Inspection Reports for
Dunmore Senior Living of Zebulon
1205 W Gannon Avenue Zebulon, NC 27597, Zebulon, NC, 27597
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43 residents
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 3, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies identified in a prior Biennial Construction Survey.
Findings
The facility had several outstanding deficiencies including unmaintained outside premises with fallen siding, walls and ceilings not kept clean and in good repair, and lack of exhaust ventilation in multiple specified areas causing humidity buildup and odor issues.
Deficiencies (3)
Outside premises were not maintained in a clean and safe condition; the top piece of siding in the gable above the 400 Hall exit door had fallen off.
Walls, ceilings, and floors were not kept clean and in good repair; specifically, the kitchen ceiling finish above the attic access panel was chipped.
Facility did not maintain exhaust ventilation in specified spaces including Women's Guest Toilet, Staff Bath, Room 402 Bath, Laundry, Soiled Linen, and 400 Hall Housekeeping; exhaust fans were not working.
Inspection Report
Follow-Up
Census: 43
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on June 18-20, 2024, initiated by the Wake County Department of Social Services on May 31, 2024.
Complaint Details
Complaint investigation was initiated by the Wake County Department of Social Services on May 31, 2024.
Findings
The facility failed to maintain hot water temperatures within required limits, ensure notification to primary care providers for abnormal blood sugar levels, complete licensed health professional support assessments quarterly, provide residents with access to a private telephone, and administer medications as ordered, including missing medications and medication errors.
Deficiencies (5)
Failed to ensure hot water temperatures at 6 of 16 fixtures accessible to residents were maintained between 100 and 116 degrees Fahrenheit.
Failed to ensure notification to the primary care provider for 1 of 5 sampled residents related to blood sugar levels outside established parameters.
Failed to ensure licensed health professional support assessments were completed quarterly for 3 of 5 sampled residents.
Failed to ensure residents had a telephone available in a private location to make and receive calls.
Failed to ensure medications were administered as ordered to 1 of 6 residents observed during medication pass and for 2 of 5 sampled residents with multiple medication errors and missing medications.
Report Facts
Deficiencies cited: 5
Residents: 43
Medication error rate: 5
Hot water fixtures: 6
Hot water fixtures total: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance person | Interviewed about hot water temperature issues and mixing valve problems. | |
| Administrator | Interviewed regarding hot water issues, licensed health professional support assessments, medication administration, and telephone access. | |
| Medication Aide (MA) | Interviewed regarding medication administration errors and medication availability. | |
| Resident Care Coordinator (RCC) | Interviewed regarding medication administration, licensed health professional support assessments, and notification procedures. | |
| Business Office Manager (BOM) | Interviewed regarding telephone access for residents. | |
| Primary Care Provider (PCP) | Interviewed regarding resident care and medication concerns. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 5, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 03/03/24 to 03/05/24 to assess compliance with state regulations for Coventry House of Zebulon.
Findings
The facility was found deficient in multiple areas including hot water temperature regulation, health care notifications and documentation, licensed health professional support, therapeutic diet menu availability, activities program, resident rights, medication administration, and accounting for residents' personal funds.
Deficiencies (11)
Failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit with fluctuations between 98 and 122 degrees F.
Failed to ensure notification to the primary care provider for elevated blood pressure results and changes in condition for Resident #1.
Failed to ensure documentation of notifications to the primary care provider for changes in condition, falls, hospitalizations, and elevated blood pressure results for Resident #1.
Failed to ensure participation by a licensed health professional in the review and evaluation of residents' health status, care plan, and care provided for 4 of 5 sampled residents.
Failed to ensure a matching therapeutic diet menu was available for food service staff for 4 of 4 sampled residents with physician-ordered therapeutic diets.
Failed to ensure all 48 residents were offered activities designed to promote active involvement with each other and the community; no activity calendar or activity director was present.
Failed to ensure residents were treated with consideration, respect, and dignity, and protected from verbal abuse and fear of retaliation from staff.
Failed to ensure medications were administered as ordered for 2 of 3 observed residents and 2 of 5 sampled residents, including errors with antibiotics, insulin, pain relief, and laxatives.
Failed to ensure medications were administered within one hour before or after the scheduled time for 1 of 5 sampled residents and a second observed resident.
Failed to ensure medication administration records were accurate for 1 of 5 sampled residents to include multiple medications for pain, hypertension, supplements, and anxiety.
Failed to ensure residents' personal funds were available upon request for 3 months for 5 of 5 sampled residents.
Report Facts
Medication error rate: 10
Residents: 48
Residents: 5
Balance: 2247.22
Balance: 355.18
Balance: 262.32
Balance: 260
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Date: Jul 25, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on July 25-26, 2019 to assess compliance with nutrition and food service regulations.
