Inspection Report
Annual Inspection
Deficiencies: 2
Jun 5, 2025
Visit Reason
The Adult Care Licensure Section and Cleveland County Department of Social Services conducted an annual survey from June 4, 2025 through June 5, 2025 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in medication labeling for one resident due to failure to ensure medication containers had correct labels reflecting current physician orders. Additionally, the electronic Medication Administration Record (eMAR) was inaccurate for two residents regarding oxygen administration orders, which were missing from the eMAR despite active physician orders and observed oxygen use.
Deficiencies (2)
| Description |
|---|
| Failed to ensure medication containers had correct labels for 1 of 5 sampled residents (Resident #2) for medications used to treat fluid overload and high blood pressure. |
| Failed to ensure the electronic Medication Administration Record (eMAR) was accurate for 2 of 5 sampled residents related to oxygen administration (#1 & #3). |
Report Facts
Sampled residents: 5
Medication label deficiency: 1
Oxygen administration eMAR deficiency: 2
Medication quantities: 19
Medication quantities: 56
Medication dispense quantities: 45
Medication dispense quantities: 90
Medication dispense quantities: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for medication cart audits, ensuring orders entered into eMAR, and sending orders to contracted pharmacy |
| Administrator | Administrator | Responsible for following up on orders and overseeing facility compliance |
| Medication Aide | Medication Aide (MA) | Administered medications, responsible for placing labels on medications and documenting oxygen administration |
| Hospice Registered Nurse | Hospice Registered Nurse (RN) | Provided oxygen order and administered oxygen to Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 10, 2025
Visit Reason
The visit was conducted as a complaint investigation regarding the facility's supervision of residents, specifically related to an incident of elopement from the Special Care Unit (SCU).
Findings
The facility failed to provide adequate supervision for one resident with a history of wandering behaviors, resulting in the resident eloping from the SCU without staff knowledge and being found off-site. This failure placed the resident at substantial risk for serious physical harm and was cited as a Type A2 violation.
Complaint Details
The complaint investigation substantiated that Resident #1, diagnosed with Alzheimer's disease and memory loss, eloped from the facility's Special Care Unit on 11/09/24 and was found off-site approximately 0.30 miles away. Staff failed to document two-hour checks and did not know how the resident eloped. The facility lacked camera or video surveillance and had no interventions in place to address wandering behaviors.
Severity Breakdown
TYPE A2 VIOLATION: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide supervision for 1 resident with a history of wandering behaviors, resulting in elopement from the Special Care Unit without staff knowledge. | TYPE A2 VIOLATION |
Report Facts
Dates of visits: 11/12/24, 11/14/24, 11/18/24, 1/09/24
Correction date deadline: Correction date for the A2 violation shall not exceed February 12, 2025
Number of times SCU doors opened: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Morehead | Adult Home Specialist | DSS Signature on report delivery |
| Jacqueline Sibley-Newton | Executive Director | Administrator/Designee who received the CAR |
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 5
Jul 13, 2023
Visit Reason
The Adult Care Licensure Section and the Cleveland County Department of Social Services conducted an annual survey and complaint investigations from 07/11/23 to 07/13/23. The complaint investigations were initiated by the Cleveland County Department of Social Services on 06/23/23.
Findings
The facility failed to ensure timely completion of resident care plans, adequate supervision of residents resulting in elopement, proper implementation and administration of physician-ordered medications, and security monitoring on exit doors in the Special Care Unit. Resident #1 eloped and was found outside overnight, and multiple medication errors were identified for Residents #1, #4, and #6.
Complaint Details
Complaint investigations were initiated by the Cleveland County Department of Social Services on 06/23/23 related to resident care and supervision issues.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 sampled residents (#4) had a care plan completed within 30 days of admission. | — |
| Failed to provide supervision for 1 of 6 sampled residents (#1) resulting in elopement from the locked Special Care Unit courtyard. | Type A1 Violation |
| Failed to ensure physician orders were implemented for 1 of 5 sampled residents (#1) for cholesterol and pain medications. | — |
| Failed to ensure medications were administered as ordered for 2 of 6 sampled residents (#4 and #6) related to blood clotting, blood sugar, and fungal infection medications. | — |
| Failed to ensure 2 exit doors to the enclosed courtyard in the Special Care Unit were equipped with a security monitoring system that activated for resident safety. | — |
Report Facts
Residents sampled: 6
Residents sampled: 5
Medication errors: 3
Medication errors: 2
Medication errors: 1
Residents present: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Responsible for completing resident care plans and verifying medication orders | |
| Administrator | Oversight of care plan completion, medication administration, and security monitoring | |
| Resident Care Director (RCD) | Responsible for medication order clarification and cart audits | |
| Medication Aide (MA) | Administered medications and involved in medication errors | |
| Special Care Unit (SCU) Coordinator | Responsible for supervision and monitoring of residents in SCU |
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 20, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow-up survey on 01/19/22 through 01/20/22 to assess compliance with therapeutic diet orders and resident care.
