Inspection Reports for The Oaks of Alamance
1670 Westbrook Avenue Burlington, NC 27215, Burlington, NC, 27215
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
14.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Capacity: 37
Deficiencies: 8
Date: Apr 16, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 04/15/25-04/16/25 to assess compliance with regulations for The Oaks of Alamance.
Findings
The facility was found deficient in multiple areas including physical environment issues such as a broken window crank and lack of window screen in one resident room, unsafe storage of hazardous substances and oxygen tanks, failure to implement physician orders for compression stockings and therapeutic diets, inaccurate medication administration records, unsecured medications in resident bathrooms, and lack of documented pre-admission screenings for special care unit residents.
Deficiencies (8)
Failed to ensure a window in a resident room was operable and had a screen.
Failed to ensure hazardous substances were kept in a separate locked area and not accessible to residents in the Special Care Unit.
Failed to maintain the facility free of hazards related to oxygen tanks not properly stored by being secured in a storage crate or cart.
Failed to implement physician's orders for compression stockings for Resident #5.
Failed to ensure therapeutic diets were served as ordered for residents with diet orders for chopped meats and nutritional supplements.
Failed to ensure medications were administered as ordered related to insulin for Resident #4.
Failed to ensure medications were stored safely and securely; over the counter medications were found unsecured in resident bathrooms.
Failed to ensure pre-admission screening was documented for appropriateness of placement in the special care unit for sampled residents.
Report Facts
Resident rooms with window issue: 1
Oxygen tanks in room 122: 23
Oxygen tanks in room 207: 6
Residents sampled: 5
Medication doses: 2
SCU licensed capacity: 16
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
This report documents a Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies identified in prior inspections have been corrected. No further action is needed.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Apr 24, 2024
Visit Reason
The Adult Care Licensure Team conducted a follow-up survey on April 23 and April 24, 2024 to verify correction of previous deficiencies.
Findings
The facility failed to ensure medication staff completed required training and passed the state medication administration examination prior to administering medications. The facility also failed to notify primary care providers for elevated blood pressures for 2 of 5 sampled residents, failed to serve 8 ounces of milk or equivalent dietary products three times daily to residents in the Memory Care Unit, failed to serve therapeutic diets as ordered for 3 of 5 sampled residents, and failed to administer medications as ordered for 1 of 5 sampled residents including two glaucoma medications. Additionally, the facility failed to ensure proper self-administration orders for medications kept at bedside.
Deficiencies (6)
Staff who administered medications had not passed the state medication administration examination prior to administering medications.
Facility failed to ensure notification to primary care provider for elevated blood pressures for 2 of 5 sampled residents.
Facility failed to ensure 8 ounces of milk or equivalent dietary products were served three times daily to residents in the Memory Care Unit.
Facility failed to ensure therapeutic diets were served as ordered for 3 of 5 sampled residents with a diet order for no concentrated sweets.
Facility failed to administer medications as ordered for 1 of 5 sampled residents including two medications for glaucoma.
Facility failed to ensure proper self-administration orders for medications kept at bedside for 1 resident.
Report Facts
Residents with elevated blood pressure not notified to PCP: 2
Residents with diet order for no concentrated sweets: 3
Residents sampled: 5
Residents in dining room observed: 12
Residents in dining room observed: 11
Gallons of milk sent daily to Memory Care Unit: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to pass state medication administration examination prior to administering medications |
| Administrator | Interviewed regarding medication aide training and notification procedures | |
| Memory Care Manager | Interviewed regarding meal service and notification procedures | |
| Resident Care Coordinator | Interviewed regarding monitoring eMAR and notification procedures | |
| Dietary Manager | Interviewed regarding meal service and therapeutic diet compliance | |
| Medication Aide | Interviewed regarding medication administration and notification of PCP | |
| Pharmacist | Interviewed regarding medication orders and dispensing | |
| Resident #3 | Resident with medication administration and self-administration deficiencies | |
| Resident #1 | Resident with elevated blood pressure and diet order deficiencies | |
| Resident #4 | Resident with elevated blood pressure and diet order deficiencies | |
| Resident #5 | Resident with diet order deficiencies | |
| Dietary Aide | Interviewed regarding meal service and knowledge of therapeutic diets | |
| Personal Care Aide | Interviewed regarding meal service in Memory Care Unit |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Apr 18, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of deficiencies not completed from the previous Biennial Survey.
