Inspection Report
Follow-Up
Deficiencies: 12
Mar 20, 2025
Visit Reason
The Adult Care Licensure Section and the Lincoln County Department of Social Services conducted a follow-up and complaint survey from March 18, 2025 through March 20, 2025.
Findings
The facility was found deficient in multiple areas including failure to complete annual medical examinations, timely resident assessments and care plans, medication administration errors, failure to notify authorities of incidents requiring emergency treatment, and incomplete special care unit resident profiles.
Complaint Details
The visit was a follow-up and complaint survey conducted from March 18-20, 2025.
Deficiencies (12)
| Description |
|---|
| Facility failed to have an FL2 medical examination completed annually for 1 of 5 sampled residents (#2). |
| Facility failed to ensure 1 of 5 sampled residents (#3) had an assessment and care plan completed within 30 days following admission. |
| Facility failed to ensure 1 of 5 sampled residents (#3) had a care plan signed by the assessor upon completion. |
| Facility failed to ensure 1 of 5 sampled residents (#3) had a care plan signed by a provider within 15 days of assessment completion. |
| Facility failed to ensure referral and follow-up to meet routine healthcare needs for 1 of 5 sampled residents (#4) related to a rejected pharmacy order for levothyroxine. |
| Facility failed to ensure 1 of 5 sampled residents (#5) rights were maintained related to a resident not having facetime calls with her family. |
| Facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents (#1 and #4) related to pain medication and hypothyroidism medication. |
| Facility failed to ensure accuracy of Medication Administration Records (MARs) and electronic MAR (eMAR) for 1 of 5 sampled residents (#1) related to pain medication. |
| Facility failed to ensure a readily retrievable record that accurately reconciled the receipt, administration, and disposition of a controlled medication for 1 of 5 sampled residents (#1). |
| Facility failed to ensure all Medicaid residents (Resident #2) were shown an accurate accounting of monies received and disbursed and the balance on hand was available upon request. |
| Facility failed to notify the local county Department of Social Services for incidents involving 2 of 5 sampled residents (Resident #1 and #4) who required emergency medical treatment. |
| Facility failed to ensure 2 of 5 sampled residents (Resident #3 and Resident #5) had Special Care Unit resident profiles completed within 30 days of admission and quarterly thereafter. |
Report Facts
Sampled residents: 5
Tramadol tablets dispensed: 75
Tramadol tablets remaining: 73
Medication administration dates: 19
Resident admission date: Apr 18, 2023
Resident admission date: Jul 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Unit Coordinator | SCC | Named in relation to responsibility for care plans, audits, and facetime calls |
| Health and Wellness Director | HWD | Named in relation to responsibility for medical exams, care plans, audits, medication administration, and incident reporting |
| Administrator | Named in relation to oversight responsibilities and knowledge of deficiencies | |
| Medication Aide | MA | Named in relation to medication administration and documentation |
| Regional Registered Nurse | RN | Named in relation to pharmacy coordination and medication order follow-up |
Inspection Report
Annual Inspection
Deficiencies: 6
Dec 4, 2024
Visit Reason
The Adult Care Licensure Section and Lincoln County Department of Social Services conducted an annual survey and complaint investigations from December 3, 2024 through December 4, 2024. The complaint investigations were initiated by Lincoln County Department of Social Services on November 18, 2024 and November 22, 2024.
Findings
The facility was found to have multiple deficiencies including failure to have a qualified Activity Director, failure to ensure referral and follow-up for acute health care needs, failure to ensure food safety and sanitation, failure to provide the required minimum hours of planned group activities, failure to notify the County Department of Social Services of accidents/incidents requiring emergency medical evaluation, and failure to maintain required Special Care Unit resident profiles and care plans.
Complaint Details
Complaint investigations were initiated by Lincoln County Department of Social Services on November 18, 2024 and November 22, 2024.
