Inspection Reports for
The Gardens of Trent

The complaint investigation focused on medication administration and incident reporting related to Resident #1, who experienced multiple hospitalizations and seizures. The facility failed to administer seizure medication as ordered and did not timely report incidents to the county department of social services. The complaint was substantiated with findings of non-compliance.

The facility was found to have a Type A1 violation for failing to ensure medications were administered as ordered by a licensed prescriber, specifically for Resident #1's seizure medication. Additionally, the facility failed to notify the county department of social services of incidents within 48 hours for one resident, resulting in a standard deficiency.

The facility has not corrected all deficiencies related to outdoor lighting, electrical outlets in wet locations, and exhaust ventilation. Specifically, exterior egress paths are not properly lit, multiple electrical outlets in the East Laundry room lack ground fault circuit interrupters, and exhaust fans in certain rooms are not operational.

The facility failed to ensure that the Estate Administrator for 4 of 4 deceased residents received refunds owed within 30 days after the residents' deaths. Delays were attributed to issues in the corporate accounting department, including lost refund requests due to staff turnover.

The complaint investigation was substantiated by findings that the facility failed to supervise a resident with dementia who eloped, failed to respond to an alarm allowing a door to be unlocked, and failed to report abuse allegations timely. The facility also failed to provide dignity and respect to a resident.

The facility failed to provide adequate supervision for residents, including one resident with dementia who eloped from the facility, resulting in a Type A1 violation for serious neglect. Additional findings included failure to respond to an audible alarm, failure to report abuse allegations timely, and failure to provide dignity and respect to residents.

The complaint investigation was triggered by an incident where Resident #1, diagnosed with dementia and intermittently disoriented, eloped from the facility on 10/25/2022. The facility failed to provide adequate supervision and timely notification to emergency services. The resident was found approximately 704 yards away at a restaurant after about 10-15 minutes. The facility's mag locks were malfunctioning, and doors were unlocked for 13-15 hours on the day of the incident.

The facility failed to provide supervision for a resident with dementia who eloped from the facility, resulting in a Type A2 violation for personal care and supervision. Additionally, the facility failed to hear and respond to an audible working sounding device for a mag lock switch, resulting in a Type B violation related to physical environment and safety.

The facility failed to provide appropriate referral and follow-up for Resident #6, who exhibited multiple aggressive behaviors towards property and other residents, resulting in incidents including property damage and altercations. The failure to notify the psychiatric provider and implement adequate interventions was deemed detrimental to resident safety.

The complaint investigation was initiated by the Craven County Department of Social Services on September 13, 2019, September 25, 2019, and October 8, 2019. The follow-up survey was conducted to verify correction of previous deficiencies.

The facility failed to maintain a hazard-free environment by improperly storing multiple portable oxygen cylinders unsecured on the floor inside two closets in resident room #13, constituting an unabated Type B Violation. Additionally, the facility failed to treat one resident with respect and dignity by blending pureed foods together instead of following the pureed menu guidance, and did not ensure residents received adequate and appropriate care related to housekeeping and furnishings.

The facility was found to have multiple deficiencies including unsafe shower head installations in shared restrooms posing injury risks to residents with dementia, improper food storage with expired and unlabeled items, and failure to serve therapeutic diets as ordered for residents. Medication administration records were also found to be incomplete or inaccurate for some residents.

Multiple deficiencies were cited related to physical plant and safety, including non-compliant bathroom renovations, lack of required plan approvals, corridor obstructions, unsecured oxygen cylinders, improperly posted evacuation plans, incomplete fire safety rehearsals, unsafe building equipment and fire safety issues, prohibited portable electric heaters, inadequate hot water temperatures, and lack of ventilation in specified areas.

The facility had multiple deficiencies related to delayed egress exit doors not complying with NC State Building Code, including missing required signage, alarms not functioning properly, and doors failing to unlock during fire alarm activation. Additionally, fire alarm system devices were not maintained in a safe and operating condition, with several heat detectors improperly mounted or missing, and a fire alarm pull station detached from the wall.

Complaint investigation initiated by the Craven County Department of Social Services on March 6, 2017, related to supervision and care concerns.

The facility failed to maintain walls, ceilings, and floors in good repair, failed to ensure 2 of 5 staff had completed required personal care training, failed to provide supervision for a resident who wandered away, failed to obtain healthcare for 3 residents including one with burns, one with catheter care issues, and one with missed medications, failed to protect a resident from neglect resulting in burns, failed to administer medications as ordered for multiple residents including insulin and antibiotics, failed to store expired medications separately, and failed to ensure medication aides received annual infection control training.

The facility was found to have multiple deficiencies including non-compliant delayed egress exit doors, lack of audible alarms, unsecured courtyard exits, outdated sanitation inspection, missing fire safety rehearsal records, malfunctioning fire safety equipment, housekeeping issues such as mold growth and dry waste traps, and inadequate lighting and ventilation in some areas.

The complaint stated the facility HVAC system was not operating and cooling the building down to the maximum temperature allowed in the corridors and the resident room temperatures were too high. The complaint was substantiated.

The complaint was substantiated. The HVAC mechanical equipment was not kept in operating condition, with the compressor to Unit #8 not operating and multiple temperature readings in corridors and resident rooms exceeding acceptable levels, indicating the central cooling system was possibly not operating correctly.

This was a follow-up complaint construction survey. The deficiencies noted during the Complaint Biennial Construction Survey had been corrected, but new citations were added.

The facility failed to maintain a clean and orderly environment to prevent bed bug infections, with multiple bedrooms not being thoroughly cleaned and staff training deficiencies noted. Additionally, building equipment was not maintained in a safe and operating condition, including missing electrical cover plates and door hardware issues affecting egress.

The complaint investigation was initiated by Craven County on December 21, 2015, related to concerns about water temperatures and restraint use.

The facility failed to maintain hot water temperatures within the required range at 11 of 19 fixtures, had multiple cleanliness and contamination issues in the kitchen and dining areas, and failed to properly obtain and document restraint orders and monitoring for 4 of 6 residents using bed rails.

The complaint alleged bed bug infestation. The complaint was substantiated.

The complaint was substantiated with findings of bed bug infestations in some residents' rooms. Multiple rooms were identified as having bed bugs, some treated and cleared, some currently being treated, and others untreated as of the inspection date.