Inspection Reports for Lawndale Manor
601 Lakeside Drive Garner, NC 27529, Garner, NC, 27529
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 27, 2023 identified deficiencies related to medication staff qualifications, resident supervision, health care follow-up, resident rights, and medication administration. Earlier inspections showed a pattern of issues including infection control lapses in 2021 and multiple building maintenance and safety deficiencies from 2015 through 2019, such as unsecured hazardous materials, fire safety equipment problems, and ventilation failures. Deficiencies primarily involved resident care concerns like supervision and medication errors, as well as physical plant and safety issues in prior years. Complaint investigations were either not present or unsubstantiated in the available reports, and no fines or enforcement actions were listed. The inspection history indicates recurring challenges in both care and facility maintenance, with recent findings continuing some prior care-related issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 27, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on September 26-27, 2023 to assess compliance with state regulations for an adult care home.
Findings
The facility was found deficient in multiple areas including medication staff qualifications, resident supervision, health care follow-up, resident rights, and medication administration. Specific issues included unqualified medication staff, inadequate supervision of a resident with frequent falls, failure to schedule neurology appointments and notify physicians of abnormal blood pressures, disrespectful treatment of a resident regarding meal location, and medication administration errors including insulin technique and missed doses.
Deficiencies (5)
Failed to ensure 1 of 3 medication staff completed required state-approved medication aide training courses.
Failed to provide adequate supervision for a resident with 18 falls over 7 months resulting in injuries and hospital visits.
Failed to provide referral and follow-up for 3 of 5 residents related to neurology appointments not scheduled and physician not notified of abnormal blood pressure.
Failed to treat a resident with respect and dignity related to forcing resident to eat in dining room and verbal altercation between staff in front of residents.
Failed to administer medications as ordered and in accordance with facility policies including insulin administration errors and missed doses of medications for diabetes, fungal infection, and urinary tract infection prevention.
Report Facts
Medication error rate: 7
Resident falls: 18
Medication doses missed: 5
Medication doses missed: 8
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 13, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey on October 12 and 13, 2021 to assess compliance with infection prevention and control requirements during the COVID-19 pandemic.
Findings
The facility failed to implement and maintain CDC and North Carolina Department of Health and Human Services guidance for screening residents for COVID-19 signs and symptoms, including daily temperature checks. Documentation of daily temperatures and symptom screening was missing, with temperature logs not updated since July 2021.
Deficiencies (1)
Failure to ensure implementation of infection prevention and control program related to COVID-19 screening and daily temperature checks for residents.
Report Facts
Date survey completed: Oct 13, 2021
Number of residents' medication administration records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Interviewed regarding temperature checks and documentation | |
| Licensed Practical Nurse (LPN) | Interviewed regarding screening and temperature checks | |
| Administrator | Interviewed regarding responsibility for temperature logs and monitoring |
Inspection Report
Capacity: 62
Deficiencies: 8
Date: Sep 12, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1991 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1991 Edition of the North Carolina Building Code(s), Institutional Occupancy.
Findings
Multiple deficiencies were cited including lack of locked janitor closets for hazardous substances, unclean and unrepaired housekeeping and furnishings, hazards related to unsecured medical oxygen cylinders, improperly maintained fire extinguishers, lack of documented fire safety rehearsals, fire alarm and emergency equipment not maintained in safe operating condition, unsafe electrical system conditions, improper storage of materials, use of prohibited portable electric heaters, and failure to maintain required exhaust ventilation systems.
Deficiencies (8)
Building was not maintained in a safe manner by not having separate locked areas for hazardous substances in janitor closets.
Building mechanical systems not kept clean and in good repair; ventilation systems with excessive dust/lint and dropped damper; floors chipped and not clean.
Building not maintained free of hazards; portable medical oxygen cylinder unsecured.
Facility failed to properly maintain fire extinguishers and associated equipment; no documentation of monthly inspections since last annual maintenance.
Fire safety rehearsals not documented for any shifts in the last 12 months.
Fire alarm system not maintained in safe and operating condition; hold open devices allow firewall doors to be held open during alarm silence; emergency lights malfunctioning; commercial kitchen hood fire suppression system lacks required inspections and documentation; smoke tight corridor doors not maintained properly; electrical system unsafe; combustible materials stored improperly.
Facility failed to prevent use of portable electric heaters, which are prohibited.
Facility failed to maintain ventilation system in rooms required to be mechanically exhausted; multiple bathrooms, utility rooms, and laundry areas had non-functioning exhaust ventilation.
Report Facts
Licensed capacity: 62
Number of vinyl composition floor tiles chipped: 20
Time since last fire extinguisher maintenance: 5
Timeframe for fire safety rehearsals documentation: 12
Clear working space required in front of electrical panels: 36
Clear working space required in front of electrical panels: 30
Storage clearance from ceiling: 24
Inspection Report
Capacity: 62
Deficiencies: 10
Date: Aug 2, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, the 1991 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure, and applicable portions of the 1991 Edition of the North Carolina Building Code(s), Institutional Occupancy.