Deficiencies (6)
| Description |
|---|
| Facility failed to have a qualified Activity Director and lacked posted activity calendars on assisted living units. |
| Facility failed to ensure referral and follow-up to meet acute health care needs for Resident #4 related to occupational therapy recommendations for adaptive eating apparatus. |
| Facility failed to ensure food stored and served was protected from contamination; expired, unlabeled, and dirty food items were found. |
| Facility failed to provide at least 14 hours of a variety of planned group activities per week for residents. |
| Facility failed to notify the County Department of Social Services of accident/incidents requiring emergency medical evaluation for 2 of 5 sampled residents (#1 and #4). |
| Facility failed to ensure Resident #4 on the Special Care Unit had a written resident profile completed within 30 days of admission and quarterly thereafter, and failed to maintain an updated yearly care plan. |
Report Facts
Licensed capacity: 13
Hours of planned group activities required: 14
Dates of complaint investigations: Complaint investigations initiated on November 18, 2024 and November 22, 2024.
Dates of survey: Survey conducted December 3-4, 2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for submitting accident/incident reports to DSS; was new and unaware of correct procedures. | |
| Special Care Coordinator | Responsible for ensuring SCU profiles and care plans were updated quarterly and yearly; was on leave since September/October 2024. | |
| Administrator | Provided information on facility staffing and deficiencies. | |
| Medication Aide | Provided information on activity program and incident reporting procedures. | |
| Dietary Aide/Cook | Provided information on food labeling and storage practices. |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 17, 2024
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously noted deficiencies.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Capacity: 96
Deficiencies: 10
Sep 14, 2023
Visit Reason
The facility was surveyed for conformance to applicable portions of the 2006 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to meet licensure and code requirements for electromagnetic locks, unsafe outside premises, poor housekeeping and furnishings, lack of fire safety rehearsals on each shift, failure to maintain fire safety and building equipment in safe operating condition, unsupervised ovens in resident activity areas, and inadequate exhaust ventilation in specified spaces.
Deficiencies (10)
| Description |
|---|
| Electromagnetic locks did not have a functioning emergency release switch at the nurses' station. |
| Outside premises were not maintained in a clean and safe condition, including a raised sidewalk creating a trip hazard and mildew on porch ceiling. |
| Walls, ceilings, and floors were not kept in good repair with water damage, cracks, mildew, worn carpet, holes in walls, and buckling flooring. |
| Facility was not conducting fire rehearsals on each shift quarterly as required. |
| Failure to maintain emergency fire alarm system devices and equipment in safe operating condition, including faulty fire alarm heads and obstructed heat detector. |
| Failure to maintain fire safety systems in safe condition, including use of non-fire resistant materials and gaps in fire resistant rated ceilings. |
| Failure to maintain electrical emergency/safety lighting equipment in safe operating condition; multiple emergency lights not illuminating on test or with bulbs out. |
| Failure to maintain fire safety equipment in safe operating condition; doors not closing and latching properly to limit spread of smoke or fire. |
| Ovens and ranges in resident activity areas were operational and not properly supervised or locked. |
| Facility did not maintain exhaust ventilation in specified spaces, including non-working exhaust fans in laundry, janitor's closet, and bathrooms. |
Report Facts
Licensed capacity: 96
Special Care Unit beds: 36
Inspection Report
Follow-Up
Deficiencies: 12
Feb 17, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous medication administration deficiencies from February 15 to 17, 2022.
Findings
The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 4 of 5 sampled residents, resulting in missed medications for dementia, vitamin D deficiency, stroke prevention, depression, anxiety, pain, high blood pressure, and high cholesterol. This failure posed risks of cognitive changes, mood changes, increased pain, stroke, heart attack, and other health complications.
