Inspection Reports for DaySpring of Wallace
4026 S NC 11 Wallace, NC 28466, Wallace, NC, 28466
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
47 residents
Based on a October 2016 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 04/23/2025 to 04/24/2025 to assess compliance with infection prevention and control policies during a COVID-19 outbreak.
Findings
The facility failed to follow CDC recommendations and its own infection control policies during a COVID-19 outbreak, including failure to quarantine COVID-19 positive residents, failure to notify the local health department, and staff not consistently wearing required PPE such as masks.
Deficiencies (1)
Failure to ensure recommendations and guidance established by the CDC and facility infection control policies were followed during a COVID-19 outbreak.
Report Facts
COVID-19 positive residents: 9
COVID-19 positive staff members: 1
COVID-19 positive residents at time of inspection: 4
COVID-19 positive residents since first case: 8
COVID-19 positive cases reported to Adult Home Specialist: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding COVID-19 positive residents, quarantine practices, and PPE use. |
| Regional Facility Nurse | Regional Facility Nurse | Interviewed about attempts to isolate COVID-19 positive residents. |
| Administrator | Facility Administrator | Interviewed about testing, reporting to Adult Home Specialist, and mask policies. |
| Adult Home Specialist | Adult Home Specialist (AHS) | Interviewed about notification and reporting of COVID-19 outbreak. |
| Medication Aide | Medication Aide (MA) | Interviewed about staff mask usage during the COVID-19 outbreak. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 21, 2025
Visit Reason
The Adult Care Licensure Section and the Duplin County Department of Social Services conducted an annual survey, follow-up survey, and a complaint investigation on January 21, 2025 and January 27-28, 2025. The complaint investigation was initiated by the Duplin County Department of Social Services on January 6, 2025.
Complaint Details
Complaint investigation was initiated by the Duplin County Department of Social Services on January 6, 2025, related to issues including a clogged resident toilet and medication refusals.
Findings
The facility failed to maintain an orderly environment, ensure staff competency validation, notify the primary care provider of medication refusals, and maintain proper food temperature for residents. Specific issues included a clogged resident toilet not promptly repaired, lack of competency validation for a medication aide, failure to notify the PCP of multiple medication refusals for a resident, and serving cold food to a resident.
Deficiencies (4)
Facility failed to maintain an environment in an orderly manner and good repair, evidenced by a clogged resident toilet that overflowed and was not promptly fixed.
Facility failed to ensure a medication aide had a licensed health professional evaluate and validate competency for Licensed Health Professional Support tasks.
Facility failed to notify the primary care provider of multiple medication refusals for a resident, placing the resident at risk.
Facility failed to ensure hot foods were maintained hot until residents were ready to eat their meals, as evidenced by a resident receiving cold pureed food.
Report Facts
Medication refusal days: 13
Medication refusal days: 17
Date of clogged toilet incident: Jan 3, 2025
Date toilet unclogged: Jan 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to have competency evaluation and validation for Licensed Health Professional Support tasks. |
| Resident Care Coordinator | Involved in communication regarding clogged toilet and medication refusals. | |
| Clinical Nurse Consultant | Responsible for completing Licensed Health Professional Support evaluations; unaware of missing evaluation for Staff A. | |
| Administrator | Responsible for notifying CNC of new hires needing LHPS evaluation; unaware of missing LHPS for Staff A and medication refusal issues. | |
| Lead Medication Aide | Aware of resident medication refusals but failed to document PCP notification. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 16, 2022
Visit Reason
The Adult Care Licensure Section and the Duplin County Department of Social Services conducted an annual survey on June 16 - 17, 2022.
Findings
The facility failed to administer medications as ordered for one sampled resident (#6), due to family refusal to allow medication administration, despite no physician orders to hold or discontinue medications. Additionally, infection control measures were not followed during medication administration, as a medication aide failed to perform hand hygiene before and after administering medications to residents.
Deficiencies (2)
Failed to administer medications as ordered for Resident #6 due to family refusal despite no physician orders to hold or discontinue medications.
Failed to ensure infection control measures during medication administration; medication aide did not perform hand hygiene before and after administering oral medications to three residents.
