Inspection Reports for Kempton of Jacksonville
3045 Henderson Drive Extension Jacksonville, NC 28546, Jacksonville, NC, 28546
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 21, 2024, identified deficiencies related to medication administration errors for two residents during the medication pass. Earlier inspections showed a pattern of construction and safety-related deficiencies, including issues with fire alarm systems, electrical outlets, and door hardware, but the April 24, 2024 follow-up survey confirmed those prior construction deficiencies had been corrected. Complaint investigations included one initiated by the Onslow County Department of Social Services, which led to the medication-related findings in the latest inspection; no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior complaints were unsubstantiated or related to physical plant issues rather than resident care. The facility’s recent correction of construction deficiencies contrasts with ongoing challenges in medication management, indicating mixed progress over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 21, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and a complaint investigation from 06/18/24 through 06/21/24. The complaint investigation was initiated by the Onslow County Department of Social Services on 05/24/24.
Complaint Details
The complaint investigation was initiated by the Onslow County Department of Social Services on 05/24/24.
Findings
The facility failed to ensure medications were administered as ordered for 2 of 4 residents observed during the medication pass, including errors with a topical pain medication and an extended-release medication for high blood pressure. The medication error rate was 7%, with 2 errors out of 28 opportunities during the 8:00am medication pass on 06/19/24.
Deficiencies (1)
Failed to ensure medications were administered as ordered for 2 of 4 residents (#7 and #9), including errors with topical Diclofenac gel and crushing extended-release Metoprolol Succinate ER tablets.
Report Facts
Medication error rate: 7
Medication opportunities: 28
Medication errors: 2
Blood pressure: 11061
Heart rate: 76
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
Report of a Construction Section Biennial Follow-Up Survey conducted on April 24, 2024.
Findings
All deficiencies identified in the previous survey have been corrected. No further action is required.
Inspection Report
Capacity: 79
Deficiencies: 4
Date: Jan 31, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for the Licensing of Adult Care Homes and applicable components of the 2005 Rules for Adult Care Homes of Seven or More Beds, as well as the 1996 North Carolina State Building Code for Group I - Institutional Unrestrained Occupancy.
Findings
Deficiencies were noted related to electrical outlets in wet locations lacking ground fault circuit interrupters (GFCI) and failure to maintain building equipment, including fire safety components and structural elements, in a safe and operating condition.
Deficiencies (4)
Multiple electrical outlets in the laundry room, behind the ice machine in the kitchen, and behind the drink station in the main dining room are not GFCI protected.
The right leaf of the fire door of the 3000 hallway did not close and latch properly.
The emergency light outside of room 404 is missing two electrical knock outs.
There is a large hole in the outside canopy just in front of the main entrance door.
Report Facts
Licensed capacity: 79
Special Care Unit beds: 22
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 10, 2018
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies.
Findings
One deficiency remains related to the fire alarm system's alarm verification feature that delays activation by 30 seconds, potentially endangering residents. The facility has a programmable delayed response feature on smoke detectors called VSMOKE, and the Fire Marshal's review of this feature is still pending.
Deficiencies (1)
Fire alarm system has an alarm verification feature enabled that delays activation for 30 seconds before activating the alarm, potentially delaying evacuation and endangering residents.
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 9, 2018
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of deficiencies cited in a prior Biennial Construction Survey.
Findings
The survey found that the staff entrance door's access controlled egress locking does not comply with the building code due to lack of a sensor. The fire alarm system has an alarm verification feature causing a 30-second delay before activation, potentially endangering residents. Additionally, the required one-hour fire rated ceilings may be compromised by improperly protected conduit penetrations in multiple locations.
Deficiencies (3)
Staff entrance door access controlled egress locking fails to comply with the Building Code due to no sensor on the inside of the exit to detect an occupant approaching the door to egress.
Fire alarm system has an alarm verification feature enabled that delays fire alarm activation for 30 seconds, potentially delaying evacuation.
Required one-hour fire rated ceilings may be compromised by improperly protected conduit penetrations in several locations including main electrical room and multiple panel closets.
Report Facts
Delay time: 30
PVC conduits: 10
PVC conduits: 2
PVC conduits: 2
PVC conduits: 2
PVC conduits: 2
PVC conduits: 2
Inspection Report
Capacity: 79
Deficiencies: 13
Date: Mar 22, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with physical plant, fire safety, and building code requirements for Liberty Commons Assisted Living, a licensed 79-bed facility with a 22-bed Special Care Unit.
