Inspection Reports for The Pines on Carmel Senior Living

The visit was conducted as a monitoring inspection to assess compliance with regulations following previous findings related to resident supervision and safety.

The facility failed to provide adequate supervision for one of seven sampled residents who eloped from the Special Care Unit (SCU) without staff knowledge, resulting in a Type A2 violation due to substantial risk of harm and neglect. The facility submitted a plan of correction with a deadline of August 9, 2025.

The inspection was a Biennial Follow Up Construction Survey conducted to verify correction of previously noted deficiencies.

Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual survey from March 25, 2025 through March 27, 2025 to assess compliance with health care, medication administration, nutrition, and medication storage regulations.

The facility was found deficient in multiple areas including failure to notify the primary care provider (PCP) and hospice for elevated blood sugars, failure to implement physician orders for medications, failure to serve therapeutic diets as ordered, failure to clarify medication orders, inaccurate medication administration records, and unsafe medication storage in resident rooms.

The report documents a Construction Section Biennial Survey conducted to assess the facility's conformance with applicable adult care home licensing rules and building codes.

Multiple deficiencies were cited related to physical plant and fire safety code compliance, including fire alarm door locking issues, missing fire-rated doors, housekeeping and maintenance problems such as unclean ceilings and unpleasant odors, hazards from improperly stored oxygen bottles and trip hazards, fire safety equipment not maintained or operating properly, mechanical equipment issues including disconnected dryer ducts and freezer doors not sealing, and non-functioning exhaust fans in specified areas.

The inspection was conducted due to a complaint investigation following incidents of resident elopement from the Special Care Unit (SCU) without staff knowledge.

The facility failed to provide adequate supervision to residents at risk of elopement, resulting in two residents eloping from the SCU. The investigation revealed deficiencies in the facility's Wandering and Elopement Prevention Plan, lack of interventions for high-risk residents, and inadequate staff awareness and documentation related to resident supervision and safety.

The complaint investigation was substantiated with findings that Resident #1 eloped through a window on 03/05/24 and Resident #2 eloped through a courtyard gate on 03/24/24. Both incidents posed substantial risk for physical harm and were classified as Type A2 violations.

The inspection was conducted due to a complaint investigation regarding the facility's failure to supervise a resident with a known history of exit seeking behaviors and wandering, which resulted in the resident eloping from the facility without staff's knowledge.

The facility failed to supervise Resident #1 who eloped from the facility, crossing a busy highway and being missing for almost 2 hours, posing substantial risk for serious harm and neglect. The facility did not have adequate interventions or precautions in place despite awareness of the resident's behaviors and mental health concerns.

The complaint investigation substantiated that Resident #1 eloped from the facility on 08/04/23, walking 0.5 miles and crossing a busy multiple-lane highway without staff knowledge, resulting in the resident missing for almost 2 hours. The facility was aware of the resident's mental health diagnosis and wandering behaviors but failed to implement adequate supervision or interventions.

Report of a Construction Section Complaint Follow-Up Survey conducted on June 8, 2023 to verify correction of previously cited deficiencies.

The facility was found not maintaining its fire protective equipment in a safe and operating manner. Specifically, the fire alarm system and two emergency exit doors leading into the SCU courtyard were not working in sync, leaving the exit doors unlocked at all times.

Complaint follow-up survey conducted; deficiencies cited requiring a Plan of Correction.

The inspection was conducted due to a complaint investigation regarding the facility's failure to supervise a resident with known exit-seeking behaviors, which resulted in the resident eloping from the facility without staff knowledge.

The facility failed to supervise Resident #4, who eloped from the facility and was found at her previous address several miles away. The investigation revealed inadequate supervision, lack of documentation of follow-up interventions, and issues with unsecured exit doors due to storm damage and ongoing repairs.

The complaint investigation substantiated that Resident #4 eloped from the facility on 04/21/23 and was missing for approximately 3 hours. The facility was notified by the resident's responsible party. This failure resulted in substantial risk for serious harm and neglect.

The Adult Care Licensure Section conducted an annual survey of THE PINES ON CARMEL SENIOR LIVING from December 6 to 9, 2022.

The facility failed to ensure timely follow-up on an endocrinology consultation for a diabetic resident, resulting in delayed medication adjustments. Additionally, the facility failed to ensure accurate documentation and administration of medications, including insulin and pain medications, for multiple residents. Medication administration records were incomplete with multiple omissions and inaccuracies, and medication orders were not always processed or followed up appropriately.

The Adult Care Licensure Section conducted a follow-up survey on 06/09/21 and 06/10/21 with an exit conference via telephone on 06/11/21 to verify correction of previous deficiencies.

