Inspection Reports for The Landings of Smithfield
200 Kellie Drive Smithfield, NC 27577, Smithfield, NC, 27577
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 8
Date: Sep 5, 2025
Visit Reason
The Adult Care Licensure Section and Johnston County Department of Social Services conducted an annual, follow-up, and complaint investigation from 09/03/25 to 09/05/25.
Complaint Details
The inspection included a complaint investigation as part of the visit from 09/03/25 to 09/05/25.
Findings
The facility failed to maintain a hazard-free environment in the special care unit, had hot water temperature issues in resident bathrooms, failed to provide personal care assistance to a resident, lacked matching therapeutic diet menus and failed to serve therapeutic diets as ordered, and had multiple medication administration errors including missed doses, incorrect dosages, and inaccurate medication records.
Deficiencies (8)
Facility failed to maintain an environment free of hazards including personal care and cleaning products accessible to residents in the special care unit.
Facility failed to maintain hot water temperatures between 100°F and 116°F in 4 of 20 resident bathroom sinks.
Facility failed to provide personal care assistance for a resident requiring help with fingernail care and dressing.
Facility failed to have matching therapeutic diet menus for residents with physician-ordered therapeutic diets.
Facility failed to serve therapeutic diets as ordered for residents with mechanical soft and chopped diets.
Facility failed to ensure medication orders were clarified for a resident including orders for nasal spray and diarrhea medication.
Facility failed to ensure medications were administered as ordered for multiple residents, including errors with allergy medications, topical ointments, pain medication, laxatives, blood thinners, acid reflux medications, and others, resulting in a Type A2 violation.
Facility failed to ensure medication administration records were accurate for a resident for a medication used to treat fever and mild to moderate pain.
Report Facts
Special Care Unit census: 19
Hot water temperature readings: 4
Medication error rate: 15
Missed doses of blood thinner: 34
Missed doses of first diuretic: 11
Missed doses of second diuretic: 18
Missed doses of thyroid medication: 24
Missed doses of nerve pain medication: 38
Missed doses of antidepressant: 20
Missed doses of acid reflux medication: 2
Missed doses of medication for Cushing's disease: 7
Missed doses of medication for restless leg syndrome: 13
Missed doses of medication for high blood pressure: 3
Missed doses of medication for acid reflux: 2
Missed doses of medication for pain and fever: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Coordinator | Special Care Coordinator (SCC) | Responsible for clarifying medication orders and reviewing medication administration records. |
| Administrator | Facility Administrator | Responsible for oversight of medication administration and compliance. |
| Medication Aide | Medication Aide (MA) | Involved in medication administration and documentation; interviewed multiple times regarding medication errors. |
| Personal Care Aide | Personal Care Aide (PCA) | Responsible for personal care tasks including fingernail care and assisting residents with dressing. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding therapeutic diet menus and meal preparation. |
| Primary Care Provider | Primary Care Provider (PCP) | Interviewed regarding medication orders and resident care. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 17, 2025
Visit Reason
This is a Construction Section Biennial Follow-Up Survey conducted to verify correction of previously cited deficiencies.
Findings
The facility has not corrected all previously cited deficiencies. Specifically, the hot water system is not maintaining the required temperature range, and exhaust fans in rooms 610 and 103 are not working properly.
Deficiencies (2)
The facility is not maintaining hot water temperatures within the required range of 100 to 116 degrees Fahrenheit; observed temperature was approximately 88 degrees Fahrenheit.
The facility is not keeping its exhaust fans in operable condition; exhaust fans in rooms 610 and 103 are not working properly.
Inspection Report
Follow-Up
Deficiencies: 7
Date: May 15, 2025
Visit Reason
This is a Construction Section Biennial Follow-Up Survey conducted to verify correction of previously cited deficiencies related to physical plant and safety code compliance.
Findings
The facility failed to correct previously cited deficiencies including lack of required documentation for special locking doors, fire safety components not maintained in safe operating condition, plumbing system issues with a full grease trap causing odor, inadequate hot water temperatures, and non-operable exhaust fans in specified areas.
Deficiencies (7)
Facility failed to have all components and procedures to properly operate doors equipped with Special Locking, affecting occupant evacuation.
Fire Alarm Control Panel lacks informational wiring and system component location diagrams.
Fire doors at main entrance of SCU have a gap larger than allowable 1/8 inch.
Fire Alarm Panel indicates trouble with NAC 3 circuit.
Facility failed to maintain plumbing system; grease trap tank full causing backup and odor in kitchen floor drains.