Findings
The survey identified multiple deficiencies including unsecured janitor closets containing hazardous materials, outside premises not maintained in a clean and safe condition, failure to maintain walls, floors, and furnishings in good repair, oxygen bottles stored without restraints, emergency equipment and electrical equipment not maintained in safe operating condition, fire safety equipment issues, plumbing equipment problems, and inadequate exhaust ventilation.
Deficiencies (10)
Hazardous materials were not kept in a locked area; two janitor's closets were unlocked containing cleaning agents.
Outside grounds were not maintained in a clean and safe condition; soffit fallen out with pest evidence and loose siding.
Facility failed to maintain walls in good repair; large hole in Med Room wall and heavily scuffed walls.
Facility failed to maintain floors in good repair; broken floor tile near closet in Room 206.
Oxygen bottles stored without restraints in Staff Storage at Nurses' Station and Room 208.
Emergency equipment not maintained in operating condition; exit lights and emergency lights not working in multiple locations.
Electrical equipment not maintained in safe condition; wall outlet missing cover plate in Room 106.
Fire safety equipment deficiencies; gaps at penetrations in fire resistant ceilings and doors not closing or latching properly.
Plumbing equipment not maintained in good operating condition; toilet in HC Bath (200 Hall) was whistling.
Exhaust ventilation not maintained at required rate; exhaust fan not working in Guest Women's Bath.
Report Facts
Total licensed capacity: 62
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 28, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on June 27-28, 2017 to verify correction of previous deficiencies related to tuberculosis testing compliance.
Findings
The facility failed to assure completion of 2-step tuberculosis (TB) testing upon admission for 2 of 5 sampled residents. Documentation and system protocols for TB testing were incomplete or lacking, including missing second step TB tests and lack of monitoring systems prior to March 2017.
Deficiencies (1)
Failure to assure 2-step tuberculosis (TB) testing was completed upon admission for residents as required by regulation.
Report Facts
Residents sampled: 5
Residents non-compliant: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health Service Director | Interviewed regarding TB testing protocols and monitoring | |
| Administrator | Interviewed regarding TB testing system and admission procedures | |
| LHPS Nurse | Responsible for administering and documenting TB tests |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 14, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey, and complaint investigation on 3/08/17, 3/09/17, 3/10/17, 3/13/17 and 3/14/17.
Complaint Details
The survey included a complaint investigation conducted on 3/08/17, 3/09/17, 3/10/17, 3/13/17 and 3/14/17.
Findings
The facility failed to assure tuberculosis testing upon admission for 2 of 6 sampled residents, failed to provide supervision for 1 of 6 residents resulting in serious injury from multiple falls, failed to report elevated blood sugars and ensure ordered insulin was available for 1 resident, and failed to administer medications as ordered including crushing enteric coated aspirin and administering ferrous sulfate without food.
Deficiencies (4)
Failed to assure Tuberculosis (TB) disease testing had been completed upon admission for 2 of 6 sampled residents.
Failed to provide supervision for 1 of 6 sampled residents related to multiple falls resulting in serious injury of multiple fractures of the right arm and right leg.
Failed to report elevated blood sugars and that ordered insulin was available for 1 of 1 sampled residents as ordered by the prescribing physician.
Failed to assure that medication (insulin) was available to administer as ordered to 1 of 1 sampled residents and 2 of 7 residents observed during medication administration of ferrous sulfate and enteric coated aspirin.
Report Facts
Dates of survey: 5
Residents sampled for TB testing: 6
Falls for Resident #6: 6
Blood sugar readings above 400: 4
Medication error rate: 6
Units of Humulin N insulin: 95
Units of Humulin N insulin: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health Services Director | Health Services Director (HSD) | Interviewed regarding TB testing, elevated blood sugars, medication administration, and supervision of residents |
| Assistant Health Services Director | Assistant Health Services Director (AHSD) | Interviewed regarding supervision of Resident #6 and medication availability |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration and documentation |
| Administrator | Administrator | Interviewed regarding resident assessments and supervision |
| Nursing Assistant | Nursing Assistant (NA) | Interviewed regarding care and supervision of Resident #6 |
Inspection Report
Routine
Deficiencies: 4
Date: Dec 10, 2015
Visit Reason
The inspection was conducted to assess compliance with state regulations regarding staff training on diabetic care, medication orders, use of physical restraints, and infection prevention in an adult care home.
Findings
The facility failed to ensure medication aides received required training on diabetic care and infection prevention, did not properly manage verbal medication orders, and used physical restraints (bed rails) without proper physician orders or care planning for sampled residents.