The facility failed to ensure competency validation, diabetic care training, medication administration training, and physician notification for out-of-range fingerstick blood sugars for sampled staff and residents. Specifically, Staff D lacked documentation of competency validation for Licensed Health Professional Support tasks, diabetic care training, and medication aide training. Resident #5's physician was not notified of low blood sugar readings, and medications were administered contrary to physician orders.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey, complaint investigation and follow up survey from March 29, 2021 through April 1, 2021.

The facility failed to maintain hot water temperatures within regulatory limits, ensure adequate staffing levels, provide proper discharge notices, complete required staff training and competency validations, provide adequate supervision for residents with wandering and behavioral issues, ensure timely referral and follow-up for health care needs, administer medications according to orders, and maintain complete resident records. These failures resulted in risks of injury, neglect, and compromised resident safety and care.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up and complaint investigation survey onsite from 10/28/20 to 10/30/20 with a desk review on 11/02/20 and telephone exit on 11/03/20.

The facility failed to notify a resident's physician to request a refill order for an as-needed medication (Clonazepam 1mg) for Resident #4, resulting in the resident experiencing increased anxiety for at least five days due to lack of medication availability between 10/25/20 and 10/29/20.

This was a complaint investigation and follow-up survey triggered by concerns about medication management for Resident #4. The complaint was substantiated as the facility did not notify the physician or pharmacy to refill the controlled substance medication, Clonazepam 1mg, leading to a medication gap from 10/25/20 to 10/29/20.

Complaint investigation survey conducted due to concerns about staffing shortages and infection control in the Assisted Living and Special Care Unit.

The facility failed to maintain adequate staffing levels in the Assisted Living and Special Care Unit, resulting in medication administration errors and inadequate resident supervision. Infection control practices were deficient, including improper PPE use, lack of social distancing, and failure to cohort COVID-19 positive residents. Multiple medications were not administered as ordered for several residents.

Complaint investigation triggered by concerns about staffing shortages, medication administration errors, and infection control deficiencies during the COVID-19 pandemic.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 12/17/19-12/18/19 to assess compliance with previously identified deficiencies.

The facility failed to provide adequate supervision for Resident #5 who experienced multiple falls without increased supervision or documentation. Additionally, the facility failed to assure physician notification for Residents #5 and #6 when blood pressure readings were outside ordered parameters.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual and follow-up survey and complaint investigation from 08/20/19 to 08/22/19, initiated by a complaint on 07/24/19.

The facility failed to provide adequate supervision for a resident with dementia and repeated falls, failed to assure referral and follow-up for acute healthcare needs for two residents, failed to implement wound care treatments as ordered for one resident, failed to provide proper dining utensils for residents in the special care unit, failed to maintain an accurate therapeutic diet list, failed to serve therapeutic diets as ordered, and failed to ensure medication aides completed required state training.

Complaint investigation initiated by Mecklenburg County Department of Social Services on 07/24/19 related to supervision and care concerns.

This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building equipment and physical plant safety.

Deficiencies were found in the building's fire safety and exhaust ventilation systems, including unsealed cable penetrations in fire-resistance-rated ceilings and a ventilation system that was running but not exhausting air properly.

The facility underwent a Construction Section Biennial Survey to assess conformance with applicable adult care home licensing rules and North Carolina Building Codes.

Multiple deficiencies were cited related to physical plant and safety, including improper operation of special locking doors, hazards from unsecured oxygen cylinders, lack of ground fault interrupters on electrical outlets in wet locations, fire safety doors not closing or latching properly, obstructed fire suppression systems, fire safety penetrations not properly sealed, sprinkler system issues, doors requiring excessive force to open, corridor doors held open improperly, electrical system deficiencies, and ventilation system failures.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey and complaint investigation on May 3-4, 2017. The complaint investigation was initiated by the Mecklenburg County Department of Social Services on March 10, 2017.

The facility failed to assure that two non-nursing staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to employment. Additionally, medication administration errors were found for one resident, including failure to administer metformin and clonazepam as ordered by the prescribing practitioner, resulting in a 7% medication pass error rate.

The complaint investigation was initiated by the Mecklenburg County Department of Social Services on March 10, 2017.

The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revisions) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.

The survey found multiple deficiencies including obstructed access to electrical panels, improper storage of oxygen cylinders, failure to maintain fire safety equipment in safe operating condition such as fire resistant doors not latching, gaps in fire resistant ceilings, non-operational emergency lights, and lack of documented monthly fire extinguisher inspections.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on March 31, 2015 and April 1, 2015 to assess compliance with regulations.

The facility was found deficient in providing timely feeding assistance to a resident requiring help during meals and failed to administer medications as ordered by the licensed prescribing practitioner for a resident with diabetes.