Inspection Report
Follow-Up
Deficiencies: 2
May 14, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 05/13/25 - 05/14/25 to verify correction of previously identified deficiencies related to medication administration and infection control.
Findings
The facility failed to ensure medications were administered as ordered for multiple residents, including failure to discontinue medications as ordered and improper administration techniques. Additionally, infection control measures were not followed during medication administration, as a medication aide handled a resident's medication with ungloved hands after it was dropped.
Deficiencies (2)
| Description |
|---|
| Failed to ensure medications were administered as ordered for residents #6, #7, and #2, including administering discontinued medications and incorrect administration methods. |
| Failed to implement infection control measures during medication pass, evidenced by handling a resident's oral medication with ungloved hands after it was dropped. |
Report Facts
Medication error rate: 6
Medication doses dispensed: 31
Medication doses remaining: 20
Medication doses dispensed: 31
Medication doses remaining: 23
Baclofen tablets dispensed: 90
Potassium Chloride tablets dispensed: 31
Potassium Chloride tablets dispensed: 30
Inspection Report
Follow-Up
Census: 22
Deficiencies: 7
Mar 14, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies.
Findings
The facility failed to maintain a hazard-free environment in the special care unit, failed to ensure medication aides completed required training and competency validations, failed to coordinate and follow-up on health care needs including lab monitoring for blood thinning medication and prostate cancer screening, and failed to administer medications as ordered with documentation inaccuracies.
Severity Breakdown
Type A2: 1
Unabated Type A1: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to maintain an environment free of hazards including personal care products accessible to residents in the special care unit. | — |
| Two medication aides administered medications without completing required clinical skills validation and passing the state-approved medication aide written exam. | — |
| Two staff lacked competency evaluation and validation for licensed health professional support tasks prior to performing tasks. | — |
| Facility failed to ensure health care coordination and follow-up for two residents including failure to monitor INR for blood thinner and failure to coordinate prostate cancer screening lab. | Type A2 |
| Medication orders were not clarified for a topical pain patch, resulting in unclear administration instructions. | — |
| Medications were not administered as ordered for three residents including errors with allergy nasal spray dosage, medication timing with meals, incorrect laxative dosage, missed doses of blood thinner, and delayed medication starts. | Unabated Type A1 |
| Medication administration records were inaccurate for four residents including missing documentation of insulin units administered, omissions in medication administration, and incomplete PRN medication documentation. | — |
Report Facts
Residents in SCU: 22
Medication error rate: 11
Warfarin tablets dispensed: 74
Warfarin tablets administered: 56
Lorazepam prn administrations: 18
Lorazepam prn administrations: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Failed to complete medication clinical skills validation and pass state-approved medication aide written exam prior to administering medications. |
| Staff F | Medication Aide | Failed to complete medication clinical skills validation and pass state-approved medication aide written exam prior to administering medications. |
| Staff B | Medication Aide and Personal Care Aide | No documentation of licensed health professional support competency validation. |
| Memory Care Director | Responsible for checking medication administration and clarifying orders; recently started processing orders. | |
| Resident Care Coordinator | Responsible for filing Warfarin orders and INR labs; lacked system to track orders and labs. | |
| Administrator | Responsible for checking personnel files and medication administration accuracy. | |
| Medication Aide | Administered medications incorrectly or failed to document administration accurately. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 5
Dec 20, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation of the facility from 12/18/24 to 12/20/24.
Findings
The facility failed to maintain a safe environment free of hazards, failed to ensure physician-signed care plans within 15 days, failed to coordinate health care referrals and follow-ups, failed to maintain adequate food supplies, and failed to administer medications as ordered resulting in a 30% medication error rate with multiple residents not receiving prescribed medications or receiving incorrect doses.
Complaint Details
The visit included a complaint investigation triggered by allegations related to medication administration and care planning deficiencies.
Severity Breakdown
Type A1: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain an environment free of hazards including personal care products and scissors accessible to residents in the special care unit. | — |
| Assessment and care plan for Resident #4 was not signed by a physician within 15 calendar days of completion of the assessment. | — |
| Failed to ensure referral and follow-up for routine and acute health care needs for Residents #1, #4, and #5 including physical therapy, urology, gero-psychiatry, and PCP follow-up after hospitalization. | — |
| Failed to maintain a 3-day supply of perishable food and a 5-day supply of non-perishable food based on census. | — |
| Failed to administer medications as ordered for multiple residents including errors with muscle relaxant, anxiety medication, inhaler, laxative, iron supplement, blood pressure medication, antidepressant, eye drops, and antipsychotics. | Type A1 Violation |
Report Facts
Medication error rate: 30
Residents in SCU: 22
Facility census: 42
Medication doses missed or not administered: 7
Medication doses missed or not administered: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for completing residents' assessments and care plans, reviewing and approving medication orders, and conducting medication cart audits. | |
| Resident Care Coordinator | Responsible for reviewing and processing paperwork including medication orders, reordering medications, and notifying pharmacy. | |
| Medication Aide | Observed administering medications, responsible for notifying RCC and HWD of medication needs and errors. | |
| Administrator | Oversight of facility operations, responsible for ensuring medication administration and food supply compliance. |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 13, 2024
Visit Reason
Follow up construction survey conducted by documentation review to verify correction of previously cited deficiencies.