Findings
The facility had multiple deficiencies related to physical plant conditions including unsafe outside premises, unclean mechanical systems, electrical hazards, improperly posted evacuation plans, fire safety issues with doors and fire-resistance-rated enclosures, lack of maintenance and documentation for the kitchen hood fire suppression system, unsafe electrical system components, and sprinkler system deficiencies such as dropped escutcheon plates and lint-covered sprinkler heads.
Deficiencies (9)
Outside grounds were not maintained in a clean and safe condition; perimeter sidewalk uneven and tripping hazards from cables across sidewalks.
Mechanical systems (HVAC supply and return grilles) had excessive dust/lint accumulation.
Electrical system was not free of obstructions and hazards; Med Cart blocking electrical panel clearance.
Evacuation diagrams were not properly posted or oriented.
Fire-resistance-rated corridor doors did not close and latch properly; conduits not firestopped in fire-resistance-rated ceiling.
Commercial kitchen hood fire suppression system lacked required inspections, maintenance, and documentation since October 2023.
Smoke tight corridor doors not maintained; doors hitting frames, excessive gaps, and doors not latching.
Electrical hazards including multi-plug adaptor without overcurrent protection, missing light bulbs exposing energized sockets, and non-powered GFCI receptacle.
Building sprinkler system not maintained; multiple dropped concealed fire sprinkler escutcheon plates exposing openings, lint-covered sprinkler head increasing response time.
Report Facts
Number of cables creating tripping hazards: 8
Required electrical panel clearance: 36
Required electrical panel clearance: 30
Gap exceeding allowable limit: 0.75
Fire resistance rating: 45
Fire resistance rating: 60
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jan 11, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 01/10/24 and 01/11/24 at The Oaks of Alamance.
Findings
The facility failed to ensure medication staff met training and examination requirements, failed to check Health Care Personnel Registry upon hire for one staff, failed to ensure physician follow-up for abnormal blood pressure readings, failed to implement physician orders for dressing changes, failed to provide proper table service with non-disposable utensils and napkins, failed to provide matching therapeutic diet menus for residents on no concentrated sweets diet, failed to administer medications as ordered for three residents, failed to document medication administration immediately after giving medications for two residents, failed to ensure physician orders for self-administration of medications, and failed to store medications in a safe and secure manner for residents with medications at bedside.
Deficiencies (10)
Failed to ensure staff who administered medications had successfully passed the state medication administration examination or completed required medication aide training prior to administering medications.
Failed to ensure one staff had no substantiated findings on the North Carolina Health Care Personnel Registry upon hire.
Failed to ensure physician follow-up was completed for a resident with blood pressure readings outside ordered parameters.
Failed to implement physician's order for dressing change for a resident.
Failed to ensure mealtime table service included a napkin and non-disposable place setting consisting of at least a knife, fork, spoon, plate, and beverage containers.
Failed to have matching therapeutic diet menus for residents on no concentrated sweets diet for food service guidance.
Failed to administer medications as ordered for three residents including continued administration of discontinued medications and failure to provide inhaler medication.
Failed to ensure staff documented medication administration immediately after administering medication for two residents.
Failed to ensure residents had physician's orders to self-administer medications for two residents who had medications at bedside.
Failed to ensure residents' medications were stored in a safe and secure manner for two residents who had medications at bedside.