Severity Breakdown
Type B Violation: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to administer donepezil 10mg as ordered for Resident #4 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer Vitamin D 1.25mg weekly as ordered for Resident #4 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer aspirin 81mg daily as ordered for Resident #4 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer sertraline 50mg daily as ordered for Resident #4 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer Seroquel 50mg twice daily as ordered for Resident #5 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer Tylenol 325mg three times daily as ordered for Resident #5 on multiple dates due to medication not being available or given. | Type B Violation |
| Failed to administer carvedilol 3.125mg twice daily as ordered for Resident #5 on multiple dates due to medication not being given. | Type B Violation |
| Failed to administer donepezil 10mg at bedtime as ordered for Resident #5 on multiple dates due to medication not being available. | Type B Violation |
| Failed to administer simvastatin 10mg at bedtime as ordered for Resident #5 on multiple dates due to medication not being available. | Type B Violation |
| Failed to administer Doxepin 10mg at bedtime as ordered for Resident #2; medication was held for 28 days without physician order or pharmacy knowledge. | Type B Violation |
| Failed to administer lidocaine HCl cream 4% topically three times daily as ordered for Resident #1 on multiple dates due to medication not being available. | Type B Violation |
| Failed to administer Salonpas Pain Relief Gel-Patch Hot Patch 0.025-1.25% daily as ordered for Resident #1 on multiple dates due to medication not being available. | Type B Violation |
Report Facts
Medication not administered: 8
Medication not administered: 28
Medication not administered: 19
Medication not administered: 22
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 5
Nov 5, 2021
Visit Reason
The Adult Care Licensure Section and the Lincoln County Department of Social Services conducted an annual and a complaint investigation from 11/02/21 to 11/05/21 with an exit via telephone on 11/05/21.
Findings
The facility failed to ensure staff completed required Health Care Personnel Registry checks prior to hire, failed to update resident assessments after significant changes, and failed to administer medications as ordered and within scheduled times. Additionally, medication aides lacked required training hours. These deficiencies resulted in medication errors, increased risk of harm, and inadequate resident care.
Complaint Details
The visit included a complaint investigation conducted from 11/02/21 to 11/05/21.
Severity Breakdown
Type A2: 1
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. | — |
| Failed to ensure an assessment and care plan was updated within 10 days following a significant change for 1 of 5 sampled residents who needed memory care due to frequent falls and increased sun-downing behaviors. | — |
| Failed to ensure medications were administered as ordered for 2 of 5 sampled residents and 1 of 6 residents observed, including failure to administer medication to decrease fluid, administering discontinued pain medication, and multiple medications not available for administration. | Type A2 |
| Failed to ensure medications were administered within one hour before or after the prescribed or scheduled times for 3 of 3 sampled residents in the Special Care Unit during the morning medication pass, resulting in medications being administered too close to the next scheduled times. | Type B |
| Failed to ensure 3 of 3 sampled medication aides who administered medications had completed the required 5-hour and 10-hour medication aide training courses. | Type B |
Report Facts
Medication error rate: 20
Residents in Special Care Unit: 18
Falls: 5
Medication doses administered late: 1
Medication doses administered late: 1
Medication doses administered late: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete required 5, 10, or 15 hours medication aide training course. |
| Staff B | Medication Aide | Failed to complete required 5, 10, or 15 hours medication aide training course. |
| Staff C | Medication Aide | Failed to complete required 5, 10, or 15 hours medication aide training course. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Aug 25, 2020
Visit Reason
The Adult Care Licensure Section conducted a state-involved complaint investigation and a COVID-19 Infection Control Survey due to concerns about the facility's handling of COVID-19 testing and infection control during an outbreak.
Findings
The facility failed to implement and maintain CDC, NC DHHS, and local health department guidance for COVID-19 testing and retesting of residents and staff during an outbreak. Testing was delayed, incomplete, and retesting of negative cases was not performed weekly as recommended, leading to increased risk of transmission and multiple resident and staff infections and deaths.
Complaint Details
The visit was complaint-related, triggered by concerns about the facility's COVID-19 outbreak management, specifically failure to test and retest residents and staff as recommended by CDC and local health authorities.
