Inspection Report
Follow-Up
Deficiencies: 3
Aug 13, 2025
Visit Reason
This is a Construction Section Biennial Follow-Up Survey conducted to verify correction of previously identified deficiencies related to physical plant and safety code compliance.
Findings
The facility was found not to be in compliance with code requirements related to electromagnetic locks and emergency release switches in the Special Care Unit (SCU). Additionally, electrical equipment including alarm systems at emergency override switches were not maintained in a safe and operating condition, with alarms failing to sound consistently.
Deficiencies (3)
| Description |
|---|
| Facility is not in compliance with code requirements for electromagnetic locks; doors did not release upon fire alarm activation. |
| Central emergency release switch did not release all doors in the SCU when activated. |
| Electrical equipment not maintained in a safe and operating condition; alarms at emergency override switch boxes did not sound or worked only about 50% of the time. |
Report Facts
Percentage alarm functionality: 50
Inspection Report
Follow-Up
Deficiencies: 2
Jun 19, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 06/17/25 to 06/19/25 to verify correction of previous medication administration deficiencies.
Findings
The facility failed to administer medications as ordered for 1 of 5 sampled residents (#1), specifically levothyroxine sodium 50 mcg and rosuvastatin calcium 40 mg, both ordered on 06/12/25 but not entered into the electronic medication administration record (eMAR) or sent to the pharmacy, resulting in no administration from 06/12/25 to 06/17/25. Facility staff were unaware of the missing orders until 06/17/25 and had not communicated with the pharmacy until 06/18/25.
Deficiencies (2)
| Description |
|---|
| Failure to administer levothyroxine sodium 50 mcg as ordered from 06/12/25 to 06/17/25 due to lack of entry in eMAR and no medication available. |
| Failure to administer rosuvastatin calcium 40 mg as ordered from 06/12/25 to 06/17/25 due to lack of entry in eMAR and no medication available. |
Report Facts
Medication administration period: 6
Number of sampled residents with medication issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | RCC | Responsible for reviewing new orders, sending orders to pharmacy, and updating eMAR; was new and unaware of missing orders until 06/17/25 |
| Health and Wellness Director | HWD | Responsible for reviewing new orders, sending orders to pharmacy, updating eMAR, and auditing eMAR; unaware of missing orders until 06/17/25 |
| Administrator | Expected staff to review new orders and audit eMAR weekly; unaware Resident #1 had missing medications | |
| Medication Aides | MA | Administered medications only if entered in eMAR; unaware of new orders for Resident #1 not entered in eMAR or sent to pharmacy |
Inspection Report
Capacity: 128
Deficiencies: 15
May 14, 2025
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for Homes for the Aged and Disabled, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including failures in fire safety systems such as delayed egress doors not releasing on fire alarm activation, emergency release switches not functioning, corridors obstructed by equipment, unsafe and unclean premises, malfunctioning electrical and fire safety equipment, inadequate hot water temperatures, and lack of exhaust ventilation in specified areas.
Deficiencies (15)
| Description |
|---|
| Delayed egress doors and electromagnetic locks did not release upon fire alarm activation. |
| Central emergency release switch did not release all doors in the Special Care Unit. |
| Delayed egress doors lacked required signage indicating door opening instructions. |
| Hold open magnets on smoke barrier doors did not release to allow doors to close upon fire alarm activation. |
| Corridors obstructed by equipment reducing clear width below six feet. |
| Outside premises not maintained in a clean and safe condition with hazards such as protruding nails and damaged exterior components. |
| Walls, ceilings, floors, and furnishings not kept clean or in good repair; presence of dust, grease accumulation, stains, leaks, and damage. |
| Facility not maintained free of hazards; missing lockset on bathroom door could trap occupants. |
| Electrical emergency/safety lighting and equipment not maintained in safe operating condition; exit signs and emergency lights failed to illuminate on test. |
| Fire safety systems compromised by holes in fire-resistant ceilings and doors requiring excessive force to close and latch. |
| Water intrusion and potential shock hazards due to tripped GFCI receptacle near water source. |
| Fire sprinkler system accelerator turned off, potentially delaying operation. |
| Screamer boxes at emergency switches failed to sound alarms consistently, risking unnoticed elopement. |
| Hot water temperatures at resident fixtures below minimum required temperature. |
| Exhaust ventilation not maintained in specified spaces, allowing buildup of humidity and odors. |
Report Facts
Total licensed beds: 128
Water temperature: 99
Water temperature: 98
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 4