Report Facts
Medication administrations: 13
Medication administrations: 15
Medication administrations: 8
Medication tablets unaccounted: 23
Medication administrations: 36
Medication administrations: 3
Medication administrations: 4
Medication administrations: 4
Medication administrations: 30
Medication administrations: 31
Medication administrations: 10
Inspection Report
Capacity: 69
Deficiencies: 15
Date: Dec 14, 2023
Visit Reason
The report documents a Construction Section Biennial Survey conducted on December 14, 2023, to assess compliance with physical plant, fire safety, and building codes applicable to the licensed adult care home facility.
Findings
Multiple deficiencies were cited related to physical plant conditions, fire safety, housekeeping, maintenance, and building equipment. Issues included inadequate smoke detection, lack of current safety inspection reports, exit door locks not operable by single hand motion, unsafe outside premises, poor housekeeping and maintenance, fire safety equipment and sprinkler system deficiencies, blocked or malfunctioning corridor doors, and non-functioning exhaust ventilation.
Deficiencies (15)
Facility failed to meet NC State Building Code at time of construction or alterations; SCU Hall living room open to corridor without adequate smoke detection.
Facility failed to maintain current building safety inspection reports within last 12 months.
Exit door locks not operable by single hand motion from inside without keys, delaying emergency egress.
Outside grounds not maintained in clean and safe condition; multiple tripping hazards and drainage issues noted.
Housekeeping deficiencies including unclean floors, ceilings, walls, mechanical systems, and plumbing; presence of organic matter and microbial growth.
Building electrical system not free of obstructions and hazards; improperly stored compressed gas cylinders; unsecured HVAC grille; cluttered storage obstructing clinical sink access; general maintenance issues.
Missing towel bars in resident bedrooms and adjoining bathrooms.
Evacuation diagrams not properly posted or oriented.
Fire-resistance-rated construction enclosures and corridor doors not maintained in safe and operating condition; missing door hinges; doors not closing or latching properly; unapproved firestopping materials; fire suppression system lacking required inspections and documentation.
Doors blocked or held open by unapproved devices or occupants, compromising fire safety.
Fire sprinkler system deficiencies including missing or dropped escutcheon plates exposing openings, lint accumulation on sprinkler heads, and storage within required clearance areas.
Fire safety equipment not maintained with required monthly inspections documented.
Exhaust ventilation system not working or malfunctioning in required spaces.
Electrical system deficiencies including unsafe multi-plug adaptors, unsecured electromagnetic hold-open devices, missing light bulbs exposing energized components, non-functional GFCI receptacle.
Egress impeded by doors requiring keys, tools, or special knowledge to open; potential to trap occupants.
Report Facts
Licensed bed capacity: 69
Date of inspection: Dec 14, 2023
Number of uneven walking surfaces: 15
Date of last annual fire protection inspection: Oct 11, 2023
Fire sprinkler clearance: 18
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 15
Date: Feb 25, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 02/23/22 to 02/25/22 to assess compliance with state regulations for The Oaks of Alamance.
Findings
The facility was found deficient in multiple areas including unlocked hazardous chemical closets, unsecured oxygen tanks, improper hot water temperatures, failure to check Health Care Personnel Registry for staff, incomplete tuberculosis testing for a resident, failure to notify providers of abnormal blood pressure readings, failure to implement and document orders for blood pressure checks and TED hose application, failure to serve milk and water as required, failure to serve therapeutic diets as ordered, medication administration errors, failure to observe medication ingestion, lack of physician orders for self-administration of medications, unlocked medication carts, and inadequate COVID-19 infection prevention practices including visitor screening and facemask use.
Deficiencies (15)
Housekeeping closets containing hazardous materials were unlocked and accessible to residents.
One unsecured oxygen tank was observed on the floor of a resident's room.
Hot water temperatures at multiple sinks and showers exceeded the allowed range of 100-116 degrees Fahrenheit.
One staff member (Maintenance Director) was hired without a documented Health Care Personnel Registry check.
