Inspection Reports for The Landings of Oak Island
2910 Pine Plantation Parkway Oak Island, NC 28461, Oak Island, NC, 28461
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Capacity: 80
Deficiencies: 2
Date: Apr 29, 2025
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2018 Edition of the North Carolina Building Code(s), I-2 Institutional Occupancy during a Construction Section Biennial Survey.
Findings
Deficiencies were cited related to failure to maintain the building's fire safety equipment systems in a safe condition, including holes or gaps in fire resistant rated ceilings and multiple exhaust fans in various utility and janitorial rooms not working.
Deficiencies (2)
Failure to maintain the building's fire safety equipment systems in a safe condition due to holes or gaps at penetrations in fire resistant rated ceilings allowing fire and smoke to spread beyond the area of origin.
Exhaust fans in multiple utility and janitorial rooms are not working, including Main Soiled Utility Room, SCU Soiled Utility Room, SCU room 506, 300 hall Soiled Utility Room, and 300 hall janitorial's closet.
Report Facts
Licensed capacity: 80
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 2, 2025
Visit Reason
The Adult Care Licensure Section completed an annual and follow-up survey from 04/01/25 to 04/03/25 to assess compliance with regulations for The Landings of Oak Island.
Findings
The facility failed to complete Resident Registers within 72 hours of admission for 4 sampled residents, failed to serve water to residents in the Special Care Unit during meals, failed to ensure one resident was treated with consideration regarding room assignment, failed to administer medications within one hour before or after scheduled times for 3 residents, and failed to ensure quarterly pharmacy review recommendations were reviewed by a resident's primary care provider.
Deficiencies (5)
Resident Registers were not completed within 72 hours of admission for 4 sampled residents (#2, #5, #6, and #7), missing admission dates and signatures.
Water was not served to each resident at each meal in the Special Care Unit; residents were only served orange juice and staff did not offer water.
Resident #3 was not treated with consideration regarding room assignment despite complaints about a suite mate's unsanitary behavior.
Medications were not administered within one hour before or after the scheduled times for residents #5, #6, and #7, including medications for urinary health, high blood pressure, pain, diabetes, and Alzheimer's disease.
Quarterly pharmacy review recommendations for Resident #1 were not reviewed by the primary care provider, with repeated recommendations unaddressed.
Report Facts
Residents in Special Care Unit dining room: 17
Residents in Special Care Unit dining room: 18
Sampled residents with incomplete Resident Registers: 4
Residents observed with late medication administration: 3
Repeated pharmacy review recommendations unaddressed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Responsible for ensuring Resident Registers were completed and signed; unaware of deficiencies in Resident Registers and late medication administration; involved in room assignment decisions. | |
| Business Office Manager | Performed monthly resident chart audits; sometimes signed Resident Registers with Administrator's permission. | |
| Medication Aide | Administered medications late; aware of late administration and notified Memory Care Coordinator. | |
| Memory Care Coordinator | Responsible for ensuring pharmacy recommendations were reviewed by PCP; unaware of late medication administration initially. | |
| Clinical Nurse Consultant | Unaware of late medication administration; stated PCP should be notified of late administration. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to provide adequate supervision and protection of residents, particularly related to violent behaviors exhibited by Resident #1 and resulting harm to other residents.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews. The facility failed to protect residents from violent behaviors by Resident #1 and another male resident, resulting in physical harm to residents. Law enforcement filed a complaint with DSS due to concerns about escalating resident behaviors and inadequate facility response.
Findings
The facility failed to provide supervision and protection in accordance with residents' assessed needs, care plans, and symptoms, resulting in physical harm to residents due to violent behaviors by Resident #1 and another male resident. Multiple incidents of resident-to-resident abuse were documented, and the facility did not adequately address or prevent these incidents.
Deficiencies (2)
Failure to provide supervision in accordance with each resident's assessed needs and current symptoms, resulting in physical attacks by Resident #1 on other Special Care Unit residents.