Feb 13, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and a follow-up survey from 02/11/25 to 02/13/25 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in housekeeping and furnishings cleanliness, failure to serve water at each meal to assisted living residents, improper medication administration including insulin given contrary to orders, and unsecured storage of non-prescription medication in a resident's room.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident room and bathroom on D Hall were not kept clean, with scattered debris, stains, and unclean toilet and shower. | — |
| Facility failed to ensure water was served at each meal for 25 of 30 assisted living residents in addition to other beverages. | — |
| Facility failed to administer insulin as ordered for Resident #2, administering lispro insulin when blood sugar was below 200, contrary to physician's orders. | Type B Violation |
| Non-prescription medication (extra strength acetaminophen) was stored unsecured in Resident #2's room without labeling or staff awareness. | — |
Report Facts
Residents present at lunch meal service: 25
Residents present at breakfast meal service: 30
Residents not served water at each meal: 25
Doses of lispro insulin administered when FSBS was below 200: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | RCC | Responsible for rounds and cleanliness checks; acknowledged lack of awareness of some deficiencies |
| Health and Wellness Director | HWD | Responsible for beverage service oversight and medication administration education; unaware of insulin administration errors |
| Administrator | Took over housekeeping duties after housekeeper quit; expected compliance with medication and cleanliness standards | |
| Medication Aide | MA | Administered insulin and medications; some confusion about insulin orders |
Inspection Report
Follow-Up
Deficiencies: 2
Jan 11, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant and construction compliance.
Findings
The facility was found not in compliance with code requirements for delayed egress doors which did not release as required. Additionally, the facility failed to submit required plans and specifications for construction or remodeling to the Division of Health Service Regulation.
Deficiencies (2)
| Description |
|---|
| Delayed egress doors did not release within 15 seconds when pressure was applied, and were programmed to stay open on a timer that staff could not disable for testing. |
| Facility did not submit plans or specifications for construction or remodeling to the Division as required. |
Report Facts
Time delayed egress doors must unlock: 15
Force applied to door: 15
Date of observation of delayed egress system addition: May 9, 2023
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 21, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 09/20/23 through 09/21/23 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure that one of five sampled residents was tested for tuberculosis upon admission, and failed to ensure follow-up with health care providers for one resident who had multiple medication refusals.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 1 of 5 sampled residents was tested upon admission for tuberculosis disease in compliance with control measures. |
| Facility failed to ensure follow-up with health care providers for 1 of 5 sampled residents who had medication refusals. |
Report Facts
Residents sampled: 5
Medication refusal occurrences: 30
Medication refusal occurrences: 31
Medication refusal occurrences: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for ensuring residents had admission requirements completed including TB skin tests; interviewed regarding TB testing and medication refusals | |
| Executive Director | Responsible for ensuring residents had documentation for TB testing; interviewed regarding TB testing and medication refusals | |
| Business Office Manager | Responsible for ensuring residents had admission requirements completed including TB skin tests; interviewed regarding TB testing | |
| Corporate Nurse | Provided orientation and training to current facility Nurse; interviewed regarding TB testing | |
| Facility Nurse | Responsible for ensuring residents received TB skin tests upon admission; interviewed regarding TB testing and medication refusals | |
| Medication Aide | Interviewed regarding Resident #2's medication refusals and communication with endocrinologist | |
| Director of Health and Wellness | Interviewed regarding medication refusal notification procedures | |
| Administrator | Interviewed regarding medication refusal notification procedures |
Inspection Report
Follow-Up
Deficiencies: 7
Aug 15, 2023
Visit Reason
This is a Construction Section Biennial Survey Follow Up conducted to verify correction of previously identified deficiencies related to physical plant and safety code compliance.
Findings
The facility was found not in compliance with code requirements for delayed egress doors, electromagnetic lock override switches, wiring diagrams, sprinkler protection, fire safety equipment maintenance, and exhaust ventilation. Several deficiencies from prior inspections remain uncorrected.