Findings
Based on documentation received on June 13, 2024, all previously cited deficiencies have been corrected or will be corrected by July 30, 2024, and no further action is required at this time.
Report Facts
Correction timeframe: Jul 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Reported follow up construction survey by documentation |
Inspection Report
Follow-Up
Deficiencies: 5
May 14, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to the physical plant and safety systems.
Findings
The survey found ongoing deficiencies including the outside grounds not maintained in a clean and safe condition, failure to maintain electrical emergency lighting, fire safety systems with holes or gaps in fire-resistant walls, fire safety doors not closing properly, loose door hardware, and plumbing equipment not maintained in safe operating condition.
Deficiencies (5)
| Description |
|---|
| Outside grounds were not maintained in a clean and safe condition; fence around SCU Courtyard is buckling and leaning with temporary bracing installed. |
| Electrical emergency light at the back exit in C Hall did not illuminate on test. |
| Holes approximately 1 inch in diameter in the wall over the icemaker in the kitchen, patched but damaged again by filter installation. |
| Fire safety doors in Room C 12 have loose door hardware and do not completely close and latch. |
| Plumbing equipment in C Hall Laundry not maintained in safe operating condition; valve box has standing water and rust from prior leak, wall not patched or painted. |
Report Facts
Date of findings: May 14, 2024
Date of plumbing findings: Aug 1, 2023
Inspection Report
Capacity: 96
Deficiencies: 14
Aug 1, 2023
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2006 Edition of the North Carolina Building Code, Institutional Occupancy; Group I-2, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including improper use of bathrooms for storage, corridor obstructions, unsafe outside premises, poor housekeeping and maintenance, electrical and fire safety equipment failures, lack of staff supervision of ovens, inadequate hot water temperatures, and non-functioning exhaust ventilation.
Deficiencies (14)
| Description |
|---|
| One of the two corridor (spa) bathrooms is being utilized for purposes other than those indicated in the rule; the spa has been converted to office space. |
| Corridors are not free of all equipment and obstructions; chairs and a PTAC unit obstruct the short corridor to Room B-5. |
| Outside grounds not maintained in a clean and safe condition; deteriorating raised planter box, sagging gutter, loose vent grille, fallen siding, and buckling fence. |
| Ceilings and floors not kept clean and in good repair; worn carpet, dirty exhaust fans, fallen door threshold, and lint accumulation. |
| Facility not maintained in an uncluttered, clean and orderly manner; excessive furniture, paint, and miscellaneous items stored in Room B-6 creating fall and fire hazards. |
| Not all electrical outlets in wet locations equipped with ground fault interrupters; GFCI at Room D 9 Bath sink does not have power and cannot be reset. |
| Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel shows trouble signal due to bad duct detectors. |
| Failure to maintain fire safety equipment; doors do not completely close and latch, emergency lights missing or not illuminating, exit signs not illuminating, holes in fire resistant ceilings, and fire caulking missing. |
| Plumbing equipment not maintained in safe and operating condition; valve box in laundry has standing water and rust. |
| Failure to maintain 18" clearance below sprinkler heads; adult diapers stored within 18" of ceiling. |
| Electrical equipment not maintained in safe and operating condition; override switch screamer boxes at courtyard doors do not alarm when opened. |
| Ovens, ranges, and cook tops in resident activity or recreational areas not maintained for operation under facility staff supervision. |
| Hot water supply to kitchen, bathrooms, laundry, housekeeping closets, and soiled utility rooms not maintained at minimum 100°F; temperatures ranged from 88°F to 104°F. |
| Facility did not maintain exhaust ventilation in specified spaces; exhaust fans not working in laundry room, soiled linen room, B Hall Spa, and D Hall guest toilets. |
Report Facts
Total licensed capacity: 96
Special Care Unit beds: 36
Water temperature range: 88
Water temperature range: 104
Inspection Report
Follow-Up
Deficiencies: 2
Mar 3, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 03/02/22 - 03/03/22 to verify correction of previous deficiencies related to medication orders and administration.
Findings
The facility failed to clarify medication orders for one resident involving insulin types and administration. Medication administration errors were observed in multiple residents, including incorrect timing, missed doses, and failure to follow medication orders and facility policies. Issues with medication reorder processes and medication availability were also identified.
