Inspection Reports for Home Place of Burlington
118 Alamance Rd, Burlington, NC 27215, United States, NC, 27215
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 9
Sep 10, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 09/09/25 to 09/10/25 to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in multiple areas including incomplete tuberculosis testing for residents, incomplete care plans lacking physician signatures, failure to ensure referrals and follow-ups for health care needs, failure to maintain accurate menu substitution records, failure to serve therapeutic diets as ordered, medication order discrepancies, failure to administer medications as ordered, inaccurate medication administration records, and failure to follow up on pharmacy review recommendations.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure 3 of 5 sampled residents had completed two-step tuberculosis testing as required. |
| Facility failed to ensure 3 of 5 sampled residents had care plans signed by a physician or extender within 15 days of assessment. |
| Facility failed to ensure referral and follow-up for 1 of 5 sampled residents who had a podiatry referral, blood pressure order with parameters, and medication refusals. |
| Facility failed to maintain a record of menu substitutions documenting what was served to residents. |
| Facility failed to ensure therapeutic diets were served as ordered for 1 of 4 residents with a finger food diet order. |
| Facility failed to clarify medication orders for 2 of 5 sampled residents related to a medication for tremors and an anti-anxiety medication. |
| Facility failed to administer medications as ordered for 2 of 5 sampled residents who each had an order for a supplement. |
| Facility failed to ensure the electronic medication administration record was accurate for 1 of 5 residents related to an anti-anxiety medication. |
| Facility failed to follow up on pharmacy review recommendations for 2 of 5 sampled residents. |
Report Facts
Residents sampled: 5
Residents with incomplete TB testing: 3
Residents with unsigned care plans: 3
Medication refusals: 9
Medication refusals: 52
Medication refusals: 48
Medication refusals: 12
Vitamin B-12 level: 1965
Vitamin B-12 tablets dispensed: 28
Primidone tablets dispensed: 56
Seroquel tablets dispensed: 25
Seroquel half-tablets dispensed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for ensuring TB testing, care plans, medication order entry, medication cart audits, and pharmacy review follow-up. |
| Executive Director | Executive Director | Oversight of facility compliance and expectations for staff regarding medication administration and care plans. |
| Cook | Cook | Responsible for updating menu substitution log and preparing meals. |
| Dietary Manager | Dietary Manager | Responsible for ensuring menu substitution log updates and dietary staff training on therapeutic diets. |
| Medication Aide | Medication Aide | Administered medications and entered orders into eMAR; did not notice discrepancies in medication orders. |
| Primary Care Provider | Primary Care Provider | Physician for residents #1 and #2; unaware of discrepancies and lack of follow-up on pharmacy recommendations. |
| Mental Health Provider | Mental Health Provider | Provider for Resident #5; unaware of PRN Seroquel order not entered in eMAR. |
| Nurse Practitioner | Nurse Practitioner | PCP office NP for Resident #2; unaware of podiatry referral and medication refusals not reported. |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 22, 2025
Visit Reason
This was a Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is needed.
Inspection Report
Capacity: 74
Deficiencies: 4
Nov 12, 2024
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess the facility's conformance with applicable building codes and adult care home rules.
Findings
Deficiencies were cited related to unsafe and non-operating building equipment, including electrical components, plumbing equipment, and corridor doors that were blocked or held open by unapproved devices.
Deficiencies (4)
| Description |
|---|
| 2nd Floor Oxygen Room light did not illuminate. |
| 2nd Floor Spa handheld shower was not attached to the wall. |
| Kitchen ice machine drain does not have a 2 inch air gap. |
| Corridor doors blocked open or held open by unapproved devices (broom in Landing Room 136, wedges in Kitchen to Dining). |
Report Facts
Total licensed capacity: 74
Inspection Report
Follow-Up
Deficiencies: 1
Nov 7, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on November 7 and 8, 2023 to verify correction of previous deficiencies related to medication administration documentation.
Findings
The facility failed to ensure electronic medication administration records (eMAR) were accurate for one resident (Resident #3) regarding documentation of finger stick blood sugar (FSBS) results. Multiple FSBS checks were not documented, and there was no documentation of required interventions such as administering orange juice or notifying the primary care provider when FSBS values were outside ordered parameters. The eMAR system lacked a designated space to enter FSBS results, leading to inconsistent documentation.
Deficiencies (1)
| Description |
|---|
| Failed to ensure electronic medication administration records (eMAR) were accurate for Resident #3 related to documenting finger stick blood sugar (FSBS) results and required follow-up actions. |
Report Facts
FSBS documentation opportunities not documented: 14
FSBS documentation opportunities not documented: 16
FSBS documentation opportunities not documented: 2
FSBS results documented: 6
FSBS results documented: 6
FSBS results documented: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Reported lack of space in eMAR to document FSBS results and failure to document FSBS or required follow-up actions. | |
| Director of Resident Care | Audited residents' eMARs but did not notice missing space for FSBS documentation; expected medication aides to document FSBS and PCP notifications in eMAR notes. | |
| Primary Care Provider | Provided information about Resident #3's FSBS orders and clinical status. |
Inspection Report
Follow-Up
Deficiencies: 2
Aug 9, 2023
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to physical plant and safety code compliance.
Findings
The facility was found to have unresolved deficiencies including lack of a wiring diagram and system components location map for electromagnetic locks adjacent to the fire alarm panel, and smoke tight corridor doors not maintained in a safe and operating condition due to a manual flush bolt circumventing automatic positive latching requirements.