Failure to protect residents from physical abuse by another Special Care Unit resident who had an extensive number of violent attacks on others.
Report Facts
Sampled residents: 5
Residents involved in abuse: 3
Behavioral incidents: 22
Corrective action plan received: 1
Corrective action deadline: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in interviews regarding facility response and supervision issues |
| Resident Care Director | Resident Care Director (RCD) | Interviewed regarding resident supervision and behavioral incidents |
| Special Care Unit Coordinator | Special Care Unit Coordinator (SCUC) | Interviewed regarding resident supervision and behavioral incidents |
| Medication Aide | Medication Aide (MA) | Interviewed regarding resident behaviors and staff concerns |
| Personal Care Aide | Personal Care Aide (PCA) | Interviewed regarding resident behaviors and staff concerns |
| Hospice Physician | Hospice Physician | Served as Resident #1's Primary Care Provider (PCP) |
| Primary Care Provider | Primary Care Provider (PCP) | Notified and involved in resident care and behavioral management |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation concerning medication administration and supervision issues related to Resident #3, who had Parkinson's disease and experienced multiple falls and injuries.
Complaint Details
The complaint investigation was substantiated, finding that Resident #3 did not receive prescribed medications and was inadequately supervised, resulting in serious physical harm including multiple falls, head injuries, and hospitalization.
Findings
The facility failed to ensure medications were administered as ordered for Resident #3, resulting in physical harm and neglect. Additionally, the facility failed to provide adequate supervision for Resident #3, leading to frequent falls and multiple injuries. The facility provided a plan of protection and a plan of correction for these violations.
Deficiencies (2)
Failure to ensure medications were administered as ordered for Resident #3, including Nuplazid and Rivastigmine, resulting in physical harm and neglect.
Failure to provide supervision in accordance with Resident #3's symptoms, resulting in frequent falls and multiple injuries.
Report Facts
Number of sampled residents: 5
Number of falls: 21
Medication doses: 30
Correction due date: Aug 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin Lovin | Executive Director | Named in relation to medication administration errors and facility oversight |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
This report documents a Construction Section Biennial Follow-Up Survey conducted to verify correction of previously identified deficiencies.
Findings
All deficiencies identified in the prior survey have been corrected. No further action is required.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
This was a Construction Section Biennial Follow-Up Survey conducted to verify correction of previously identified deficiencies.
Findings
The facility was found not to be maintaining its doors in a safe manner, as both sets of doors leading into the dining room were being held open with wedges, potentially exposing occupants to fire or smoke hazards.
Deficiencies (1)
Facility is not maintaining its doors in a safe manner; doors leading into the dining room were held open with wedges.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 5, 2023
Visit Reason
This document is a Corrective Action Report (CAR) related to medication administration violations identified during a prior inspection of an adult care home.
Findings
The facility failed to ensure proper administration of medications according to physician orders and facility policies, including missed pre-operative and post-operative eye medications for Resident #3 and unsafe medication administration practices by staff.
Deficiencies (3)
Facility failed to ensure administration of pre-operative and post-operative eye medications for Resident #3 as ordered by physician.
Facility failed to assure safe administration of medications by Medication Aides, including pre-pouring and pre-charting medications and administering medications by non-MA staff.
Facility failed to notify county Department of Social Services of accidents and incidents requiring medical evaluation for 10 of 10 sampled reports.
Report Facts
Sampled residents: 5
Missed doses: 6
Medication administration errors: 10
Corrective action deadlines: Jun 4, 2023
Corrective action deadlines: Jun 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Ash | Administrator | Administrator who submitted the Plan of Correction and signed acceptance of POC. |
| Staff A | Medication Aide | Observed pre-pouring and pre-charting medications and unsafe medication administration. |
| Staff B | Medication Aide Supervisor | Known to pre-pour medications and set a bad example for other Medication Aides; was terminated for reasons unrelated to medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation with visits on 03/08/23, 03/27/23, 04/05/23, and 04/11/23 to investigate medication administration and reporting of accidents and incidents at The Landings of Oak Island adult care home.