Hot water temperature throughout facility approximately 80°F, below required minimum of 100°F.
Facility is not keeping exhaust fans in operable condition; no exhaust fan in SCU spa and fans in rooms 610 and 103 not working properly.
Report Facts
Temperature: 80
Gap size: 0.125
Inspection Report
Capacity: 66
Deficiencies: 6
Date: Jan 14, 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 2012 Edition of the North Carolina Building Code, Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to meet code requirements for special locking doors, poor housekeeping with walls and ceilings not kept clean or in good repair, failure to maintain fire safety equipment properly, inadequate hot water temperature, and non-operable exhaust fans in certain areas.
Deficiencies (6)
Fire Alarm Control Panel's Special Locking System lacks informational wiring and system component location diagrams.
Walls, ceilings, and floors or floor coverings are not kept clean and in good repair; walls are extremely scuffed with drywall damage in common and resident areas.
Failure to maintain building's fire safety equipment in safe condition; holes or gaps at penetrations in fire resistant ceilings and improper sealing materials used in electrical and laundry rooms.
Fire doors at main entrance of SCU have gaps larger than allowable; exit doors in SCU lack required audible alarms; multiple screamer boxes do not sound when covers are removed.
Hot water temperature throughout the facility is approximately 80 degrees Fahrenheit, below the required minimum of 100 degrees Fahrenheit.
Exhaust fans are not operable in the SCU spa and rooms 610 and 103.
Report Facts
Total licensed beds: 66
Hot water temperature: 80
Allowable fire door gap: 0.125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Meyer | Conducted the Construction Section Biennial Survey | |
| Maintenance Director | Interviewed regarding fire alarm system and fire safety equipment deficiencies |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Sep 26, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on 09/25/24-09/26/24. The complaint investigations were initiated by the Johnston County Department of Social Services on 09/17/2024.
Complaint Details
Complaint investigations were initiated by the Johnston County Department of Social Services on 09/17/2024 and included issues with resident call bell functionality and theft of personal property.
Findings
The facility failed to ensure a resident's call bell was functional and accessible, failed to complete initial resident assessments within required timeframes, failed to maintain residents' rights by preventing theft of personal property, and failed to secure medication carts. Additionally, the facility did not complete required Health Care Personnel Registry reports after allegations of theft were reported.
Deficiencies (6)
Failed to ensure that a resident's electrically operated call bell could be activated with a single action, remain on until deactivated by staff, and be within reach of the resident's bed.
Failed to ensure an initial assessment was completed within 72 hours of admission using the Resident Register for 2 of 7 sampled residents.
Failed to ensure an initial assessment of each resident was completed within 30 days following admission and at least annually thereafter using an assessment instrument for 2 of 5 sampled residents.
Failed to ensure residents were free from theft of personal property.
Failed to ensure medications were stored securely as evidenced by 2 medication carts left unlocked and unattended.
Failed to complete a Health Care Personnel Registry 24-Hour Initial Report and a Five Working Day Investigative Report after the Administrator became aware of allegations of theft.
Report Facts
Work orders placed for call bell repair: 3
Missing cash amount for Resident #6: 35
Missing cash amount for Resident #7: 200
Missing cash amount for Resident #8: 100
Duration medication carts left unlocked: 10
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 12, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigation on 07/12/2024. The complaint investigations were initiated by the Johnston County Department of Social Services on 05/10/2024 and 06/10/2024.
Complaint Details
Complaint investigations were initiated by the Johnston County Department of Social Services on 05/10/2024 and 06/10/2024.
Findings
The facility failed to ensure medication aides completed state-approved training and passed required exams, failed to maintain current medical examinations for residents, failed to ensure medication orders were reviewed and signed every six months, failed to administer medications as ordered including errors with antibiotics and topical medications, failed to properly dispose of expired and wasted medications, failed to maintain quarterly resident profiles for special care residents, and failed to follow infection control policies including hand hygiene and outbreak notification.
Deficiencies (8)
Failed to ensure documentation for 5 of 5 sampled medication aides who administered medications completed state approved medication aide training and 1 of 5 sampled medication aides had not passed the written medication aide exam within 60 days of completion.
Failed to ensure 1 of 4 reviewed residents had a current medical examination (FL-2) completed annually.
Failed to ensure all current orders for medications and treatments were reviewed and signed by the resident's physician or prescribing practitioner at least every six months for 1 of 5 sampled residents and 2 of 4 residents observed during medication pass.