Deficiencies (7)
| Description |
|---|
| Delayed egress doors did not release within 15 seconds when pressure was applied, except on fire alarm activation. |
| No central override switch for electromagnetic locks on front entry doors; not connected to central override in SCU. |
| No wiring diagram or system components location map provided under glass adjacent to fire alarm panel. |
| A 24" x 24" broom closet in SCU Kitchen lacks sprinkler protection. |
| Facility did not submit plans or specifications for construction or remodeling to the Division as required. |
| Fire safety equipment not maintained in operating condition; kitchen sprinkler head heavily rusted. |
| Exhaust ventilation not maintained in specified spaces; exhaust fans in B Hall Housekeeping and Half Bath not working. |
Report Facts
Dimensions of broom closet: 24
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 27, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey from January 26, 2022 through January 27, 2022 to assess compliance with health care regulations.
Findings
The facility failed to ensure proper follow-up with health care providers for one resident regarding anti-coagulant medication management and scheduled INR lab work. Specifically, the facility missed collecting an ordered INR lab on 01/20/22 and did not notify the primary care provider of missed or refused warfarin doses, placing the resident at risk for serious complications.
Deficiencies (1)
| Description |
|---|
| Failed to ensure follow-up with health care providers for 1 of 5 sampled residents related to anti-coagulant medication and scheduled INR lab work. |
Report Facts
Warfarin dose discrepancy: 5
INR lab results: 1.51
INR lab results: 1.53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Director of Health and Wellness | Interviewed regarding missed INR lab and facility procedures. |
| Executive Director | Executive Director | Interviewed regarding lab collection responsibilities and facility protocols. |
Inspection Report
Capacity: 128
Deficiencies: 14
Dec 12, 2019
Visit Reason
Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety standards applicable to the facility.
Findings
Multiple deficiencies were cited related to physical plant and safety including failure to meet code requirements for special locking doors, corridor obstructions, lack of wanderer alarms, poor housekeeping and maintenance issues, fire extinguisher maintenance lapses, emergency lighting failures, door operation and fire safety concerns, sprinkler system issues, and ventilation system failures.
Deficiencies (14)
| Description |
|---|
| Facility failed to meet code requirements for special locking doors and emergency release switches. |
| Corridors were obstructed, blocking egress during emergencies. |
| Exit doors accessible by residents lacked functioning sounding devices for wanderer alarms. |
| Building ceilings and walls were not kept clean and in good repair, including mold and deteriorated ceiling assemblies. |
| Hazards present due to unsecured portable oxygen cylinder and lack of vacuum breaker on shampoo sink. |
| Fire extinguishers were not properly maintained or inspected monthly. |
| Emergency lighting and exit signs failed to illuminate on backup power or lacked test buttons. |
| Doors required excessive force to open and some fire-resistance-rated doors were held open improperly. |
| Cooking equipment was improperly positioned under fire suppression system nozzles. |
| Fire-resistance-rated door assemblies and smoke barriers had gaps or were missing components compromising smoke containment. |
| Fire sprinkler heads were obstructed and sprinkler escutcheon plates were missing. |
| Corridor doors were blocked open by wedges or chairs, preventing proper closure. |
| Required exhaust ventilation system in housekeeping area was not functioning. |
| Electrical system deficiencies including non-functioning GFCI outlets and unsafe multiple plug adaptors. |
Report Facts
Total licensed beds: 128
Fire extinguisher requirement: 1
Inspection Report
Annual Inspection
Deficiencies: 9
May 3, 2018
Visit Reason
The Adult Care Licensure Section conducted an Annual survey from 05/01/18 to 05/03/18 at Carillon Assisted Living of Salisbury.
Findings
The facility was found deficient in multiple areas including competency validation for medication aides, tuberculosis testing upon admission, health care follow-up, nutrition and food service, therapeutic diet accuracy and compliance, medication order clarification, and use of physical restraints without proper orders and assessments.