Severity Breakdown
Type A1 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure recommendations and guidance established by the CDC, NC DHHS, and local health department were implemented and maintained to protect residents during the COVID-19 pandemic, specifically related to timely and repeated testing of residents and staff during an outbreak. | Type A1 Violation |
| Failure to ensure all residents were free from neglect related to Resident Rights, specifically related to failure to follow COVID-19 testing and retesting guidance leading to increased risk of disease transmission and harm. | Type A1 Violation |
Report Facts
Residents present: 34
Residents tested positive: 19
Residents tested negative: 16
Staff total: 40
Staff tested: 19
Staff tested positive: 13
Staff tested negative: 5
Deaths: 10
Residents not retested: 9
Staff not retested: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for communicating with local health department and directing outbreak activities during Administrator's absence |
| Unnamed Administrator | Administrator | Responsible for outbreak testing and retesting, communicated with Health and Wellness Director and local health department |
| Unnamed Memory Care Director | Memory Care Director (MCD) | Directed staff testing and resident testing in Memory Care Unit |
| Unnamed Adult Home Specialist | Adult Home Specialist (AHS) | Interviewed regarding outbreak awareness and testing recommendations |
| Unnamed Local Health Department Health Director | Health Director (HD) | Provided guidance and oversight for outbreak testing and infection control |
| Unnamed Local Health Department Assistant Health Director | Assistant Health Director (AHD) | Sent multiple emails with testing guidance and recommendations |
| Unnamed Local Health Department Communicable Disease Nurse | Communicable Disease Nurse (CD Nurse) | Provided CDC guidance and testing recommendations to facility staff |
Inspection Report
Capacity: 96
Deficiencies: 10
Oct 11, 2019
Visit Reason
The facility was surveyed for conformance to applicable portions of the 2006 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified related to housekeeping, maintenance, safety, and equipment. These included unclean ceilings and equipment, damaged and hazardous flooring and handrails, unsecured oxygen bottles, malfunctioning life safety and fire safety equipment, electrical and plumbing issues, lack of staff supervision of ovens, and non-working exhaust ventilation in required areas.
Deficiencies (10)
| Description |
|---|
| Ceilings and equipment were not kept clean, including heavy accumulation of lint, grease, and dust on exhaust fans and HVAC grilles. |
| Floors were not kept clean and in good repair; frayed or buckled carpet could cause trips and falls. |
| Facility was not maintained free of hazards; loose hand grip at toilet and unsecured oxygen bottle found. |
| Life safety equipment was not maintained in a safe and operating condition; smoke detector not secure and multiple sprinkler heads dropped leaving holes or gaps in rated ceiling assemblies. |
| Failure to maintain building's fire safety systems; doors missing strikes or not latching properly. |
| Failure to install and maintain required plumbing safety devices; damaged vacuum breaker on utility sink. |
| Electrical equipment not maintained in safe and operating condition; cracked GFCI outlet. |
| Plumbing equipment not maintained in safe and operating condition; water heater missing pressure relief valve piping and disconnected combustion air pipe. |
| Facility did not monitor ovens, ranges, or cook tops in activity areas; oven left operable without staff supervision. |
| Facility did not provide working exhaust ventilation in required areas including utility closets, half baths, janitor closets, guest toilets, and laundry areas. |
Report Facts
Total licensed capacity: 96
Special Care Unit beds: 36
Hole size: 2
Hole size: 2
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 21, 2018
Visit Reason
The Adult Care Licensure Section and the Lincoln County Department of Social Services conducted an annual survey on February 20 and 21, 2018 to assess compliance with regulations.
Findings
The facility failed to administer a prescribed medication (Keflex) to one resident (Resident #5) as ordered by a licensed prescribing practitioner. The discharge summary and medication orders were not received or processed timely, resulting in no administration of the antibiotic after hospital discharge.
Deficiencies (1)
| Description |
|---|
| Failure to administer medication as ordered by a licensed prescribing practitioner for Resident #5 prescribed Keflex. |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Interviewed regarding missing discharge summary and medication orders for Resident #5 |
| Medication Aide | Medication Aide (MA) | Interviewed about medication administration and paperwork for Resident #5 |
| Second Shift Supervisor | Second Shift Supervisor | Interviewed about receipt and processing of hospital discharge paperwork |
| Activity Director | Activity Director (AD) | Former facility transporter responsible for bringing hospital paperwork |
| Executive Director | Executive Director | Interviewed about facility procedures for handling hospital discharge paperwork |
| Primary Care Physician | Resident #5's Primary Care Physician (PCP) | Interviewed regarding medication orders and resident condition |
Inspection Report
Capacity: 96
Deficiencies: 7
Sep 6, 2017
Visit Reason
The facility was surveyed for conformance to applicable portions of the 2006 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified related to physical plant safety and maintenance, including unsafe outside premises with tripping hazards, obstructed emergency egress pathways, displaced or missing fire sprinkler head escutcheons creating gaps in fire resistant ceilings, failure to maintain fire safety equipment and doors in safe operating condition, and non-operating exhaust fans.
