Inspection Reports for Seven Lakes Assisted Living
292 McDougall Drive West End, NC 27376, West End, NC, 27376
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
50 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 3
Date: Oct 2, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual, follow-up, and complaint investigation from 09/30/25 to 10/02/25 at Seven Lakes Assisted Living.
Complaint Details
Complaint investigation included allegations of residents being treated disrespectfully, inappropriate isolation due to COVID-19, and medication errors. The complaint was substantiated with findings of staff rudeness, improper isolation practices, and medication administration errors.
Findings
The facility failed to maintain clean furniture in the special care unit, treated residents without dignity and respect including inappropriate isolation due to COVID-19, and had medication administration errors involving inhaler dosing and discontinued diabetes medication.
Deficiencies (3)
Facility failed to ensure 7 of 15 chairs in the special care unit living room were clean.
Facility failed to ensure residents were treated with dignity and respect, including inappropriate isolation due to COVID-19 and improper meal setup for residents eating in their rooms.
Facility failed to ensure medications were administered as ordered for 2 of 3 residents, including errors with an inhaler for COPD and a medication for diabetes.
Report Facts
Residents present: 50
Residents in special care unit: 28
Medication error rate: 7
Chairs unclean: 7
Medication doses remaining: 44
Medication doses used: 16
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies.
Findings
Not all previously cited deficiencies have been corrected. The facility does not meet the requirements of NFPA 72 regarding fire alarm system hold-open devices, which remain engaged when the system is placed in silence mode instead of being manually reset.
Deficiencies (1)
Facility does not meet NFPA 72 requirements; all doors equipped with held-open devices controlled by the fire alarm system shall remain dis-engaged until the fire alarm system is manually reset.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Conducted the Biennial Follow Up Construction Survey. | |
| Maintenance Manager | Interviewed regarding fire alarm system deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 31, 2024
Visit Reason
The Adult Care Licensure Section and Moore County Department of Social Services conducted a follow-up survey on July 30-31, 2024 to verify correction of previous deficiencies.
Findings
The facility failed to ensure medication aides had proper state-approved medication administration training documentation and employment verification. Additionally, the facility failed to clarify medication orders for one resident and failed to administer medications as ordered for two residents, including errors with insulin, inhaler use, and medication timing.
Deficiencies (3)
Failed to ensure 3 of 6 sampled medication aides had medication aide employment verification or required state-approved medication administration training documentation.
Failed to clarify medication orders for 1 of 5 sampled residents for medications to treat shortness of breath, chest congestion, and a rash.
Failed to ensure medications were administered as ordered for 1 of 5 residents observed during medication pass including errors with rapid-acting insulin and inhaler; and for 1 of 5 residents including an error with medication for enlarged prostate symptoms.
Report Facts
Medication error rate: 7
Sampled medication aides: 6
Medication administration training hours: 15
Resident sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to have state approved medication administration training certificate |
| Staff C | Medication Aide | Failed to have medication aide employment verification and state approved training certificate |
| Staff D | Medication Aide | Failed to have medication aide employment verification and state approved training certificate |
| Staff F | Medication Aide | Failed to have medication aide employment verification and state approved training certificate |
| Administrator | Provided interviews regarding medication aide training and personnel file audits | |
| Regional Director of Operations | Provided interview regarding personnel file audits and medication aide training | |
| Vice President of Clinical Services | Provided interview regarding medication administration training requirements | |
| Resident Care Coordinator | Provided interview regarding medication administration and blood sugar monitoring | |
| Medication Aide | Interviewed about medication administration practices for residents | |
| Resident #5's hospice nurse | Provided interview regarding medication orders and administration for Resident #5 | |
| Resident #1's primary care provider | Provided telephone interview regarding blood sugar monitoring and inhaler use for Resident #1 |
Inspection Report
Annual Inspection
Census: 36
Capacity: 60
Deficiencies: 9
Date: May 17, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow up survey and complaint investigation on May 14 - 17, 2024. The complaint investigation was initiated by the Moore County Department of Social Services on April 16, 2024.