Deficiencies (4)
Failure to assure medication aide completed training on care of diabetic residents prior to insulin administration.
Failure to assure verbal medication orders were countersigned by prescribing practitioner within 15 days.
Failure to assure physical restraints (bed rails) were used only with physician order and after care planning.
Failure to assure mandatory annual infection prevention training was completed for medication aides.
Report Facts
Medication aides sampled: 2
Residents sampled: 5
Residents with restraint issues: 2
Dates of verbal orders unsigned: 3
Dates of infection prevention training missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Failed to complete diabetic care training and improperly administered insulin without priming pen. |
| Staff A | Medication Aide | Missing documentation of mandatory annual infection prevention training for 2015. |
| Assistant Health Services Director | Responsible for maintaining staff records, required training, and medication orders follow-up. | |
| Health Services Director | Oversaw training programs and medication order processes. | |
| Director of Health Services | Interviewed regarding restraint use and facility policies. | |
| Hospice Nurse | Provided verbal medication orders and was responsible for some medication orders for residents. |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Oct 20, 2015
Visit Reason
This report is of a Followup Survey conducted to verify correction of previously cited deficiencies. The followup survey revealed that all deficiencies were not corrected, requiring a new plan of correction.
Findings
The facility was found to have multiple unresolved deficiencies including damaged and moldy wallboard, loose shower tiles, plumbing equipment not maintained safely, corridor doors held open improperly, breaches in fire-resistance-rated construction, use of prohibited portable electric heaters, and inadequate exhaust ventilation.
Deficiencies (7)
Walls, ceilings, and floors or floor coverings not kept clean and in good repair; mold behind commode and loose shower tiles allowing water intrusion.
Building plumbing equipment not maintained safely; floor drain grate below floor level creating tripping hazard; rusty ceiling supply register.
Corridor doors held open by devices that do not release properly, preventing rapid closing and latching, compromising fire and smoke containment.
Fire and smoke resistance of doors compromised; excessive gaps and broken wire glass in kitchen to dining doors.
Breaches in fire-resistance-rated ceiling assembly including unsealed cable penetration and unprotected conduit penetration.
Use of unvented and portable electric heaters prohibited; portable electric heater found in Director of Health Care's office.
Exhaust ventilation system failed to remove required amount of air in laundry and water heater/janitor closet areas.
Report Facts
Date of followup survey: Oct 20, 2015
Floor drain grate depth: 0.625
Fire-resistance-rated ceiling hole size: 0.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob Getchell | Surveyor who conducted the followup survey on October 20, 2015 |
Inspection Report
Complaint Investigation
Capacity: 62
Deficiencies: 14
Date: Aug 7, 2015
Visit Reason
The inspection was a Biennial Construction Complaint Survey conducted to assess conformance with applicable licensing rules and building codes for an adult care home licensed for 62 beds.
Complaint Details
The visit was triggered by a complaint, as indicated by the report title 'Biennial Construction Complaint Survey'.
Findings
Multiple physical plant deficiencies were identified including obstructed corridors, damaged floors and walls, inadequate housekeeping, missing or broken furnishings, fire safety equipment and plan deficiencies, unsafe building equipment and doors, improper storage of medical oxygen cylinders, use of prohibited portable electric heaters, and inadequate exhaust ventilation.
Deficiencies (14)
Corridors were obstructed with furniture, restricting exit paths.
Floors were not maintained in good repair with loose tiles, holes, and unraveling carpet creating tripping hazards.
Walls, ceilings, and furnishings were damaged, stained, or had mold, indicating poor housekeeping and maintenance.
Plumbing equipment was not maintained safely, including a floor drain grate below floor level and missing toilet seat.
Bedrooms lacked required individual towels and towel bars.
Fire extinguishers lacked documentation of monthly inspections on annual maintenance tags.
Fire safety rehearsals were not conducted quarterly on each shift as required.
Corridor doors were held open by devices preventing proper closure and latching, compromising fire safety.
Some doors required keys to exit, exit signs were misleading, and fire/smoke resistance of doors was compromised.
Commercial kitchen hood fire extinguishing system lacked required inspections and documentation.
Breaches in fire-resistance-rated construction were noted, including unsealed cable penetrations and openings.
Portable medical oxygen cylinders were improperly stored unsecured in beverage crates.
Use of unvented and portable electric heaters was observed, which is prohibited.
Exhaust ventilation systems were operating but failed to remove the required amount of air in multiple areas.
Report Facts
Licensed capacity: 62
Tripping hazard hole size: 2
Tripping hazard hole depth: 0.75
Fire extinguisher inspection frequency: 12
Fire safety rehearsals performed: 3
Fire safety rehearsals required: 9
Fire-resistance-rated ceiling hole size: 0.75
Oxygen cylinders found: 5
Exhaust ventilation rate: 2
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