Inspection Reports for Poplar Grove
300 West Ashe Street Burgaw, NC 28425, Burgaw, NC, 28425
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jul 31, 2025
Visit Reason
The Adult Care Licensure Section and Pender County Department of Social Services conducted an annual survey and complaint investigation from 07/29/25 to 07/31/25. The complaint investigation was initiated by the Department of Social Services on 07/08/25.
Complaint Details
Complaint investigation was initiated by the Department of Social Services on 07/08/25 related to Resident #3's fall and injury requiring medical evaluation.
Findings
The facility was found deficient in multiple areas including failure to provide proper discharge notices, failure to ensure timely referral and follow-up for acute health care needs, failure to implement physician orders for daily dressing changes, failure to administer scheduled medications as ordered, inaccurate medication administration records, failure to follow infection control measures during medication administration, failure to properly witness medication destruction, failure to maintain accurate controlled substance records, and failure to notify the county department of social services of an incident requiring medical evaluation.
Deficiencies (9)
Facility failed to ensure a written discharge notice was hand delivered or sent by certified mail to the responsible party or legal representative for 1 of 2 sampled residents prior to discharge.
Facility failed to ensure referral and follow-up to meet the acute health care needs of 1 of 5 sampled residents related to notifying a resident's primary care provider of a skin irritation, causing a delay in treatment.
Facility failed to ensure implementation of orders for 1 of 5 sampled residents related to daily dressing changes.
Facility failed to ensure that a medication was administered as ordered for 1 of 5 sampled residents related to a medication used to treat moderate to severe pain.
Facility failed to ensure the medication administration records were accurate for 2 of 6 sampled residents including documentation for controlled substances and a vitamin supplement.
Facility failed to ensure infection control measures were implemented during medication passes by a medication aide who failed to wash or sanitize hands prior to preparing and after administering multiple oral medications and an eye drop; and administered a medication that was dropped on the medication cart to a resident.
Facility failed to ensure medications destroyed at the facility for 1 of 1 sampled resident were witnessed by a licensed pharmacist, dispensing practitioner, or a designee of the licensed pharmacist or dispensing practitioner.
Facility failed to ensure controlled substances destroyed at the facility for 1 of 1 sampled resident were witnessed by a licensed pharmacist, dispensing practitioner, or a designee of the licensed pharmacist or dispensing practitioner.
Facility failed to notify the county department of social services of an incident resulting in injury requiring a medical evaluation for 1 of 5 sampled residents.
Report Facts
Medication doses missed: 29
Medication doses destroyed: 39
Medication doses destroyed: 161
Medication doses destroyed: 29
Medication doses administered: 93
Medication doses administered: 83
Medication doses administered: 25
Medication doses administered: 24
Medication doses administered: 1
Medication doses administered: 25
Medication doses wasted: 39
Medication doses wasted: 73
Medication doses administered: 1
Medication doses wasted: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director and licensed Administrator | Named in multiple findings including discharge notice failure, medication destruction, and medication administration oversight. |
| Resident Care Coordinator | Resident Care Coordinator | Named in multiple findings including medication destruction, medication administration oversight, and controlled substance record reconciliation. |
| Medication Aide | Medication Aide | Named in findings related to medication administration, medication destruction, and controlled substance record reconciliation. |
| Primary Care Provider | Primary Care Provider | Named in findings related to failure to notify and follow-up on resident health needs and medication orders. |
Inspection Report
Capacity: 60
Deficiencies: 5
Date: May 27, 2025
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 North Carolina State Building Code, the 1996 Rules for Adult Care Homes, and applicable portions of the 2005 Rules for Licensing of Adult Care Homes.
Findings
Multiple deficiencies were cited including failure to properly operate doors with special locking, inadequate housekeeping and maintenance such as ceiling repair issues, lack of ground fault circuit interrupters on electrical outlets in wet locations, unsafe electrical equipment maintenance, and non-operable exhaust fans in laundry and soiled utility rooms.
Deficiencies (5)
Facility failed to meet code requirements for doors equipped with Special Locking due to inadequate informational wiring diagram and missing identification of electrical panel circuit.
Facility is not being maintained in a safe manner; ceiling in the main dining room is not in good repair.
Electrical outlets behind washer and dryer in main laundry room are not GFCI protected.
Failure to maintain building's electrical equipment in a safe condition; light in 100 hall water heater room is loose from ceiling.
Exhaust fans in laundry room and soiled utility room are not working.