Deficiencies (2)
| Description |
|---|
| No wiring diagram or system components location map provided under glass adjacent to the fire alarm panel for electromagnetic locks. |
| Smoke tight corridor doors not maintained in a safe and operating condition; manual flush bolt on inactive leaf circumvents automatic positive latching requirements. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding difficulties locating original designer of the electromagnetic lock system and inability to replace manual flush bolt on corridor doors. |
Inspection Report
Follow-Up
Deficiencies: 4
Aug 2, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 08/01/23-08/02/23 to verify correction of previous deficiencies related to medication administration competency and other regulatory requirements.
Findings
The facility failed to ensure medication aides completed required training and competency evaluations before administering medications. Additionally, medications were not administered as ordered for Resident #2, including delays in antibiotic, antidepressant, and blood thinner administration. Medications were also found unsecured in residents' rooms, and the facility failed to notify the County Department of Social Services of incidents requiring emergency medical evaluation for two residents.
Severity Breakdown
Unabated Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 medication aides completed medication clinical skills checklist, passed the state medication administration exam, and completed required training before administering medications. | — |
| Failed to ensure medications were administered as ordered for Resident #2, including missed doses of antibiotic, antidepressant, blood thinner, and pain medication. | Unabated Type B Violation |
| Failed to ensure residents' medications were stored in a safe and secure manner; OTC medications were unsecured in Resident #5's room and Resident #7 self-administered medications not properly secured. | — |
| Failed to notify the County Department of Social Services of incidents requiring emergency medical evaluation for Residents #5 and #6. | — |
Report Facts
Medication administration days missed: 14
Medication administration days missed: 11
Medication administration days missed: 9
Acetaminophen administrations: 53
Acetaminophen tablets remaining: 53
Aspirin tablets available: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Named in medication administration competency deficiency for not completing required training and exams. |
| Staff E | Medication Aide | Named in medication administration competency deficiency for not completing required training and exams. |
| Resident Care Director | Responsible for sending incident/accident reports to County DSS; failed to report incidents timely. | |
| Administrator | Interviewed regarding medication administration and incident reporting deficiencies. | |
| Licensed Practical Nurse | LPN | Interviewed regarding medication administration and training deficiencies. |
| Medication Aide | MA | Multiple MAs interviewed regarding medication administration and storage practices. |
Inspection Report
Annual Inspection
Deficiencies: 6
Sep 9, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on September 8-9, 2021 to assess compliance with regulatory requirements for the facility.
Findings
The facility was found deficient in multiple areas including failure to ensure staff had current CPR certification, failure to test residents for tuberculosis upon admission, failure to serve therapeutic diets as ordered, failure to administer medications as prescribed, inaccurate medication administration records, and failure to implement COVID-19 screening and monitoring protocols as required.
Deficiencies (6)
| Description |
|---|
| Failure to ensure at least one staff person on premises had current CPR certification within last 24 months. |
| Failure to ensure 2 of 5 residents were tested for tuberculosis upon admission. |
| Failure to serve therapeutic diets as ordered for 1 of 5 sampled residents. |
| Failure to administer medications as ordered for 1 of 5 sampled residents related to multiple medications including Cardizem ER, cyanocobalamin, galantamine, vitamin D3, and Eliquis. |
| Failure to maintain accurate medication administration records for 2 of 5 sampled residents including documentation omissions for multiple medications. |
| Failure to implement CDC and state COVID-19 guidance related to daily screening and temperature monitoring of residents. |
Report Facts
Shifts without CPR certified staff: 20
Residents sampled: 5
Medication doses not documented: 7
Medication doses not documented: 2
Medication tablets dispensed: 30
Medication tablets remaining: 29
Medication tablets remaining: 54
Medication tablets remaining: 9
Medication tablets remaining: 13
Medication tablets remaining: 5
Medication tablets remaining: 9
Medication tablets dispensed: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in CPR certification deficiency |
| Staff B | Medication Aide | Named in CPR certification deficiency |
| Staff C | Medication Aide | Named in CPR certification deficiency |
| Memory Care Director | Named in CPR certification deficiency and staffing | |
| Director | Named in CPR certification deficiency and staffing | |
| Business Office Manager | Responsible for CPR certification tracking | |
| Medication Aide | Interviewed regarding medication administration and documentation | |
| Administrator | Interviewed regarding multiple deficiencies and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 29, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from September 27-29, 2017 to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to ensure staff CPR certification was current for 3 of 5 sampled staff, failure to serve milk at least twice daily to a resident as per dietary orders, and failure to clarify a physician's sliding scale insulin order leading to unclear medication administration instructions.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure 3 of 5 sampled staff had completed CPR and choking management training within the last 24 months. | Type B Violation |
| Facility failed to assure milk was served at least twice daily for 1 of 3 residents served meal trays in their rooms. | — |
| Facility failed to contact the physician for clarification of a Humalog sliding scale insulin medication order for 1 of 2 residents, resulting in unclear insulin administration instructions. | — |
Report Facts
Staff CPR certification: 3
Sampled staff: 5
Residents served meal trays: 3
Residents with milk service deficiency: 1
Blood glucose levels range: 429
Blood glucose levels range: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide and Supervisor | Named in CPR certification deficiency |
| Staff F | Medication Aide and Supervisor | Named in CPR certification deficiency |
| Staff G | Medication Aide and Supervisor | Named in CPR certification deficiency |
| Business Office Manager | Responsible for staff CPR certification documentation and scheduling | |
| Executive Director | Responsible for staff scheduling and oversight | |
| Resident Care Director | Responsible for medication order transcription and review | |
| Medication Aide | Administered insulin and reported unclear insulin orders | |
| Second Medication Aide | Reported unclear insulin orders and need for clarification |
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