Findings
The facility failed to assure that 8 ounces of milk was served twice daily to residents as required. Observations and interviews revealed milk was only served at breakfast and not offered during lunch or dinner meals, despite the menu indicating milk should be served three times daily.
Deficiencies (1)
Facility failed to assure 8 ounces of milk was served twice daily to residents; milk was only served at breakfast and not offered during lunch or dinner meals.
Report Facts
Residents present at lunch: 36
Residents present at dinner: 35
Gallons of milk observed: 10
Inspection Report
Capacity: 60
Deficiencies: 7
Date: Aug 22, 2018
Visit Reason
This 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 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
The facility failed to maintain fire resistance in construction in a safe condition, including openings and penetrations in the one-hour fire rated roof/ceiling assembly in multiple locations. Emergency lights failed to illuminate at several locations. The hot water system was found to have unsafe temperature settings, with water temperatures reaching 140 degrees F, exceeding the maximum allowed, which was corrected by maintenance and plumbers.
Deficiencies (7)
Facility failed to maintain fire resistance in construction in a safe condition, including a 24"x24" opening in the ceiling due to recent water heater installations in the Sprinkler Riser Room violating the one-hour fire rated roof/ceiling assembly.
Ceiling piping penetrations in the one-hour fire rated roof/ceiling assembly have voids and lack fire resistance in the Sprinkler Riser Room.
Openings around flue pipes from gas appliances at the ceiling lack fire resistance in the one-hour fire rated roof/ceiling assembly.
Fresh air grilles in the one-hour fire rated roof/ceiling assembly lack fire resistance in the Sprinkler Riser Room and Main Electrical Room.
A 3" diameter hole in the ceiling above the 3-compartment sink in the Kitchen penetrates the one-hour fire roof/ceiling assembly.
Emergency lights at Front Door/Outside, Main Laundry, and End Porch/300 Hall did not illuminate when tested.
Hot water temperatures exceeded safe minimum and maximum ranges; water tested at 140 degrees F in Spas and Resident Room sinks. Immediate action taken to turn off hot water supply to sinks. Water heaters were reset from 150 degrees F to 110 degrees F and system flushed.
Report Facts
Total licensed capacity: 60
Opening size: 24
Hole diameter: 3
Hot water temperature: 140
Previous water heater setting: 150
Reset water heater setting: 110
Emergency light failure locations: 3
Inspection Report
Capacity: 60
Deficiencies: 9
Date: Sep 29, 2016
Visit Reason
This was a Biennial Construction Survey to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged.
Findings
Multiple deficiencies were cited including failure to maintain ceiling finishes in food service areas, interior door hardware, plumbing fixtures, mechanical exhaust components, fire safety documentation and penetrations, electrical panel access, and exhaust ventilation in resident bathrooms.
Deficiencies (9)
Failed to maintain finishes on ceiling surfaces in areas that serve food to residents due to previous water migration.
Interior door in Utility Room has missing door hardware preventing latching.
Toilet is loose in Men's Bathroom across from Nurse's Station.
Exhaust duct unfastened to ceiling housing in Room 407.
Failed to post required documentation for Special Locking Systems as per NC State Building Code.
Penetrations through fire-rated construction invalidated ceiling integrity; hole filled with non-fire-resistant foam in outside Mechanical Room.
Sheet-rock ceiling damaged due to installation of new pressure gauge on sprinkler riser in Sprinkler Riser Room.
Household items and equipment blocking access to electrical circuit panels in Electrical Panel Room.
Mechanical exhaust fans not exhausting interior air in all Resident Bathrooms in the 200 & 400 Halls.
Report Facts
Licensed capacity: 60
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 2
Date: Jun 21, 2016
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted an annual survey on June 21-22, 2016 to assess compliance with regulations.
Findings
The facility failed to ensure dietary menus accounted for residents' food preferences, particularly regarding tuna dislike, and failed to administer medications within the required time frame for 2 of 7 residents observed during medication administration.
Deficiencies (2)
Dietary menus were not planned taking into account residents' food preferences and customs, including residents disliking tuna.
Medications for blood pressure, gastrointestinal problems, depression, seizure disorders, and nerve pain were not administered within one hour before or after the scheduled time for 2 of 7 residents observed.
Report Facts
Census: 39
Medication administration delays: 11
Medication administration delays: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | In charge of Medication Aides and interviewed regarding medication administration practices |
| Chief Operations Officer | Chief Operations Officer (COO) | Interviewed about medication administration and facility operations |
| Medication Aide | Medication Aide (MA) | Observed administering medications and interviewed about medication pass timing |
| Activities Director | Activities Director | Conducted resident council meetings regarding food likes and dislikes |
| Director of Operations | Director of Operations | Interviewed about complaint handling and food dislike issues |
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