Report Facts
Licensed capacity: 60
Inspection Report
Capacity: 60
Deficiencies: 11
Date: Dec 5, 2018
Visit Reason
The report documents a biennial construction section survey of Ashe Gardens, a 60-bed Special Care Unit, to assess compliance with the 1996 North Carolina State Building Code and applicable adult care home regulations.
Findings
The facility failed to meet several physical plant and safety requirements including improper handling and storage of medical oxygen cylinders, lack of staff knowledge and key possession for emergency release switches on magnetic exit doors, inadequate fire drill rehearsals, malfunctioning fire alarm silence feature, compromised fire-rated doors and ceilings, and sprinkler system deficiencies.
Deficiencies (11)
Facility failed to meet NC State Building Code regarding special locking (magnetic locks) on exit doors; staff lacked keys or awareness of emergency release switches.
Building was not maintained safely due to improper handling and storage of portable medical oxygen cylinders.
No documentation of required monthly fire extinguisher inspections in the dining room.
Ice machine drain line was improperly placed directly on the floor, risking contamination.
No key onsite to allow entry into the Administrator's office to survey for hazards.
Fire drill rehearsals were not conducted quarterly on each shift as required; records lacked descriptions of rehearsals.
Fire alarm system 'Silence' feature was non-functional.
Corridor doors were prevented from closing and latching properly, including propped open fire door and wedged doors.
One-hour fire rated ceilings were compromised due to missing or improperly fitted sprinkler escutcheons in multiple locations.
Sprinkler system was not maintained safely; flexible conduit pulled apart exposing wires on sprinkler riser.
Unsealed wire penetration in the ceiling of the medication room compromised fire rated ceiling integrity.
Report Facts
Total licensed capacity: 60
Number of portable medical oxygen cylinders improperly stored: 8
Fire drill rehearsals missing: 2
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 23, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation from 2017-03-15 to 2017-03-17 and 2017-03-21 to 2017-03-23 with an exit conference conducted by telephone on 2017-03-23.
Complaint Details
The survey included a complaint investigation conducted from 2017-03-21 to 2017-03-23.
Findings
The facility failed to maintain compliance with housekeeping, furnishings, personal care and supervision, and health care requirements. Multiple residents experienced falls resulting in serious injuries including fractures and head injuries. The facility also failed to ensure proper follow-up for residents' health care needs and behavioral interventions. The facility's management and policies were not effectively implemented, contributing to neglect and harm to residents.
Deficiencies (6)
Facility failed to assure walls, floors, ceiling air vents, and carpet were kept clean and in good repair.
Facility failed to assure nightstands and chairs were kept clean and in good repair.
Facility failed to provide supervision in accordance with residents' assessed needs and current symptoms, resulting in multiple falls and injuries.
Facility failed to assure referral and follow-up to meet routine and acute health care needs, including psychiatric follow-up and notification of health care providers regarding residents' conditions and missed appointments.
Facility failed to assure each resident was free of abuse and neglect related to health care, supervision, and overall management of the facility.
Facility administrators failed to assure management, operations, policies and procedures were implemented to maintain residents' rights to be free of serious harm and neglect.
Report Facts
Residents sampled: 7
Residents with falls resulting in serious injuries: 3
Residents with behavioral issues resulting in injury: 1
Incident reports for Resident #3: 7
Hemoglobin lab result: 7.7
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 27, 2017
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of items cited during the 11/15/2016 Biennial Survey that remain to be corrected.
Findings
The facility failed to meet NC State Building Code requirements for special locking on exit doors due to lack of an automatic fire sprinkler system in the 100 Hall Water Heater Room and absence of a wiring schematic for the special locking system. Additionally, the facility did not ensure privacy in bathrooms with multiple commodes or showers, as evidenced by the lack of privacy curtains in the common bathroom near Bedroom 109.
Deficiencies (3)
Facility failed to meet NC State Building Code requirements for special locking on exit doors due to lack of automatic fire sprinkler system in 100 Hall Water Heater Room.
Facility failed to have a wiring schematic posted for the special locking system components at the FACP.
Facility failed to ensure bathrooms and toilet rooms with multiple commodes and showers provide privacy partitions or curtains.
Inspection Report
Follow-Up
Census: 60
Deficiencies: 13
Date: Nov 22, 2016
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 11/15/16-11/17/16 and 11/21/16-11/22/16 to verify correction of previous deficiencies.