Findings
The facility failed to ensure therapeutic diets were served as ordered for 3 of 3 sampled residents, including two residents with orders for nectar thickened liquids who were served vegetable medley soup with thin liquid, and one resident on a consistent carbohydrate diet who was served a regular strawberry mousse dessert. This failure posed risks such as aspiration pneumonia and elevated blood sugars.
Severity Breakdown
Type B Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure therapeutic diets were served as ordered for 3 of 3 sampled residents, including serving thin liquid soup to residents ordered nectar thickened liquids and serving regular dessert instead of sugar-free dessert to a diabetic resident. | Type B Violation |
Report Facts
Number of sampled residents with diet order issues: 3
Correction deadline: Mar 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding diet orders, responsible for ordering foods and thickening soup. | |
| Special Care Unit Coordinator | Interviewed about staff responsibilities for thickening liquids and diet order communication. | |
| Personal Care Aide | Interviewed about serving meals and thickened liquids. | |
| Medication Aide | Interviewed about serving meals and thickened liquids. | |
| Speech Therapist | Recommended nectar thick liquids for Resident #6. | |
| Primary Care Physician | Provided diet orders and confirmed risks related to improper diet consistency. | |
| Administrator | Interviewed about facility expectations and contracted menu provider instructions. | |
| Health and Wellness Director | Responsible for providing kitchen with diet orders and diet clarifications. |
Inspection Report
Follow-Up
Deficiencies: 2
Dec 4, 2020
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and a COVID-19 Infection Control survey with an onsite visit on 12/03/20 and desk review and telephone exit on 12/04/20.
Findings
The facility failed to ensure physician notification and follow-up for two residents regarding oxygen saturation and weight/blood pressure parameters, and failed to implement physician's orders for another resident regarding the application of thromboembolic deterrent hose and a chair/bed alarm.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure physician notification for 2 of 5 sampled residents related to not obtaining parameters and not notifying the physician of low oxygen saturation levels and weight/blood pressure parameters. | Type A1 Violation |
| Failed to implement physician's orders for 1 of 5 sampled residents regarding the application of thromboembolic deterrent hose and a chair/bed alarm. | — |
Report Facts
Oxygen saturation readings: 76
Oxygen saturation readings: 100
Weight range (lbs): 296
Weight range (lbs): 308.6
Blood pressure readings: 140
Blood pressure readings: 196
Date of skin tear: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide (MA)/supervisor | Provided verbal standing orders and described oxygen saturation notification process for Resident #2 | |
| Resident Care Coordinator (RCC) | Responsible for processing physician's orders and faxing oxygen saturation results; interviewed regarding notification procedures | |
| Resident Services Director (RSD) | Nurse responsible for overseeing clinical operations and auditing physician orders | |
| Administrator | Interviewed regarding awareness of orders and facility expectations | |
| Memory Care Manager (MCM) | Responsible for ensuring TED hose application | |
| Executive Director | Responsible for clinical staff oversight and auditing processes |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 9, 2020
Visit Reason
The Adult Care Licensure Section conducted a Complaint Investigation and a COVID-19 focused Infection Control survey with an onsite visit on September 09, 2020 and a desk review and telephone exit on September 14, 2020.
Findings
The facility failed to ensure the acute healthcare needs were met for Resident #1 related to injuries sustained after a fall and evidence of blood in her brief. There was a 19-hour delay in sending Resident #1 to the hospital resulting in hospitalization with a flailed chest, multiple rib fractures, massive bruising, and pneumothorax requiring two chest tubes. The facility also failed to notify the resident's PCP timely about the fall, bruising, pain complaints, and blood in the brief.
Complaint Details
This was a complaint investigation triggered by concerns about Resident #1's fall, delayed hospital transfer, and failure to notify the PCP of injuries and blood in the brief. The complaint was substantiated based on observations, interviews, and record reviews.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure acute healthcare needs were met for Resident #1 after a fall, resulting in delayed hospital transfer and serious injuries including flailed chest, rib fractures, bruising, and pneumothorax. | Type A1 Violation |
| Failure to assure residents were free from neglect related to healthcare referral and follow-up, specifically failure to notify PCP of bruising, pain, and blood in Resident #1's brief. | — |
Report Facts
Delay in hospital transfer: 19
Date of fall: Aug 31, 2020
Date of hospital transfer: Sep 1, 2020
Date of survey completion: Sep 14, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Operations Specialist / Resident Services Director | Facility RN who assessed Resident #1 and instructed PCP notification for X-ray | |
| Administrator | Facility administrator who delegated clinical responsibilities to RN and expected timely reporting | |
| Memory Care Coordinator (MCC) | Staff responsible for oversight on Resident #1's hall, observed bruising but did not see RN assessment | |
| Third shift supervisor | Supervisor on duty during Resident #1's fall who delayed incident report and hospital transfer | |
| Primary Care Provider (PCP) | Resident #1's physician who was not timely notified of fall, bruising, pain, or blood in brief |
Inspection Report
Routine
Capacity: 96
Deficiencies: 14
Apr 25, 2019
Visit Reason
Routine Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and other regulatory requirements for an adult care home licensed for 96 beds including 60 Special Care Unit beds.