Deficiencies (7)
| Description |
|---|
| Outside grounds not kept in a safe condition due to a tripping hazard from a gap around a sewer cleanout in the patio concrete. |
| Emergency egress pathways obstructed by wheelchairs and a medication cart in the Special Care Unit (S.C.U.), corrected during survey. |
| Fire sprinkler head escutcheons displaced or missing, creating gaps in fire resistant rated ceilings in multiple locations including 'A' Hall Room #11, laundry area, resident sitting room, 'C' Hall covered patio, and S.C.U. storage room. |
| Stored items in S.C.U. linen closet within 4 inches of fire sprinkler head, violating minimum 18 inch clearance. |
| Doors in staff lounge and vending area do not completely close and latch, compromising smoke compartment safety. |
| S.C.U. courtyard gate bottom binds and drags on sidewalk, only opening approximately 24 inches, potentially delaying emergency evacuation. |
| Exhaust ventilation equipment not maintained; seven of nine exhaust fans examined in 'A' Hall did not operate. |
Report Facts
Total licensed beds: 96
Gap width: 3.25
Gap depth: 4
Exhaust fans not operating: 7
Exhaust fans examined: 9
S.C.U. courtyard gate opening width: 24
Fire sprinkler clearance violation: 4
Required fire sprinkler clearance: 18
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 3
May 10, 2016
Visit Reason
The Adult Care Licensure Section and the Lincoln County Department of Social Services conducted an annual survey on May 10 - 11, 2016 to assess compliance with regulations for Carillon Assisted Living of Lincolnton.
Findings
The facility was found to have violations related to the use of non-surge protected electric outlet adapters in 3 of 39 occupied resident rooms and the use of prohibited space heaters in 14 of 39 occupied resident rooms. The facility lacked a written policy on space heater use and had not adequately trained staff on these safety issues.
Severity Breakdown
Type B Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Use of non-surge protected electric outlet adapters in 3 of 39 occupied resident rooms (Rooms A-1, A-9 and B-9). | Type B Violation |
| Use of space heaters in 14 of 39 occupied resident rooms (Rooms A-1, A-2, A-9, A-12, A-15, B-2, B-7, B-10, C-14, D-2, D-3, D-4, D-7 and D-15), which is prohibited. | Type B Violation |
| Failure to assure residents received care and services that are adequate, appropriate and in compliance with federal and state laws and rules related to housekeeping and furnishings and other requirements. | Type B Violation |
Report Facts
Occupied resident rooms with non-surge protected outlet adapters: 3
Occupied resident rooms with prohibited space heaters: 14
Total occupied resident rooms during inspection: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding safety training and use of outlet adapters and space heaters; shared between this facility and a sister facility. | |
| Executive Director | Interviewed regarding facility policies on outlet adapters and space heaters. | |
| Director of Clinical Services | Interviewed regarding facility policies on outlet adapters and space heaters. | |
| Personal Care Aide | Interviewed regarding hazards in resident rooms and use of space heaters. |
Inspection Report
Capacity: 96
Deficiencies: 3
Sep 9, 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 the North Carolina State Building Code 2006 Edition Group I-Institutional Occupancy during a Biennial Construction Survey.
Findings
Deficiencies were cited related to maintenance and safety issues including unserviced HVAC supply and return air grilles with excessive particulate build-up, non-functioning emergency wall light, and failure of mechanical exhaust fans to operate in certain areas, affecting all residents and staff.
Deficiencies (3)
| Description |
|---|
| Facility has not maintained and serviced the HVAC supply and return air grilles, with excessive particulate build-up in the AL Dining Room. |
| Facility life-safety devices have not been maintained; emergency wall light outside Room 11 did not illuminate during emergency mode test. |
| Facility failed to provide exhaust ventilation where odors are generated; mechanical exhaust fans in Kitchen Mop Sink Closet and 'B' Hall Spa Bathroom are not operating when switched on. |
Report Facts
Licensed capacity: 96
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