Findings
The facility failed to assure safety in housekeeping, timely notification of primary care providers for acute health needs, proper medication administration, accurate diet orders and feeding assistance, adequate staffing in the Special Care Unit, and maintenance of residents' rights and dignity.
Deficiencies (13)
Facility failed to assure the facility was free of safety and fall hazards due to stacking and storing boxes in the resident common area.
Facility failed to notify the Primary Care Provider of acute health care needs of 3 of 5 sampled residents resulting in hospitalization with sepsis, uncontrolled blood sugars, and lack of follow-up evaluation.
Facility failed to implement Primary Care Provider orders for weekly weights and monthly vital signs for 2 of 5 sampled residents.
Facility failed to assure food and beverages were protected from contamination as evidenced by flies in the kitchen and dining room.
Facility failed to assure water was served to 3 of 3 residents with orders for thickened liquids at 4 of 4 meals observed.
Facility failed to maintain an accurate and current list of residents with physician-ordered therapeutic diets for guidance of food service staff for 4 of 5 sampled residents.
Facility failed to assure therapeutic diets were served as ordered by the resident's physician for 4 of 5 residents sampled.
Facility failed to assure residents needing help in eating were assisted in an unhurried manner that maintains dignity and respect; staff did not always sit while feeding residents.
Facility failed to ensure residents were treated with respect, dignity, and full recognition of individuality and right to privacy related to moving freely in the community dining room at meal times.
Facility failed to maintain an accurate and readily retrievable record of controlled substances resulting in inaccurate records for Clonazepam and Temazepam for 1 of 2 residents with orders for controlled substances.
Facility failed to assure minimum number of staff were present at all times to meet the needs of residents in the Special Care Unit for multiple shifts sampled.
Facility failed to assure each resident received care and services which were adequate, appropriate, and in compliance with relevant laws and rules related to nutrition and food services, controlled substances, special care unit staffing, and residents' rights.
Facility failed to assure each resident was free of neglect related to healthcare, medication administration, and management of the facility.
Report Facts
Residents present: 60
Staffing hours shortfall: 3.81
Staffing hours shortfall: 3.25
Staffing hours shortfall: 7.15
Staffing hours shortfall: 8.75
Staffing hours shortfall: 12.93
Staffing hours shortfall: 1.33
Staffing hours shortfall: 2.95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Primary Care Provider | Named in medication error finding for Resident #5 antibiotic delay and hospitalization | |
| Business Office Manager | Acknowledged fall hazard from stacked boxes | |
| Activity Director | Interviewed regarding fall hazard and scheduling specialty appointments | |
| Executive Director | Multiple interviews regarding facility deficiencies and corrective actions | |
| Medication Aide | Named in medication administration errors and follow-up | |
| Dietary Manager | Named in dietary and therapeutic diet deficiencies | |
| Memory Care Manager | Responsible for monitoring orders and clarifications | |
| Nurse Practitioner | Provided diet orders for Resident #4 | |
| Pharmacist | Interviewed regarding medication orders and controlled substances |
Inspection Report
Capacity: 60
Deficiencies: 13
Date: Nov 15, 2016
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with North Carolina State Building Code, Rules for Adult Care Homes, and licensing requirements for a 60-bed Special Care Unit.
Findings
Multiple deficiencies were cited including lack of automatic fire sprinkler system in certain areas, missing fire safety documentation, inadequate bathroom privacy, missing hand grips, poor housekeeping and maintenance, fire safety rehearsal documentation missing, unsafe building equipment and emergency lighting, and ventilation system failures.
Deficiencies (13)
Facility failed to meet NC State Building Code for special locking on exit doors due to lack of automatic fire sprinkler system and missing wiring diagram and system map at Fire Alarm Control Panel.
Facility failed to maintain current sanitation and fire safety inspection reports, including missing annual Fire Marshal/Inspection Report and outdated Fire Sprinkler System Inspection.
Bathrooms and toilet rooms lacked privacy partitions or curtains for multiple commodes and showers.
Hand grips were missing or loose at commodes, tubs, and showers accessible to residents.
Walls, ceilings, floors, and furniture were not kept clean and in good repair; chronic unpleasant odors present due to plumbing trap drying allowing sewer gases.
Facility was not maintained free of hazards; dust/lint accumulation on HVAC grilles and unsecured portable medical oxygen cylinders stored improperly.
Residents' bedrooms lacked individual clean towels and/or towel bars in good repair.
Facility failed to rehearse and document fire plan quarterly on each shift as required.