One resident (#4) did not have documented two-step tuberculosis testing as required.
Facility failed to notify providers for abnormal blood pressure readings for 2 residents (#2 and #3).
Facility failed to implement and document orders for blood pressure checks (#1 and #4) and TED hose application/removal (#2).
Facility failed to serve 8 ounces of milk twice daily to residents as required by the posted menu.
Facility failed to serve water with meals to all residents as required by the posted menu.
Facility failed to serve therapeutic diets as ordered for 2 residents (#2 and #5), including pureed diet and thickened liquids.
Facility failed to administer medications as ordered for 2 residents (#3 and #5), including lack of medication availability and excess medication remaining.
Medication aides failed to observe a resident (#2) taking medications, leaving medications unattended in a cup.
Facility allowed a resident (#3) to keep medications at bedside without a physician's order for self-administration.
Medication cart was left unlocked and unattended with keys in the lock slot on two occasions.
Facility failed to implement COVID-19 infection prevention guidance including visitor screening, temperature checks, and facemask use by visitors and staff.
Report Facts
Residents not served milk: 26
Milk available: 12
Residents not served water: 26
Residents not served water: 18
Remaining inhalations: 22
Residents served: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Hired without documented Health Care Personnel Registry check; unaware of requirement to wear surgical facemask. | |
| Administrator | Responsible for oversight of compliance with regulations including medication administration, infection control, and dietary services. | |
| Resident Care Coordinator | Responsible for resident record preparation and oversight of infection control and dietary orders; unavailable for interview. | |
| Medication Aides | Left medication cart unlocked; failed to observe medication ingestion; failed to document medication reorders. | |
| Dietary Staff | Failed to serve milk and water as required; unaware of menu requirements. | |
| Speech Therapist | Reported resident #5 was served non-pureed food despite pureed diet order. | |
| Pharmacist | Reported medication discrepancies and lack of orders for self-administration. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 8, 2018
Visit Reason
This is a Construction Section Follow-up Survey to verify correction of previously cited deficiencies and to identify any outstanding issues requiring correction and a new Plan of Correction.
Findings
Some previously cited deficiencies have been corrected; however, an outstanding deficiency remains related to the outside premises not being maintained in a clean and safe condition, including rotten fascia trim, deteriorating porch soffit, and clogged gutters.
Deficiencies (1)
Outside premises are not maintained in a clean and safe condition, including rotten fascia trim outside the Exit by Room 126, soft and deteriorating porch soffit beside the A/C units, and gutters clogged with pine needles.
Inspection Report
Capacity: 69
Deficiencies: 15
Date: Aug 2, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted on August 2, 2018, to assess compliance with physical plant, housekeeping, fire safety, and equipment maintenance regulations for The Oaks of Alamance facility.
Findings
Multiple deficiencies were identified including failure to separate clean and soiled linens, unsafe and deteriorated outside premises, poor housekeeping with holes and damage in walls, ceilings, floors, and doors, unsecured oxygen tanks, fire safety equipment and doors not maintained properly, electrical and mechanical equipment issues, and plumbing equipment not maintained safely.
Deficiencies (15)
Soiled linens were not kept separate from clean linens; open tubs of soiled linens were on the laundry room floor.
Outside premises not maintained clean and safe; rotten fascia trim, deteriorating porch soffit, clogged gutters.
Walls, ceilings, floors, and furnishings not maintained in good repair; holes in walls, loose door hardware, damaged shower wall, loose handrails.
Facility not maintained free of hazards; nine unsecured oxygen tanks in oxygen supply closet.
Fire safety components not maintained; doors propped open with unapproved devices, fire safety equipment stored too close to ceiling.
Fire resistant rated ceilings compromised by holes, gaps, missing sprinkler escutcheon plates, and unsealed penetrations.
Electrical emergency/safety lighting equipment not maintained; exit signs and emergency lights failed to illuminate during tests.