Findings
The survey identified multiple deficiencies including noncompliance with emergency release switch key requirements, lack of sensors and timing on access-controlled egress locks, outdated fire alarm inspection reports, missing hand grips in bathrooms, corridor obstructions, improper storage of medical oxygen cylinders, lack of documented monthly inspections of fire suppression systems, inadequate fire drill rehearsals, malfunctioning smoke detectors and emergency lights, corridor doors failing to latch properly, compromised fire-rated walls and ceilings, and dirty duct smoke detector sampling tubes.
Deficiencies (13)
Facility equipped with magnetic locks on exit doors without staff carrying emergency release switch keys.
Staff entrance door access control lacks sensor and push-to-exit switch does not remain unlocked for 30 seconds.
Most recent fire alarm system inspection report dated 4-28-2016, not inspected annually as required.
No hand grip provided at the tub in the shower room in Special Care.
Corridor not free of obstructions; furniture and appliances stored reducing clear width to less than 5 feet.
Improper handling and storage of portable medical oxygen cylinders in unapproved containers and locations.
No documentation of monthly inspections for range hood fire suppression system.
Fire drill rehearsals not conducted quarterly on each shift; records show rehearsals only during 1st shift.
Corridor smoke detector near Administrator's office activated but failed to trigger fire alarm system.
Battery powered emergency lights failed to work properly in multiple locations.
Many corridor doors do not close and latch properly, including double doors with only bale catches and doors propped open or with holes.
Required one-hour fire rated walls and ceilings compromised by holes, penetrations, and unsealed conduit penetrations.
Duct mounted smoke detector sampling tube in attic very dirty and holes oriented away from airflow.
Report Facts
Licensed capacity: 79
Special Care Unit beds: 22
Fire alarm inspection date: Apr 28, 2016
Fire drill shifts: 3
Inspection Report
Capacity: 79
Deficiencies: 8
Date: May 18, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant requirements and building safety codes for Liberty Commons Assisted Living.
Findings
The facility was found to have multiple deficiencies including staff not carrying emergency release keys for magnetic locks, lack of inspection tags on fire suppression systems, malfunctioning emergency release switch, improperly installed smoke detector sampling tube, compromised fire-rated walls and ceilings, and a door that could not close properly to resist smoke passage.
Deficiencies (8)
Most staff did not carry emergency release switch keys for magnetic locks on exit doors of the Special Care Unit.
No inspection tag provided on the range hood fire suppression system, which must be inspected monthly.
Required central emergency release switch for magnetic locking system did not work consistently.
Smoke detector and junction box hanging out of ceiling in storage room compromising fire protection.
Sampling tube for duct mounted smoke detector installed with holes oriented away from airflow direction.
Unsealed penetrations in attic smoke barrier walls compromising one-hour fire rated construction.
Gypsum compound and tape falling off ceiling above commercial dryer.
Strike missing at latchset on janitor's closet door preventing proper closure and smoke resistance.
Report Facts
Total licensed beds: 79
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 22, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on April 20 - 22, 2016 to assess compliance with state regulations.
Findings
The facility failed to maintain hot water temperatures within the required range in resident bathrooms, had issues with physician notification for residents with pain and abnormal blood sugars, and failed to administer medications as ordered due to medication availability issues.
Deficiencies (5)
Hot water temperatures were not maintained between 100 and 116 degrees Fahrenheit for 5 of 35 sinks and showers in resident bathrooms.
Failed to assure physician notification for 2 of 5 sampled residents for pain and decreased mobility resulting in a fall, and for abnormal blood sugar levels.
Failed to assure medication (Klonopin) was administered as ordered for 1 of 5 sampled residents due to medication unavailability from 02/08/16 to 02/16/16.
Failed to assure provision of pharmaceutical services to meet residents' needs related to accurate ordering, receiving, and administering of medications for 1 of 5 residents.
Failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to referral and follow-up.
Report Facts
Hot water sinks monitored: 35
Hot water sinks out of range: 5
Residents sampled: 5
Days medication not administered: 9
Correction date: 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding hot water temperature issues, medication availability, and physician notification | |
| Maintenance Staff Person | Interviewed and observed regarding hot water temperature monitoring and adjustments | |
| Personal Care Aide (PCA) | Interviewed regarding resident assistance and hot water temperature complaints | |
| Medication Aide (MA) | Interviewed regarding blood sugar monitoring and medication administration | |
| Wellness Coordinator (WC) | Interviewed regarding blood sugar monitoring and physician notification | |
| Medication Aide/Supervisor in Charge (MA/SIC) | Interviewed regarding medication ordering and refill processes |
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