Building fire safety and emergency equipment were not maintained in safe and operating condition, including holes and gaps in fire-resistance-rated ceiling assemblies, and multiple emergency lights failing to illuminate on backup power.
Interior doors were not maintained in safe and operating condition, including doors not latching, holes in doors, loose handles, and doors requiring extra force to close.
Electrical system was not maintained safe, including missing light fixture lens, unsafe multi-plug adaptor use, and missing weatherproof cover on GFCI outlet.
Building sprinkler system was not maintained safe and operating; sprinkler heads obstructed with lint and escutcheon plates missing or dropped allowing spread of smoke and heat.
Exhaust ventilation system failed to operate properly in multiple areas, allowing build-up of odors.
Report Facts
Total licensed capacity: 60
Date of inspection: Nov 15, 2016
Last fire sprinkler system inspection: 201411
Size of hole in fire-resistance-rated ceiling: 18
Number of portable oxygen cylinders improperly stored: 3
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jun 13, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey, a follow-up survey and a complaint investigation on June 08-10 and June 13th, 2016.
Findings
The facility was found deficient in multiple areas including medication aide qualifications, personal care and housekeeping staffing, tuberculosis testing, health care referrals, medication administration, nutrition and food service, resident rights, special care unit staffing, and controlled substance screening for new staff.
Deficiencies (13)
Staff performing Medication Aide duties had not completed required continuing education or worked as medication aides within the required timeframe.
Personal Care Aides were assigned housekeeping duties including laundry during resident care hours, leading to resident clothing being lost or mixed up.
One resident was not tested for tuberculosis upon admission as required.
One resident did not receive referral to wound clinic as ordered for evaluation of a lower leg lesion.
One resident did not have weights and accuchecks obtained as ordered by the physician.
Residents who did not come to the dining room during snack times did not receive snacks.
Two residents with physician orders for honey thick liquids and nutritional supplements did not receive them as ordered.
Feeding assistance was not provided during 5 of 5 meals observed, with residents eating with fingers, food being taken by other residents, and flies landing on food.
Resident's mattress was placed directly on the floor without a current physician order, raising concerns about dignity and safety.
Medications were not administered as ordered for 3 of 7 residents, including missed doses and incorrect dosages.
One medication aide had not completed required five and ten hour Medication Aide Training; another had no verification of working as a medication aide within the required prior 24 months.
Two staff hired after 10/1/13 did not have completed or documented controlled substance screening upon hire.
Facility failed to assure minimum staffing levels in the Special Care Unit for multiple shifts over several months.
Report Facts
Medication doses missed: 18
Special Care Unit census: 54
Staffing shortfall hours: 9.7
Staffing shortfall hours: 13.85
Staffing shortfall hours: 6.83
Staffing shortfall hours: 12.4
Staffing shortfall hours: 5.74
Staffing shortfall hours: 20.75
Staffing shortfall hours: 5.13
Staffing shortfall hours: 6.3
Staffing shortfall hours: 5.13
Staffing shortfall hours: 10.28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Named in medication aide training deficiency |
| Staff E | Medication Aide | Named in medication aide training deficiency |
| Staff A | Personal Care Aide | Named in controlled substance screening deficiency |
| Staff C | Personal Care Aide | Named in controlled substance screening deficiency |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 1, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on September 1-4, 2015 to assess compliance with regulations.
Findings
The facility failed to maintain hot water temperatures within the required range at several fixtures and had multiple medication administration errors affecting 7 of 14 residents observed, including late administration and incorrect procedures.
Deficiencies (2)
Hot water temperatures were not maintained between 100 and 116 degrees Fahrenheit at 1 of 32 resident bathroom fixtures and 2 of 2 fixtures in a community shower room.
Medications were not administered as ordered by the licensed prescribing practitioner and in accordance with facility policies for 7 of 14 residents, including errors with timing and administration procedures.
Report Facts
Medication error rate: 28
Number of medication errors: 8
Number of residents with medication errors: 7
Number of fixtures with hot water temperature issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Medication Aide | Named in multiple medication administration errors and interviews regarding late medication passes. |
| Regional Director | Regional Director | Interviewed regarding medication packaging and administration issues. |
| Corporate Maintenance Worker | Maintenance Worker | Responsible for checking water temperatures weekly and maintaining logs. |
| Contract Pharmacy Provider Pharmacist | Pharmacist | Interviewed regarding medication packaging and clinical issues. |
Report
Sep 24, 2019
Report
Apr 1, 2019
Report
Nov 9, 2018
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