by sharing glucose meters between residents.
Report Facts
Medication pass error rate: 13
Weight loss: 20
Percocet doses discrepancy: 2
Percocet doses discrepancy: 4
Percocet doses discrepancy: 2
Percocet tablets missing: 5
Controlled drug count: 79
Controlled drug count: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Medication Aide | Accused of diverting narcotic medications; tested positive for narcotics; suspended and no longer employed. |
| Resident Care Coordinator | Responsible for managing medication aides and medication administration documentation; unaware of incomplete documentation of PRN medications. | |
| Administrator | Responsible for facility oversight; unaware of medication aides not documenting PRN medications; did not report drug diversion to law enforcement. |
Inspection Report
Follow-Up
Deficiencies: 14
Date: Jul 24, 2017
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted a follow-up survey and complaint investigation on July 19-21, 2017, and July 24, 2017. The investigation was initiated due to a complaint on June 27, 2017.
Complaint Details
The complaint investigation was initiated by the Alexander County Department of Social Services on June 27, 2017, related to concerns about staff impairment and other regulatory compliance issues.
Findings
The facility failed to ensure compliance in multiple areas including qualifications of the Activity Director, tuberculosis testing for staff, diabetic care training for medication aides, medication administration errors, failure to provide therapeutic diets as ordered, inadequate infection control practices, failure to report impaired staff to the Health Care Personnel Registry, and failure to maintain accurate controlled substance records. Several residents were affected by these deficiencies, including failure to administer medications and lack of appropriate activities.
Deficiencies (14)
Facility failed to ensure the Activity Director met qualifications and performed required activities.
Facility failed to assure 1 of 5 staff were tested upon employment for tuberculosis disease.
Facility failed to assure diabetic care training was provided for 3 of 3 sampled medication aides.
Facility failed to ensure therapeutic diets were served as ordered for 4 of 4 sampled residents.
Facility failed to clarify readmission medication orders that were incomplete for 1 of 4 sampled residents.
Facility failed to ensure medications were administered as ordered to 4 of 6 sampled residents, including failure to administer pain medication and readmission medications.
Facility failed to maintain accurate medication administration records for 2 of 6 sampled residents.
Facility failed to maintain accurate controlled substance records for 1 of 4 sampled residents.
Facility failed to protect residents by not reporting impaired staff to the Health Care Personnel Registry.
Facility failed to implement proper infection control procedures for blood glucose monitoring, including sharing glucose meters without proper disinfection.
Facility failed to assure 3 of 5 sampled staff completed infection control training within 30 days of hire.
Facility failed to assure 1 of 5 medication aides completed the 15 hour medication training.
Facility failed to ensure residents were treated with respect related to extra servings of coffee and treatment of a vegetarian resident.
Facility failed to ensure 1 of 1 sampled residents had an injectable medication available for home health to administer and failed to try to obtain the medication.
Report Facts
Medication administration opportunities: 62
Medication administration opportunities: 32
Controlled substance tablets unaccounted for: 195
Medication administration opportunities: 66
Medication administration opportunities: 54
Medication administration opportunities: 40
Medication administration opportunities: 83
Medication administration opportunities: 72
Medication administration opportunities: 12
Medication administration opportunities: 116
Medication administration opportunities: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Activity Coordinator / Housekeeper | Failed to meet qualifications for Activity Director and did not conduct required activities |
| Staff C | Medication Aide | Impaired on duty, failed diabetic training, failed to administer medications properly |
| Staff D | Medication Aide | Failed diabetic training |
| Staff E | Medication Aide | Failed diabetic training, incomplete medication training documentation |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Apr 11, 2017
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted an annual survey, a follow-up survey and a complaint investigation on April 11, 12, and 13, 2017. The complaint investigation was initiated by the Alexander Department of Social Services on April 4, 2017.
Complaint Details
Complaint investigation was initiated by the Alexander Department of Social Services on April 4, 2017 related to supervision and medication issues.
Findings
The facility failed to maintain a clean and hazard-free environment, failed to conduct required fire drills, failed to maintain safe and operating electrical equipment, failed to provide adequate supervision resulting in resident falls, failed to assure timely health care referrals and follow-ups, failed to serve therapeutic diets as ordered, failed to provide an active activities program, and failed to maintain accurate medication administration and controlled substance records.
Deficiencies (13)
Facility failed to maintain the home in a clean manner free from hazards related to cigarette butts, ashes, dirt and paper trash on the smoking porch.