Deficiencies (2)
| Description |
|---|
| Failed to clarify medication orders for Resident #3 involving scheduled and sliding scale insulin. |
| Failed to administer medications as ordered and in accordance with facility policies for Residents #1, #3, #6, #7, and #8, including errors with timing, missed doses, and medication availability. |
Report Facts
Medication error rate: 10
Medication cards in stacks: 8
Medication cards in stacks: 5
Medication cards in stacks: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for clarifying medication orders and overseeing medication administration and reorder processes | |
| Medication Aide | Observed administering medications and involved in medication errors and reorder processes | |
| Operations Manager at contracted pharmacy | Provided information on medication orders, refills, and pharmacy communication |
Inspection Report
Follow-Up
Deficiencies: 3
Dec 15, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to health care and medication administration for Resident #2.
Findings
The facility failed to ensure referrals for physical and speech therapy were implemented and failed to implement physician orders for accuchecks and multiple medications for Resident #2. This included failure to administer insulin and other medications as ordered, resulting in high documented blood sugar levels and increased risk to the resident's health and safety.
Severity Breakdown
Type B Violation: 1
Unabated Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure referrals related to orders for physical therapy and speech therapy were implemented for Resident #2. | — |
| Failed to ensure physician orders for accuchecks were implemented for Resident #2. | Type B Violation |
| Failed to administer medications as ordered for Resident #2, including insulin, anxiety, sleep disorder medications, and dietary supplements, resulting in high blood sugar levels. | Unabated Type B Violation |
Report Facts
Blood glucose reading: 400
Blood glucose reading: 317
Deficiency correction deadline: 2022
Resident sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for processing physician orders and sending them to the contracted pharmacy; failed to send all pages of Resident #2's FL-2 to pharmacy. |
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for reviewing physician orders and ensuring medication orders were faxed to pharmacy; acknowledged missing pages of Resident #2's FL-2 were not faxed. |
| Executive Director | Executive Director (ED) | Responsible for overseeing admission process and ensuring orders were processed; unaware of missing faxed pages and medication administration failures. |
| Second former PCP | Primary Care Provider | Provided physician order review and expressed concerns about medication administration failures for Resident #2. |
| First former PCP | Primary Care Provider | Completed Resident #2's FL-2 prior to transfer and expected new facility to implement orders. |
| Medication Aide | Medication Aide | Administered medications based on eMARs; did not check physician orders against eMARs or medication on hand. |
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 30, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 09/29/21-09/30/21 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure proper health care referral and follow-up for one resident who required orthopedic, neurology, bone density, and Reclast infusion appointments. Additionally, the facility failed to administer medications as ordered for another resident, resulting in missed doses of antihypertensive and diabetic medications due to lack of medication availability.
Severity Breakdown
Type B Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure health care referral and follow-up for 1 of 5 sampled residents who was ordered orthopedic follow-up, neurology consult, bone density test, and Reclast infusion. | Type B Violation |
| Failed to administer medications as ordered for 1 of 5 sampled residents related to antihypertensive and diabetic medications, resulting in missed doses and lack of medication availability. | Type B Violation |
Report Facts
Sampled residents: 5
Missed doses of Losartan: 17
Missed doses of Metformin: 16
Survey completion date: Sep 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Responsible for referrals; started working 09/27/21; did not follow up on appointments for Resident #5 | |
| Administrator | Interviewed regarding referral and medication processes; expressed concerns about staff transitions and process failures | |
| Resident Care Coordinator (RCC) | Had access to appointment calendar; responsible for medication order entry and communication | |
| Medication Aide (MA) | Administered medications; reported medication shortages and reorder processes |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 3, 2021
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation survey with an onsite visit on 02/03/21, a desk review on 02/04/21, and a telephone exit on 02/04/21.
Findings
The facility failed to ensure implementation of CDC and NC DHHS COVID-19 guidance, including proper use of face masks by staff and proper screening of staff for COVID-19 symptoms and temperature checks. Multiple observations and interviews revealed staff and administrative personnel not wearing masks correctly and inadequate monitoring and collection of COVID-19 screening forms.
Complaint Details
The complaint investigation was triggered by concerns about staff not wearing masks properly and inadequate screening. A resident reported a medication aide not wearing a mask during medication delivery. Interviews confirmed staff and administrative personnel often wore masks incorrectly and screening processes were insufficiently monitored.