Complaint Details
The visit was triggered by complaints regarding medication administration errors and failure to report accidents and incidents. The complaint was substantiated based on interviews, observations, and record reviews revealing multiple medication administration failures and lack of required reporting to DSS.
Findings
The facility failed to administer medications according to physician orders and facility policies, resulting in missed pre-operative and post-operative eye medications for Resident #3, and failed to report required accidents and incidents to the county Department of Social Services. Multiple medication administration deficiencies were identified, including unsafe practices by Medication Aides and failure to document medication administration properly.
Deficiencies (4)
Failed to ensure administration of pre-operative and post-operative eye medications for Resident #3 as ordered by physician, resulting in missed doses and prolonged recovery.
Failed to assure safe administration of medications by Medication Aides, including pre-pouring and pre-charting medications and dropping off medications without observation.
Failed to assure that only authorized persons administered medications, including a Medication Aide requesting assistance from a non-Medication Aide to give medications.
Failed to notify the county Department of Social Services of accidents and incidents requiring medical evaluation for 10 of 10 sampled reports.
Report Facts
Number of sampled residents with medication error: 1
Number of sampled accident reports not reported to DSS: 10
Number of medication doses not administered: 14
Number of medication doses missed pre-operatively: 6
Number of medication cups observed pre-poured: 7
Number of residents with pre-poured medications observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Observed pre-pouring and pre-charting medications and difficulty locating medications |
| Staff B | Medication Aide Supervisor | Known to pre-pour medications, supervise medication administration, and was terminated unrelated to medication administration |
| Lisa Ash | Administrator | Received the Corrective Action Report on 05/05/23 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 3, 2022
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation on 06/02/22 and 06/03/22 related to the facility's failure to notify the Primary Care Provider (PCP) of the acute health care needs of Resident #4 concerning the use of a lymphedema compression pump.
Complaint Details
Complaint investigation conducted on 06/02/22 and 06/03/22 regarding failure to notify PCP and manage Resident #4's lymphedema compression pump. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to notify the PCP about Resident #4's acute health care needs related to the lymphedema compression pump. Documentation and interviews revealed discontinuation and lack of use of the device without proper notification or orders, and the facility lacked licensed staff to supervise the device. Resident #4's lymphedema condition could worsen without proper management.
Deficiencies (1)
Facility failed to notify the Primary Care Provider of the acute health care needs for Resident #4 related to a lymphedema compression pump.
Report Facts
Resident sample size: 5
Dates of complaint investigation: 06/02/22 and 06/03/22
Dates of lymphedema compression pump orders: Physician's order dated 12/27/21, PCP order dated 01/17/22
Dates of eMAR documentation: December 2021, January 2022, February 2022 - June 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Resident #4's lymphedema compression pump and facility staffing | |
| Personal Care Assistant (PCA) | Interviewed about observation of lymphedema compression device in Resident #4's room | |
| Resident Care Coordinator (RCC) | Interviewed about facility's inability to provide services for lymphedema compression pump | |
| Licensed Health Professional Support (LHPS) nurse | Interviewed about discovery and removal of lymphedema compression pump and notification to PCP | |
| Lead Medication Aide (MA)/Supervisor | Interviewed about application and discontinuation of lymphedema compression pump | |
| Medication Aide (MA)/Supervisor | Interviewed about training and documentation related to lymphedema compression pump | |
| Former Administrator | Interviewed about prior knowledge and facility policy on lymphedema compression pump | |
| Occupational Therapist (OT) | Interviewed about treatment of Resident #4's lymphedema and device use | |
| Compression pump lymphedema specialist | Interviewed about device order, training, and staff communication |
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