Facility failed to assure rehearsals of the fire plan were performed quarterly on each shift as required.
Facility failed to maintain building and electrical equipment in safe and operating condition related to exposed wires, missing light bulbs and globes, dust build-up, and exposed switch boxes.
Facility failed to provide supervision of residents with physical decline and history of falls, resulting in serious injuries.
Facility failed to assure referral and follow-up to meet routine and acute health care needs for residents with complex care needs and post-fall injuries.
Facility failed to ensure Licensed Health Professional Support evaluations were completed quarterly and included required assessments and recommendations.
Facility failed to assure all therapeutic diets were served as ordered related to puree and no concentrated sweets diet orders.
Facility failed to develop a program of activities designed to promote residents' active involvement; scheduled activities did not take place and no alternatives were provided.
Facility failed to assure one resident received Endocet as prescribed.
Facility failed to assure all medications administered to one resident were dispensed from the pharmacy and properly labeled, resulting in administration of unlabeled medications brought from home.
Facility failed to assure accuracy of electronic Medication Administration Records for two residents related to documentation of medications administered, including sliding scale insulin, Flexeril, and as needed medications.
Facility failed to assure readily retrievable records were available to account for disposition of controlled substances and to ensure accurate reconciliation for three residents, resulting in missing narcotics and residents not receiving medications as ordered.
Facility failed to assure after a prospective employee's controlled substance screening tested positive for oxycodone that a second examination and screening was performed or a physician's statement was provided verifying the prescription.
Report Facts
Deficiencies cited: 13
Missing Hydromorphone doses: 288
Missing Endocet doses: 108
Missing Methadone doses: 133
Missing Oxycodone doses: 120
Missing Ativan doses: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Left work after discovery of missing narcotics; suspected in medication diversion. |
| Resident Care Coordinator | Resident Care Coordinator | Had positive drug screen for oxycodone; failed to provide required verification; responsible for medication administration oversight. |
| Administrator | Facility Administrator | Responsible for overall facility compliance and oversight; unaware of many deficiencies until survey. |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 4, 2016
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted a follow-up survey and complaint investigation initiated on August 4, 2016.
Complaint Details
Complaint investigation was part of the follow-up survey initiated on August 4, 2016.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, personal care staff training and competency, diabetic care training for medication aides, failure to perform ordered daily blood pressure checks for a resident, verbal abuse and disrespectful treatment of residents by staff, lack of clinical validation for medication aides, and failure to conduct required drug screening for a staff member.
Deficiencies (7)
Facility failed to clean and maintain floors, ceiling fans, shower and tub rooms, and repair walls and broken window in resident rooms.
Facility failed to assure documentation that 3 of 9 sampled staff who provided personal care had completed required 80-hour personal care training and competency evaluation within 6 months of hire.
Facility failed to assure 3 of 3 medication aides received training by a licensed health professional on care of diabetic residents prior to administering insulin.
Facility failed to perform daily blood pressure checks as ordered for 1 of 3 residents reviewed.
Facility failed to treat residents with respect, dignity, and full recognition of individuality; residents were not allowed to make decisions about when to watch TV or smoke and were subject to verbal abuse by staff.
Facility failed to assure 3 of 3 medication aides who administered medications were clinically validated to administer medications.
Facility failed to assure an examination and screening for controlled substances was performed for 1 of 9 sampled staff hired after 10/1/13 before employment.
Report Facts
Resident rooms with housekeeping deficiencies: 12
Staff personal care training deficiencies: 3
Medication aides lacking diabetic training: 3
Days with missing blood pressure checks: 16
Days with missing blood pressure checks: 12
Staff medication aides lacking clinical validation: 3
Staff without drug screening: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Medication Aide | Named in findings related to verbal abuse, lack of diabetic training, lack of clinical validation, and failure to complete drug screening. |
| Staff B | Personal Care Aide / Medication Aide | Named in findings related to lack of diabetic training and clinical medication validation. |
| Staff C | Medication Aide | Named in findings related to lack of diabetic training and clinical medication validation. |
| Staff D | Named in findings related to lack of personal care training and competency. | |
| Staff E | Personal Care Aide | Named in findings related to lack of personal care training and competency. |
| Staff F | Named in findings related to lack of personal care training and competency. | |
| Staff J | Medication Aide | Mentioned in relation to blood pressure checks for Resident #3. |
Inspection Report
Deficiencies: 6
Date: Jul 1, 2016
Visit Reason
The inspection was a Biennial Construction Survey conducted to assess compliance with the 2005 Rules for Adult Care Homes of Seven or More Beds, focusing on physical plant and safety requirements.