Findings
Multiple deficiencies were cited including unlabeled emergency release switches, missing current fire and sprinkler inspection reports, loose hand grips in bathrooms, corridor obstructions, non-working wanderer alarms, unsafe outside premises, poor housekeeping and maintenance, unsecured oxygen cylinders, electrical safety issues, non-functional emergency lighting and exit signs, fire safety code violations, lack of proper control over ovens, inadequate hot water temperatures, and non-functional exhaust ventilation systems.
Deficiencies (14)
| Description |
|---|
| Central on/off emergency release switch for the Special Locking System is not labeled. |
| Facility failed to maintain current annual fire alarm and sprinkler system inspection reports. |
| Commode side hand grip (grab bar) in Bedroom C-6 Bathroom is loose. |
| Corridors obstructed by equipment and furniture, including walker and chair reducing corridor width to 23 inches. |
| Exit doors accessible by residents lack functioning sounding devices activated when doors open. |
| Outside grounds not maintained in a clean and safe condition; rotting picket on guardrail and blistering porch ceiling paint. |
| Walls, mechanical systems, and furniture not kept clean and in good repair; holes in walls and excessive dust/lint accumulation. |
| Building not maintained free of hazards; exposed mounting brackets with sharp edges and unsecured portable oxygen cylinders. |
| Electrical outlets in wet locations lack ground fault interrupters or GFCI outlets not functioning properly. |
| Emergency exit signs and emergency lights did not illuminate on backup power; electrical panels with exposed energized components. |
| Fire safety deficiencies including unsealed penetrations in fire-resistance-rated ceilings and walls, missing door handles, doors not latching, and sprinkler escutcheon plates missing or displaced. |
| Range in B Hall Activity Room energized without staff supervision. |
| Hot water temperature at Bedroom A11 Bathroom sink was 66°F after running more than 8 minutes, below minimum required 100°F. |
| Exhaust ventilation systems in A Hall Utility Closet and Restroom near Bedroom B-9 did not work. |
Report Facts
Licensed bed capacity: 96
Special Care Unit beds: 60
Hot water temperature: 66
Corridor width obstruction: 23
Inspection Report
Capacity: 96
Deficiencies: 14
Apr 19, 2017
Visit Reason
This is a biennial construction section survey to ensure the facility meets applicable regulations including the 1996 Regulations for Homes for the Aged and Disabled, 2005 Regulations for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
The survey identified multiple deficiencies related to physical plant and fire safety including missing sanitation and fire safety inspection reports, lack of hand grips in bathrooms, presence of black mold, hazards related to exit signs and emergency lighting, compromised fire rated walls and ceilings, improperly mounted sprinkler escutcheons, malfunctioning exit signs, corridor doors not closing or latching properly, missing exit signs, open spaces in electrical panels, and dirty ceiling radiation dampers. Several deficiencies were corrected during the survey.
Deficiencies (14)
| Description |
|---|
| Missing fire and building safety inspection reports including fire marshal report and sprinkler system inspection. |
| No hand grip provided at the tub in the Spa on B Hall. |
| Walls and ceiling of the sprinkler riser room covered with black mold. |
| Exit sign at rear of kitchen directing exiting in wrong direction. |
| Addition to dining room not provided with battery powered emergency light. |
| Sprinkler head in C Hall dining covered with lint. |
| Records of fire plan rehearsals lacked description of what the rehearsal involved. |
| One-hour fire rated walls and ceilings compromised with holes and penetrations in multiple locations. |
| Sprinkler escutcheons missing or not tightly fitted in multiple locations. |
| Exit signs in kitchen and corridor near room C6 failed to illuminate on battery backup test. |
| Corridor doors prevented from closing quickly and latching including soiled linen room door wedged open, craft room door propped open, and bedroom B15 door not latching. |
| Only one exit sign provided on D Hall beyond smoke barrier doors; missing exit signs at smoke barrier doors. |
| Open space in circuit breaker panel K in kitchen exposing electrified parts. |
| Ceiling radiation dampers in some return ducts were dirty and may not close properly in fire event. |
Report Facts
Licensed bed capacity: 96
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 23, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on October 22 and October 23, 2015 at Carillon Assisted Living of Asheboro. Additionally, an Annual and Follow-up survey was conducted on October 28 and October 29, 2015 at Carillon Assisting Living of Shelby.