Severity Breakdown
Type B Violation: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to assure competency validation for Licensed Health Professional Support tasks for 1 of 6 sampled staff (Medication Aide). | — |
| Failed to ensure 1 of 5 sampled residents was tested upon admission for tuberculosis disease. | — |
| Failed to notify physician for 1 of 5 sampled residents regarding medication used to treat Parkinson's disease. | — |
| Failed to provide proper table service including non-disposable silverware and beverage containers for residents eating in their rooms. | — |
| Failed to maintain an accurate and current listing of residents with physician-ordered therapeutic diets for 1 of 6 residents sampled. | — |
| Failed to serve therapeutic diet as ordered for 1 of 5 residents with an order for a regular ground meat diet. | — |
| Failed to ensure contact with prescribing physician for clarification of sliding scale insulin orders with no parameters for 1 of 5 residents. | — |
| Failed to assure physical restraints were used only after assessment and care planning with physician's order for 3 of 3 sampled residents with bed rails. | Type B Violation |
| Failed to ensure medication aide had completed Medication Clinical Skills Competency checklist prior to administering medications. | — |
Report Facts
Medication administration dates: 23
Resident blood sugar range: 429
Resident blood sugar range: 366
Residents sampled: 6
Residents sampled: 5
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Named in competency validation and medication clinical skills checklist findings. |
| Executive Director | Provided information on competency validation, medication clinical skills checklist, and physical restraint policies. | |
| Resident Care Coordinator | Responsible for ensuring competency validations and therapeutic diet list accuracy. | |
| Regional Registered Nurse | RN | Responsible for completing competency checklists and reviewing therapeutic diet lists. |
| Dietary Manager | Provided information on food service and therapeutic diet list. |
Inspection Report
Capacity: 128
Deficiencies: 11
Nov 1, 2017
Visit Reason
Biennial construction section survey to ensure compliance with applicable state rules and building codes for adult care homes.
Findings
The facility was found to have multiple physical plant deficiencies including exit door locks not operable by single hand motion, mis-positioned stoves affecting fire suppression, compromised fire safety equipment and fire rated walls, malfunctioning warning devices, doors propped open or missing latchbolts, loosely mounted sink, and non-functioning exhaust ventilation in the janitor's closet.
Deficiencies (11)
| Description |
|---|
| Exit doors failed to provide single hand motion locks at all exits equipped with exit signs. |
| Stoves in the kitchen were moved forward causing range hood fire suppression nozzles to be misdirected; deficiency corrected during survey. |
| Shower wand hose in Spa on D Hall long enough to reach sink basin without vacuum breaker, risking water contamination. |
| Magnetic hold open devices on fire and smoke partition doors re-energized before fire alarm system fully reset, allowing potential smoke/fire spread. |
| Special locking magnetic locks on exit doors re-energized before fire alarm system fully reset, potentially delaying evacuation. |
| Sprinkler accelerator appeared turned off, risking sprinkler system failure in fire. |
| One-hour fire rated walls and ceilings compromised with holes and penetrations not properly sealed. |
| Warning device ('screamer') protecting emergency release switch not working at exit from C Hall near room C1. |
| Corridor doors prevented from closing quickly and latching; includes missing latchbolt on mop closet door and door to bedroom D15 propped open (corrected during survey). |
| Sink in public men's bathroom not tightly mounted to wall, posing injury risk. |
| Exhaust fan not working in janitor's closet on C Hall, failing to maintain required ventilation. |
Report Facts
Total licensed beds: 128
Inspection Report
Capacity: 128
Deficiencies: 9
Dec 11, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes and physical plant requirements for an adult care home licensed for 128 beds.
Findings
The facility was found to have multiple deficiencies including malfunctioning emergency lights, compromised fire-rated walls and ceilings, obstructed sprinkler heads, non-functioning warning devices, unsafe mounting of lavatories, holes in corridor doors, improper handling of portable medical oxygen cylinders, improperly sealed waste drains, and non-functioning exhaust ventilation in specified areas.
Deficiencies (9)
| Description |
|---|
| Battery powered emergency lights would not work when tested at porch in Special Care, dining in Special Care, and corridor at room B5. |
| Required one-hour fire rated walls and/or ceilings were compromised with unsealed sleeves, unprotected pipe penetrations, missing sprinkler escutcheon, and holes in corridor doors. |
| Sprinkler head in riser room was obstructed by fire caulk. |
| Warning sounding device covering magnetic locking emergency release switch failed to sound when lifted. |
| Cast iron lavatory loosely mounted to the wall in visitors men's bathroom. |
| Building not maintained safely due to improper handling of portable medical oxygen cylinders stored without container in Nurse office. |
| Several waste drains not properly sealed including open wall drains in utility closet and resident laundry, and dry hopper trap in utility room. |
| Ice machine drain line was only 1 inch above floor drain, not meeting code requirement of at least 2 inches. |
| Facility failed to maintain required exhaust ventilation in working condition in Spa and resident laundry in Special Care. |
Report Facts
Licensed beds: 128
Special Care Unit beds: 36
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