Deficiencies (1)
| Description |
|---|
| Failure to implement CDC and NC DHHS guidance for infection prevention and control during COVID-19, including improper mask use and inadequate staff screening. |
Report Facts
Date of onsite visit: Feb 3, 2021
Date of desk review: Feb 4, 2021
Date of telephone exit: Feb 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Sales | Director of Sales | Observed not wearing mask properly; interviewed about mask policies and screening |
| Dietary Manager | Dietary Manager | Observed coughing without covering mouth; did not complete COVID-19 screening questions properly; worked while symptomatic |
| Executive Director | Executive Director | Responsible for staff mask compliance and COVID-19 screening oversight; interviewed multiple times |
| Transportation Coordinator | Transportation Coordinator | Collected and reviewed staff COVID-19 screening logs; interviewed about screening process |
| Business Office Manager | Business Office Manager | Interviewed about staff mask use and screening form collection |
| Special Care Manager | Special Care Manager | Observed wearing mask improperly |
| Supervisor | Supervisor | Reported staff mask noncompliance and screening practices |
| Personal Care Aide | Personal Care Aide | Interviewed about mask use observations |
Inspection Report
Annual Inspection
Capacity: 96
Deficiencies: 12
Oct 25, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2006 Edition of the North Carolina Building Code, as part of a biennial survey.
Findings
The inspection identified multiple deficiencies including obstructions in corridors, floors, walls, and ceilings not kept in good repair, lack of ground fault interrupters at wet locations, failure to maintain fire safety equipment and electrical emergency lighting in safe operating condition, and mechanical equipment clogged with dust.
Deficiencies (12)
| Description |
|---|
| Corridors were obstructed by a chair and med carts near the nurses' station, partially blocking exit paths. |
| Floors in residents' bathrooms were stained due to moisture seepage under vinyl floors. |
| Walls had two nail pops at the top of the corridor wall outside Room C14. |
| Ceilings were separating at seams with flaking finish outside guest baths. |
| Ground fault circuit interrupters (GFCI) at wet locations did not reset when tested (Room D11 bath and D Hall screened porch). |
| Fire safety doors on B Hall and D Hall cross corridors did not latch but were corrected during survey. |
| Battery backup did not function on exit sign outside Room C16. |
| Doors held open with unapproved devices (trash cans) in B Hall Soiled Linen room. |
| Mechanical equipment such as R/A grille and filter in SCU Living Room clogged with dust; exhaust fan by Room C4 had heavy dust accumulation restricting airflow. |
| Fire resistant rated ceiling penetrations had gaps allowing potential spread of fire and smoke; sprinkler escutcheon plate dropped leaving a gap (corrected on site). |
| Door hardware broken in kitchen janitor's closet preventing door from closing and latching. |
| Folding table in D Hall Resident laundry extended into doorway preventing door closure. |
Report Facts
Licensed bed capacity: 96
Inspection Report
Annual Inspection
Capacity: 96
Deficiencies: 4
Oct 29, 2015
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2006 Edition of the North Carolina Building Code, Institutional Occupancy; Group I-2, as part of a biennial survey.
Findings
The inspection identified multiple deficiencies including lack of current sanitation inspection reports, failure to maintain fire safety systems with gaps in fire resistant ceilings, non-functioning electrical exit signs and emergency lights, and non-operational exhaust fans in various utility and resident areas.
Deficiencies (4)
| Description |
|---|
| Facility failed to have current sanitation inspection reports available for review within the calendar year for the building and kitchen. |
| Failure to maintain fire safety systems evidenced by gaps and open penetrations in fire resistant rated ceilings allowing potential spread of fire and smoke. |
| Multiple electrical exit signs and emergency lights did not illuminate when tested on battery power or house current in various locations including 'A' Hall Electrical Room, Kitchen, Resident Laundry, Special Care Unit, and hallways. |
| Exhaust fans in soiled clothing/utility room, janitor's closet, laundry areas, and Special Care Unit restrooms were not working, failing to provide required mechanical exhaust ventilation. |
Report Facts
Licensed beds: 96
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 17, 2015
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation at Carillon Assisted Living of Fayetteville from April 14-17, 2015, triggered by concerns about supervision and resident safety.
Findings
The facility failed to provide adequate supervision on the Special Care Unit for residents at risk of wandering and falls, resulting in a resident's death due to a fall. Multiple interviews, record reviews, and observations revealed lapses in monitoring and care protocols.
Complaint Details
The complaint investigation was substantiated based on record reviews, interviews, and observations. The investigation found inadequate supervision leading to a resident's fall and death, with failures in monitoring and communication among staff.
Severity Breakdown
Type A1 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide supervision in accordance with residents' assessed needs, care plan, and current symptoms, resulting in a Type A1 violation. | Type A1 Violation |
| Failure to ensure residents received adequate care and services in compliance with relevant federal and state laws and regulations related to personal care and supervision. | Type A1 Violation |
Report Facts
Dates of investigation: 4
Number of sampled residents: 5
Falls documented: 13
Falls documented: 10
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