Complaint Details
The complaint investigation was initiated by the Moore County Department of Social Services on April 16, 2024.
Findings
The facility failed to ensure safety and security on the Special Care Unit related to windows that could be fully opened by residents, failed to ensure medication staff qualifications, failed to ensure personal care aides were primarily tasked with direct care, failed to provide adequate supervision for residents with multiple falls and injuries, failed to ensure referral and follow-up for acute health care needs, failed to complete timely Licensed Health Professional Support evaluations, failed to serve water at meals, failed to serve meal supplements as ordered, and failed to administer medications as ordered including medication errors with antihypertensives, insulin, and antidepressants.
Deficiencies (9)
Facility failed to ensure safety and security on the Special Care Unit related to windows installed with latches that could be pressed down allowing full opening and were not monitored by staff.
Facility failed to ensure 4 of 4 medication staff had completed required diabetic training and one staff had medication aide testing not verified until survey date.
Facility failed to ensure personal care aides were primarily tasked with direct personal care and supervision and not routinely assigned housekeeping and laundry duties during 7am to 9pm.
Facility failed to ensure supervision for 2 residents with multiple falls resulting in injuries and hospitalizations, including one resident who died from fall-related injuries.
Facility failed to ensure referral and follow-up to meet acute health care needs of 2 residents related to notifying PCP for low blood pressure and multiple meal refusals with significant weight loss prior to hospice initiation.
Facility failed to ensure Licensed Health Professional Support evaluation was completed at least quarterly for 3 residents with specific care tasks.
Facility failed to ensure water was served at breakfast and lunch for both Assisted Living and Special Care Unit residents.
Facility failed to ensure meal supplements were served as ordered for 2 residents.
Facility failed to ensure medications were administered as ordered for 3 residents including an antihypertensive medication error, insulin administration errors, and antidepressant dosing errors.
Report Facts
Licensed capacity: 60
Census: 36
Medication error rate: 4
Supplement shakes order: 75
Weight: 89.5
Weight loss: 15
FSBS checks: 93
FSBS less than 150: 89
FSBS 150 or greater: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Manager | Memory Care Manager | Involved in findings related to window safety, medication errors, and communication with PCP. |
| Resident Care Coordinator | Resident Care Coordinator | Involved in medication order review and fall supervision. |
| Administrator | Administrator | Provided information on facility policies, supervision, and medication administration. |
| Medication Aide | Medication Aide | Involved in medication administration and reporting errors. |
| Personal Care Aide | Personal Care Aide | Involved in resident care and supervision findings. |
| Activities Director | Activities Director | Provided information on resident supervision and behaviors. |
| Licensed Health Professional Support Nurse | LHPS Nurse | Performed LHPS evaluations and reported delays. |
| Pharmacist | Pharmacist | Provided information on medication orders and pharmacy processes. |
| Primary Care Provider | Primary Care Provider | Provided medical orders and information related to residents' care. |
| Hospice Nurse | Hospice Nurse | Involved in care and assessment of Resident #6 after falls. |
Inspection Report
Plan of Correction
Capacity: 60
Deficiencies: 9
Date: Nov 7, 2018
Visit Reason
This report documents a Construction Section Biennial Survey conducted to assess compliance with the 1984 Rules for Homes for the Aged, the 2005 Regulations for Adult Care Homes, and the 1978 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including lack of current fire safety inspection reports, improper use of bathrooms for storage, unlocked hazardous substance storage, unclean and damaged furnishings, presence of hazards such as exposed metal edges and unsecured oxygen bottles, failure to conduct quarterly fire drill rehearsals on each shift, and failure to maintain fire safety and plumbing equipment in safe operating condition.
Deficiencies (9)
Facility did not maintain current fire safety inspection reports; most recent was dated June 21, 2017.