Report Facts
Medication doses not administered: 10
Medication supply: 60
Medication supply: 60
Medication supply: 45
Medication supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Unit (SCU) Coordinator | Interviewed regarding medication administration and family refusal. | |
| Medication Aide (MA) | Interviewed regarding refusal to administer medications per family member's directive and failure to perform hand hygiene. | |
| MA/Supervisor | Interviewed regarding family refusal to allow medication administration. | |
| Resident Care Coordinator (RCC) | Interviewed regarding family refusal and medication administration issues. | |
| Administrator | Interviewed regarding family refusal, medication orders, and facility policies. | |
| Primary Care Provider (PCP) | Interviewed regarding medication orders, family refusal, and tapering of medications. | |
| Pharmacy Technician | Interviewed regarding medication orders and dispensing. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 19, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building maintenance and safety.
Findings
The facility was found to have multiple deficiencies including hazards from broken or partially removed items, improperly posted evacuation maps, lack of ground fault interrupters on electrical outlets in wet locations, and unsafe conditions caused by propped open self-closing doors that could affect fire containment.
Deficiencies (4)
Building was not maintained free of hazards due to mounting brackets with sharp edges left attached to the wall.
Facility failed to properly post and maintain evacuation maps oriented to actual floor arrangement.
Electrical outlets in wet locations lacked ground fault interrupters; one outlet had reverse polarity wiring.
Facility not maintained in safe and operating condition by blocking self-closing doors from closing completely, affecting smoke and fire containment.
Inspection Report
Capacity: 80
Deficiencies: 17
Date: Jun 12, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted on June 12, 2018, to assess compliance with the 1996 Rules for Licensing of Adult Care Homes and applicable building codes for the facility licensed for 80 beds with a 30 bed Special Care Unit (SCU).
Findings
Multiple deficiencies were cited including corridors obstructed by furniture, plumbing equipment not maintained cleanly, unsecured oxygen cylinders, hazards from mounting brackets, failure to properly post evacuation plans, incomplete fire drill rehearsals, lack of ground fault interrupters in wet locations, emergency equipment not functioning properly, fire and smoke barriers not maintained, fire sprinkler system issues, blocked self-closing doors, corridor doors not resisting smoke passage, and electrical system deficiencies.
Deficiencies (17)
Corridors are not free of obstructions, with large chairs encroaching on required corridor width.
Building plumbing equipment not maintained clean and orderly; ice machine drains improperly piped and algae growth present.
Building walls not kept clean and in good repair; hole in wall above electrical panel.
Community bath commode has a very loose seat.
Oxygen cylinders stored unsecured in beverage and plastic crates.
Mounting brackets for removed towel bars and soap dispenser remain attached to walls with rough and sharp edges.
Evacuation maps improperly posted and maintained; red-inked symbols faded and maps not oriented to actual floor arrangement.
Fire drill rehearsals not performed regularly on each shift quarterly; missing rehearsals in multiple shifts over last 12 months.
Electrical outlets in wet locations lack ground fault interrupters; some outlets without power and untestable.
Emergency lighting did not illuminate on backup power during test.
Smoke barrier doors do not close completely due to hitting stops or doorframe.
Fire safety compromised by gaps around cables and pipes not firestopped; deteriorated fire-resistance-rated ceiling assembly; improperly seated attic access panel.
Fire sprinkler system deficiencies including missing escutcheon plates exposing openings, dropped escutcheon plates, and debris-loaded sprinkler heads.
Self-closing doors blocked open with wedges, bottles, or stepladders preventing proper closure and smoke/fire containment.
Corridor doors held open with wedges or bottles preventing rapid release and latching; some doors have gaps or holes compromising smoke resistance.
Pair of corridor doors equipped with manual flush bolt circumventing positive latching requirement.
Emergency override switch on special locking system exit door has broken cover plate.
Report Facts
Licensed capacity: 80
Oxygen cylinders unsecured: 16
Fire drill rehearsals missing: 4
Fire sprinklers missing escutcheon plates: 5
Holes in corridor doors: 4
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 2
Date: Oct 28, 2016
Visit Reason
The Adult Care Licensure Section and the Duplin County Department of Social Services conducted an annual and follow-up survey on October 26-28, 2016.
Findings
The facility failed to ensure residents were served meals on non-disposable dishes, as observed during lunch and dinner on 10/27/16, and failed to administer medications as ordered for one resident with diabetes, resulting in an insulin administration error.
Deficiencies (2)
Residents were served meals on paper plates due to running out of non-disposable plates, violating nutrition and food service rules.
Medication administration error for Resident #2 involving early administration of Humalog insulin not in accordance with physician orders.