Failed to ensure medications were administered as ordered for 2 of 4 residents observed during medication pass including errors with an antibiotic, a topical medication, and for 2 of 5 sampled residents pertaining to a nasal spray, a medication for anxiety, and a medication to treat gastro-esophageal reflux.
Failed to ensure an expired medication was destroyed at the facility or returned to the pharmacy within 90 days of the expiration date for 1 of 5 sampled residents.
Failed to ensure a controlled substance not administered was destroyed and documented on the medication administration record or controlled substance record showing the reason and manner of destruction for 1 of 6 residents sampled.
Failed to ensure quarterly resident profiles to assess special care residents' needs were conducted for 1 of 1 sampled resident.
Failed to ensure medications were administered in accordance with infection control measures by 1 of 2 medication aides observed during the medication pass who did not sanitize or wash hands between preparation and administration of medications, did not don gloves for fingerstick blood sugar, and failed to notify the local health department and post signage pertaining to a COVID outbreak in the Special Care unit.
Report Facts
Medication error rate: 5
Medication administration records reviewed: 3
Medication cart audits frequency: 2
Medication cart audits frequency: 1
Medication cart audits frequency: 3
Medication cart audits frequency: 1
Medication wastage events: 5
Medication wastage quantity: 5
Medication wastage quantity: 19
Medication wastage quantity: 420
Medication wastage quantity: 12
Medication wastage quantity: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide/Supervisor | Named in medication aide training and certification deficiencies |
| Staff B | Medication Aide/Personal Care Aide | Named in medication aide training and certification deficiencies |
| Staff C | Medication Aide/Personal Care Aide | Named in medication aide training and certification deficiencies |
| Staff D | Personal Care Aide | Named in medication aide training and certification deficiencies |
| Staff E | Medication Aide | Named in medication aide training and certification deficiencies |
| Business Office Manager | Responsible for medication aide certification checks and personnel records | |
| Administrator | Interviewed multiple times regarding deficiencies and facility operations | |
| Regional Supervisor | Interviewed regarding medication aide training and certification | |
| Registered Nurse | Interviewed regarding medication aide training and certification | |
| Special Care Unit Director | Interviewed regarding medication aide training and certification | |
| Resident Care Coordinator | Interviewed regarding medication orders, medication refills, and care plans | |
| Medication Aide | Interviewed regarding medication administration and wastage | |
| Pharmacist | Interviewed regarding medication administration and wastage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding supervision failures at The Landings of Smithfield adult care home.
Complaint Details
The complaint investigation substantiated that the facility failed to supervise a cognitively impaired resident who eloped and was missing for about 17 hours, exposed to hypothermia and injury.
Findings
The facility failed to provide adequate supervision to one resident who exhibited wandering behaviors and eloped from the facility without staff knowledge, resulting in risk of serious harm. The resident was missing for approximately 17 hours in cold and rainy conditions, constituting a Type A2 violation.
Deficiencies (1)
Failure to provide supervision to one of five residents sampled who exhibited wandering behaviors resulting in elopement without staff knowledge.
Report Facts
Residents sampled: 5
Hours missing: 17
Temperature low: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanee Eley | Campus Director | Administrator/Designee who received the Corrective Action Report |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 7, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on July 6, 2022 - July 7, 2022.
Complaint Details
The visit included a complaint investigation related to medication administration errors for Resident #5 and accuracy of medication records for Resident #4.
Findings
The facility failed to administer medications as ordered for 1 of 5 sampled residents related to medication for constipation and failed to ensure electronic medication administration records were accurate for 1 of 5 sampled residents related to medication for high blood pressure.
Deficiencies (2)
Failed to administer medications as ordered for Resident #5 related to administration of medication used to treat constipation (Docusate Sodium).
Failed to ensure electronic medication administration records (eMARs) were accurate for Resident #4 related to a medication administered to treat high blood pressure (Metoprolol Tartrate) not documented on the MAR.
Report Facts
Number of sampled residents with medication administration issues: 2
Medication dosage: 200
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for updating medications on eMAR and notifying pharmacy; unaware of medication errors for Resident #5 and Resident #4 | |
| Executive Director | Confirmed responsibility of RCC to update eMAR and expected medication cart audits weekly | |
| Pharmacist | Provided information about medication orders and dispensing for Resident #4 | |
| Medication Aide | Administered medications according to EMARs; did not discard medications from multi-dose packaging | |
| Primary Care Provider | Notified of medication errors and confirmed medication needs for Residents #4 and #5 |
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