Findings
The facility was found deficient in maintaining current sanitation and fire safety inspection reports, proper handling of portable medical oxygen cylinders, fire safety rehearsal documentation, and building equipment safety including emergency lighting and fire-rated wall integrity.
Deficiencies (6)
Required annual fire alarm system inspection report could not be located.
Most recent Fire Marshal building safety inspection report was dated 2013, not annually updated as required.
Portable medical oxygen cylinder was stored in no container, posing a hazard.
Records of fire safety rehearsals lacked description of what the rehearsal involved.
Battery powered emergency light near Administrator's office would not work when tested.
One-hour fire rated walls and/or ceilings were compromised; two sprinkler escutcheons not tightly fitted to kitchen ceiling.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 17, 2016
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted a follow-up survey on February 17, 2016 to assess compliance with activity program requirements.
Findings
The facility failed to assure a minimum of 14 hours of planned group activities per week were scheduled. Observations and interviews revealed no activities were taking place during the visit, the activity calendar lacked start and end times, and staff reported limited time for activities due to other duties. A new Activity Director had just started two days prior to the survey.
Deficiencies (1)
Facility failed to assure a minimum of 14 hours of planned group activities per week were scheduled.
Report Facts
Hours of planned group activities required: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Responsible for activities; reported staff do activities if they have time and that the previous activity staff person left two weeks prior | |
| Administrator | Reported community activities and hiring of new staff person to provide 14 hours of activities weekly; new Activity Director started 02/15/17 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 14, 2015
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted an annual survey and complaint investigation on December 7 - 11, 2015 and December 14, 2015. The complaint investigation was initiated by the Alexander County Department of Social Services on July 20, 2015.
Complaint Details
The complaint investigation was initiated by the Alexander County Department of Social Services on July 20, 2015.
Findings
The facility failed to assure quarterly fire plan rehearsals on each shift, maintain hot water temperatures at resident fixtures, ensure tuberculosis testing for staff, complete resident assessments timely, provide supervision to prevent sexually inappropriate behaviors, schedule sufficient group activities and outings, prevent diversion of controlled medications, maintain accurate controlled drug records, report suspected drug diversions to the pharmacy and Health Care Personnel Registry, and ensure overall management compliance.
Deficiencies (12)
Failed to assure rehearsals of the fire plan were performed quarterly on each shift in accordance with local Fire Prevention Code.
Failed to maintain hot water temperatures at 1 tub and 2 sinks used by residents at a minimum of 100 degrees Fahrenheit.
Failed to assure tuberculosis testing for 1 of 5 sampled staff was completed in compliance with control measures.
Failed to assure assessments for 9 of 14 residents were completed within 30 days following admission and annually thereafter.
Failed to provide supervision for 1 of 14 sampled residents who demonstrated sexually inappropriate behaviors towards 2 residents.
Failed to assure a minimum of 14 hours of planned group activities per week that promote socialization, physical interaction, group accomplishment, creative expression, increased knowledge and learning of new skills.
Failed to assure that each resident shall have the opportunity to participate in at least one outing every other month.
Failed to assure 2 of 6 sampled residents were free from exploitation by diversion of their controlled medications by staff (Zolpidem 10mg and Norco 5/325).
Failed to assure accountability of controlled drugs as evidenced by failure to assure accurate records of receipt, administration, and disposition of controlled drugs for 4 of 6 sampled residents.
Failed to report suspected diversion of controlled drug medications by staff to the dispensing pharmacy for 2 of 6 sampled residents.
Failed to investigate and report 3 suspected staff who had allegations of controlled drug diversion to the Health Care Personnel Registry.
Failed to assure residents were free from abuse, neglect, and exploitation in the areas of supervision to prevent sexual assault, diversion of controlled medications, and management of facilities.