Report Facts
Residents present during lunch meal: 47
Residents served on paper plates: 2
Sampled residents for medication review: 5
Units of Humalog insulin administered incorrectly: 7
Blood sugar reading: 311
Blood sugar reading: 318
Blood sugar reading: 38
Blood sugar reading: 44
Hours of training for Medication Aides: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Aware residents were not to be served on paper products and reported shortage of plates | |
| Administrator | Interviewed regarding awareness of residents being served on disposable dishes and directed corrective actions | |
| Medication Aide | Administered insulin incorrectly to Resident #2 and described medication administration process | |
| Resident Care Director (RCD) | Observed medication pass, reported insulin administration error, and coordinated follow-up | |
| Nurse Practitioner (NP) | Assessed Resident #2 after insulin administration error and changed medication orders | |
| Pharmacy Representative | Explained medication order entry and pop-up system for medication administration times | |
| Personal Care Aides (PCA) | Delivered snacks to residents and described Resident #2's snack preferences | |
| Facility Administrator | Described Medication Aide training and medication administration policies |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 21, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies at Dayspring of Wallace.
Findings
Most cited deficiencies were corrected; however, one deficiency remained regarding staff not carrying emergency release switch keys for magnetic locks on exit doors as required by code.
Deficiencies (1)
Facility has not maintained measures for special locking (magnetic locks) on exit doors; all staff must carry emergency release switch keys but only the med tech was carrying one.
Inspection Report
Capacity: 80
Deficiencies: 5
Date: May 11, 2016
Visit Reason
The inspection was a Biennial Construction Survey to ensure the facility meets the 1996 Rules for the Licensing of Adult Care Homes and the North Carolina State Building Code Volume I-General Construction 1996 Edition - Institutional - Group I-Unrestrained Occupancy.
Findings
Multiple deficiencies were cited including failure to maintain emergency release keys for magnetic locks on exit doors, damaged wood veneer on interior doors, interior doors not latching properly affecting fire safety, failure to provide proper exhaust ventilation in certain areas, and poor maintenance of HVAC air distribution grilles and duct housings.
Deficiencies (5)
Facility staff in the Special Care Unit were not all carrying emergency release switch keys for magnetic locks on exit doors as required.
Interior wood doors had scratched and damaged veneer edges at hinges in multiple rooms.
Interior doors did not latch or operate properly, preventing containment of fire and/or smoke.
Mechanical exhaust fans were not exhausting interior air in resident bathrooms and chemical storage room in the 300 Hall.
HVAC supply and return-air grilles were not clean, with excessive particulate build-up, peeling finishes, and rust in various locations.
Report Facts
Licensed capacity: 80
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 4
Date: Jun 18, 2015
Visit Reason
The Adult Care Licensure Section and the Duplin County Department of Social Services conducted an annual survey on June 16-18, 2015 to assess compliance with regulations.
Findings
The facility failed to ensure medication aides received required training on diabetic care, failed to assure referral and follow-up for routine and acute health care needs for residents, and failed to conduct controlled substance screening for some employees prior to employment. Additionally, sanitation scores were below required levels at another facility during an annual survey.
Deficiencies (4)
Failed to assure that 3 of 5 sampled medication aides received training by a licensed health professional on the care of diabetic residents prior to insulin administration.
Failed to assure referral and follow-up to meet routine and acute health care needs for 2 of 5 residents, including coordinating pacemaker checks and toenail care.
Failed to assure that an examination and screening for the presence of controlled substances was performed for 2 of 6 sampled employees prior to employment.
Failed to maintain a North Carolina Division of Environmental Health approved sanitation classification of 85 or above at all times.
Report Facts
Resident census: 68
Number of diabetic residents: 24
Residents receiving scheduled insulin: 8
Residents receiving sliding scale insulin: 6
Sanitation score: 84
Number of sampled medication aides without training: 3
Number of sampled employees without controlled substance screening: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Supervisor in Charge / Medication Aide | Named in deficiency for lack of diabetic care training. |
| Staff F | Supervisor in Charge / Personal Care Assistant | Named in deficiency for lack of diabetic care training. |
| Staff H | Supervisor in Charge | Named in deficiency for lack of diabetic care training. |
| Staff B | Personal Care Assistant | Named in deficiency for lack of controlled substance screening prior to employment. |
| Staff C | Supervisor in Charge | Named in deficiency for lack of controlled substance screening prior to employment. |
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