Bathrooms were utilized for storage purposes, specifically the community bath by Room 106.
Hazardous substances were not kept in a separate locked area; med room was unlocked with medicine packets and dangerous items accessible.
Floors were heavily stained and not kept clean; furnishings were damaged including bathroom doors and shower chairs.
Facility was not maintained free of unpleasant odors; strong odor noted in Room 205.
Furnishings were not maintained free of hazards; exposed rough metal edges and unsecured oxygen bottles present.
Fire drill rehearsals were not conducted quarterly on each shift; no records since July 25, 2018.
Fire safety equipment not maintained in safe operating condition; doors difficult to close, gate framing warped.
Plumbing equipment not maintained in safe operating condition; leaking water heater and improper plumbing installation.
Report Facts
Licensed capacity: 60
Date of last fire alarm inspection: Jun 21, 2017
Number of unsecured oxygen bottles: 3
Number of small oxygen bottles stacked: 10
Date of last fire drill record: Jul 25, 2018
Inspection Report
Capacity: 60
Deficiencies: 4
Date: Feb 2, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey to ensure the facility meets the 1984 Rules for Homes for the Aged, applicable portions of the 2005 Regulations for Adult Care Homes of seven or more beds, and the 1978 Edition Volume I of the North Carolina State Building Code-Section 409-Institutional Occupancies.
Findings
Deficiencies were cited related to failure to maintain floor coverings and finishes, ceiling construction and finishes damaged by water migration or previous roof leaks, breaches in one-hour rated ceiling construction compromising fire safety, and failure to maintain emergency lighting in a safe and operating condition.
Deficiencies (4)
Facility failed to maintain floor coverings and finishes; floor surfaces in multiple rooms need cleaning and waxing.
Facility failed to maintain ceiling construction and finishes; ceilings damaged due to water migration and/or previous roof leaks in multiple locations.
Facility was not maintained in a safe manner due to breaches of the one-hour rated ceiling construction invalidating its integrity, potentially affecting fire and smoke containment.
Facility failed to maintain emergency lighting in a safe and operating condition; exterior emergency wall light at SCU Courtyard gate does not illuminate when tested.
Report Facts
Licensed capacity: 60
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 31, 2014
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation from 12/29/2014 through 12/31/2014 regarding concerns about the facility's failure to assure timely referral and follow-up for health care needs of residents.
Complaint Details
Complaint investigation conducted from 12/29/2014 to 12/31/2014. The complaint involved failure to assure timely physician referral and follow-up for Resident #2's poor appetite, medication refusal, and wound care, leading to health decline and worsening decubitus ulcer. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to assure timely referral to the physician for poor appetite, medication refusal, and wound care for Resident #2, resulting in continued decline in health and worsening of a decubitus ulcer. Documentation and interviews revealed lack of physician notification, missed wound care, medication refusals, and cancelled follow-up appointments.
Deficiencies (2)
Failed to assure referral to the physician for poor appetite, medication refusal, and wound care in a timely manner for Resident #2, resulting in continued decline and worsening of a decubitus ulcer.
Failed to ensure residents received care and services which are adequate, appropriate, and in compliance with relevant federal and state laws and rules and regulations related to health care.
Report Facts
Dates of complaint investigation: 12/29/2014 through 12/31/2014
Resident #2 admission date: 12/12/2013
Decubitus ulcer measurements: 3 cm x 5 cm (hospital consult 12/9/2013), 3.5 cm x 3.5 cm (physician assessment 12/16/2013), 6 cm x 3 cm x 3 cm (stage IV ulcer on 12/25/2013)
Medication refusal counts: Resident #2 refused multiple doses of various medications (e.g., 9 of 10 Gingko biloba doses, 8 of 20 Hydralazine doses, etc.)
Incident report vital signs: Temperature 99.1°F, blood pressure 180/70, pulse 110, respirations 22, blood sugar 90 (12/25/2013 incident)
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