Report Facts
Fire rehearsals: 13
Fire rehearsals: 12
Fire rehearsals: 1
Residents sampled: 14
Staff sampled: 5
Controlled drug tablets: 180
Controlled drug tablets missing: 155
Controlled drug tablets missing: 14
Controlled drug patches: 10
Controlled drug patches administered: 6
Controlled drug patches documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Suspected of diverting controlled drugs, refused drug test, and was terminated |
| Staff G | Medication Aide | Suspected of diverting controlled drugs and was terminated |
| Staff H | Medication Aide | Suspected of diverting controlled drugs and was terminated |
| Director | Responsible for facility management and oversight, suspected staff diversion but did not report to HCPR | |
| Administrator | Facility Administrator, responsible for total operation, unaware of missing controlled drugs | |
| Staff B | Personal Care Aide | Signed for controlled drug deliveries |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 15, 2015
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted a follow-up survey and complaint investigation on 4/14/15 and 4/15/15.
Complaint Details
The visit was a follow-up survey and complaint investigation conducted on 4/14/15 and 4/15/15. The previous Type A2 violation was not abated.
Findings
The facility failed to assure adequate and appropriate infection control procedures were implemented for blood glucose monitoring for at least 2 of 10 residents with orders for finger stick blood sugars by borrowing lancet devices from other residents for one resident who did not have a lancet device available. The previous Type A2 violation related to infection prevention was not abated.
Deficiencies (1)
Failed to assure adequate and appropriate infection control procedures for blood glucose monitoring by borrowing lancet devices from other residents.
Report Facts
Residents with FSBS orders: 10
FSBS checks: 27
FSBS refusals: 5
Date of correction: Apr 17, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Documented obtaining FSBS from Resident #4 and involved in infection control deficiency |
| Staff B | Medication Aide | Documented obtaining FSBS from Resident #4 and interviewed regarding lancet device use |
| Facility Director | Director/Administrator | Interviewed regarding infection control policy and deficiency; had been Director for 3 weeks |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 27, 2015
Visit Reason
The Adult Care Licensure Section and the Alexander County Department of Social Services conducted an annual, follow-up and complaint investigation on January 27, 28 & 29, 2015. The complaint investigation was initiated by the Alexander County Department of Social Services on December 09, 2014.
Complaint Details
The complaint investigation was initiated by the Alexander County Department of Social Services on December 09, 2014.
Findings
The facility failed to meet multiple regulatory requirements including management oversight, nutrition and food service safety, medication administration errors, improper storage of controlled substances, inadequate infection prevention practices including sharing lancet devices, incomplete infection control training for medication aides, and failure to maintain resident rights.
Deficiencies (11)
Administrator failed to assure total operation of the facility met rules related to management, nutrition, medication administration, controlled substances, infection prevention, infection prevention training, medication aide training and resident rights.
Facility failed to store and prepare food in a manner to protect from contamination.
Facility failed to provide table services that included a knife for all residents.
Facility failed to maintain matching therapeutic diet menus in the kitchen for 9 of 9 residents with therapeutic diets.
Facility failed to serve water to each resident in addition to other beverages.
Facility failed to maintain a current listing of residents with therapeutic diets for guidance of food service staff for 9 of 9 residents.
Facility failed to assure residents received medications as ordered by a licensed prescribing practitioner for 5 of 8 residents (Lopressor, Digoxin, Novolog, Lorazepam, and Metformin).
Facility failed to properly store Schedule II medication under double lock and proper supervision at all times.
Facility failed to assure adequate and appropriate infection control procedures were implemented for blood glucose monitoring by sharing a lancing device when used for different residents for 8 of 8 sampled residents.
Facility failed to assure 1 of 1 Medication Aide staff employed at the facility for at least one year had completed the annual state approved infection control training.
Facility failed to assure 2 of 3 sampled Medication Aide staff who were hired or began performing Medication Aide duties after 10/01/13 met the requirements for performing unsupervised Medication Aide duties.
Report Facts
Residents with therapeutic diets: 9
Residents with medication errors: 5
Medication observations: 31
Percocet tablets stolen: 200
Medication Aide staff not meeting requirements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete annual state approved infection control training; used common lancet pen for FSBS |
| Staff B | Medication Aide | Failed to meet training requirements for unsupervised medication aide duties; medication errors observed |
| Staff D | Medication Aide | Failed to meet training requirements for unsupervised medication aide duties |
| Administrator | Failed to assure total operation of facility met rules; believed staff used disposable lancet devices; scheduled infection control training | |
| Director | Delegated management tasks; unaware of infection control training completion; unaware of table service requirements; failed to secure controlled substances | |
| Cook A | Cook | Unaware of food service orientation training; failed to provide knives; thawed meat improperly |
| Cook B | Cook | Unaware of food service orientation training; thawed meat improperly; no sanitizer test strips |
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