Findings
At Carillon Assisted Living of Asheboro, the facility failed to ensure medications prepared in advance were properly labeled and enclosed, specifically prefilled syringes of Morphine Sulfate for Resident #5 were unlabeled and incorrectly dosed. At Carillon Assisting Living of Shelby, the facility failed to assure Resident #5 was served a 2 gram sodium diet as ordered by the prescribing practitioner, instead serving the regular diet without the low sodium modification.
Complaint Details
The visit included a complaint investigation related to medication administration practices involving Resident #5 at Carillon Assisted Living of Asheboro.
Deficiencies (2)
| Description |
|---|
| Medications prepared for administration in advance were not kept enclosed in a sealed container with proper labeling for Resident #5, including unlabeled prefilled syringes of Morphine Sulfate. |
| Resident #5 was served a regular diet instead of the ordered 2 gram sodium diet. |
Report Facts
Number of residents sampled: 5
Medication dose: 0.25
Medication dose: 5
Medication bottle volume: 15
Medication bottle remaining volume: 13
Diet sodium restriction: 2
Lasix dosage: 20
Lasix duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Administered Morphine Sulfate medication once on 10/01/15 at 9:48 pm, unaware of incorrect dose | |
| Resident Care Director | Aware of prefilled syringes in medication cart and that they should have been labeled | |
| Second Medication Aide | Administered one syringe to Resident #5, signed out medication on MAR and controlled substance log | |
| Hospice Nurse | Assigned to Resident #5, aware of labeling requirements but was not the nurse who filled the syringes | |
| Administrator | Aware Hospice Nurses prefilled syringes and expected labeling, but was unaware syringes were unlabeled | |
| Regional Nurse | Unaware of unlabeled syringes in medication cart, expected proper filling and labeling by pharmacy or Hospice | |
| Dietary Manager | Reported facility's regular diets are no added salt diets and no menu for 2gm sodium diet | |
| Corporate Nurse | Reported policy to clarify unavailable therapeutic diets and acknowledged missing diet order for Resident #5 | |
| Facility Nurse | Assessed Resident #5's feet and legs for edema on 10/29/15 |
Inspection Report
Capacity: 96
Deficiencies: 15
Feb 20, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes and regulations for the licensed adult care home.
Findings
The facility was found to have multiple deficiencies related to building safety, fire protection, housekeeping hazards, equipment maintenance, and safety features including improperly protected kitchen range hood ducts, inadequate exit signage, missing or incomplete fire safety inspection reports, compromised fire rated walls and ceilings, malfunctioning emergency release switches, unsecured ranges in activity rooms, and night lights that could be switched off, presenting safety hazards to residents.
Deficiencies (15)
| Description |
|---|
| Exhaust duct for kitchen range hood was less than 18 inches from combustibles and not fire protected. |
| Only one exit sign visible beyond cross-corridor doors on D Hall when doors are closed. |
| Required annual fire alarm system inspection report could not be located. |
| Required annual Fire Marshal building and safety inspection report could not be located. |
| Sprinkler system inspection report dated 4-2-2014 listed deficiencies with no evidence of correction including missing 5 year internal inspection, uncalibrated gauges, missing FDC sign, missing 10 year sample testing, and missing sprinkler escutcheon on front porch. |
| Directional arrows on exit sign near Administrator's office direct toward locked unit without exit sign or evacuation route. |
| Hose at mop sink in kitchen utility closet long enough to reach sink basin without vacuum breaker, risking contamination. |
| One-hour fire rated walls and ceilings compromised in multiple locations with unsealed penetrations, inoperable smoke dampers, damaged enclosures, and missing or improperly installed sprinkler escutcheons. |
| Cross-corridor doors near room A8 equipped with latching hardware but one door failed to latch closed during fire alarm activation. |
| Main emergency release switch on Special Locking on C Hall intermittently failed to relock doors and courtyard gate, making it unreliable. |
| Exit door near room C5 was difficult to open, potentially delaying evacuation. |
| Sampling tubes for all duct mounted smoke detectors were dirty, risking detector failure. |
| Range in activity room on C Hall was not locked in off position and unattended by staff, presenting danger. |
| Range in activity room on D Hall was not locked in off position and staff was not constantly present, presenting danger. |
| Night lights in corridors could be easily switched off from corridor switches, allowing corridors to be completely dark and presenting danger to residents. |
Report Facts
Licensed beds: 96
Sprinkler system inspection date: Apr 2, 2014
Loading inspection reports...