Fire safety equipment not maintained; holes in resident room doors and gaps between doors and frames.
Plumbing equipment not maintained; dry water seals, improperly sealed drains, and sealed off urinal allowing water seal to dry.
Mechanical equipment not maintained; freezing pipes and dirty sampling tube in duct.
Fire safety doors do not close and latch properly, allowing potential smoke and fire spread.
Electrical equipment not maintained safely; outlets near water sources failed GFCI testing.
Fire safety magnetic hold open device not secure and pulling away from wall.
Electrical heater falling off wall in riser room.
Cross corridor fire doors did not latch during fire alarm test.
Report Facts
Licensed capacity: 69
Unsecured oxygen tanks: 9
Holes in wall: 12
Holes in ceiling: 12
Fire safety doors not latching: 2
Outlets failing GFCI test: 2
Inspection Report
Follow-Up
Deficiencies: 5
Date: Mar 2, 2017
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new citations.
Findings
The facility failed to maintain current annual sanitation and fire safety inspection reports, had emergency equipment not maintained in safe and operating condition including non-working exit signs and fire suppression systems, had a corridor door wedged open preventing proper closure, and failed to maintain proper exhaust ventilation in specified areas.
Deficiencies (5)
Facility failed to maintain current annual sanitation and fire safety inspection reports.
Emergency equipment not maintained in safe and operating condition; exit sign near Bedroom 110 did not work on backup power.
Commercial kitchen hood's fire extinguishing system lacked required inspections, maintenance, and documentation.
Corridor door near Bedroom 108 was wedged open, preventing rapid release and proper closure.
Facility failed to maintain exhaust ventilation system in proper working order; soiled linen room and Bedroom 104 bathroom exhaust systems did not work.
Report Facts
Date of last Annual Fire Alarm System Inspection: Dec 2, 2015
Date of last semi-annual maintenance of kitchen hood fire suppression system: 201607
Inspection Report
Follow-Up
Deficiencies: 11
Date: Dec 14, 2016
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building safety, fire safety, and physical plant conditions.
Findings
The facility failed to maintain current sanitation and fire safety inspection reports, had multiple deficiencies in exit door locks not operable by single hand motion, housekeeping issues including stained ceilings and dust accumulation, electrical outlets in wet locations lacking ground fault interrupters, unsafe and non-operating building equipment including emergency exit signs and fire sprinkler heads obstructed by debris, fire safety issues such as holes in fire-resistance-rated ceilings and doors held open by wedges, lack of proper inspections and documentation for the commercial kitchen hood fire extinguishing system, and inadequate exhaust ventilation in several rooms.
Deficiencies (11)
Facility failed to maintain current annual sanitation and fire safety inspection reports.
Exit door locks did not provide single hand motion to exit the building.
Walls, ceilings, floors, and furniture were not kept clean and in good repair; ceiling stained near corridor door.
Facility failed to maintain building free of obstructions and hazards; excessive dust/lint on HVAC returns.
Electrical outlets in wet locations lacked ground fault interrupters or were non-functional.
Building emergency equipment including exit signs and fire sprinkler heads were not maintained in safe and operating condition.
Interior doors were not maintained in safe and operating condition; door closures and coordinators not functioning properly.
Commercial kitchen hood fire extinguishing system lacked required inspections, maintenance, and documentation.
Fire safety compromised by holes and gaps in fire-resistance-rated ceiling assemblies and doors held open by wedges.
Fire sprinkler escutcheon plates missing or improperly installed, allowing spread of fire and smoke.
Facility failed to maintain exhaust ventilation system in proper working order in multiple rooms.
Report Facts
Date of last Fire Marshal Inspection: Aug 28, 2015
Date of last Fire Alarm System Inspection: Dec 2, 2015
Hole size in fire-resistance-rated ceiling: 80
Fire sprinkler maintenance date: 201607
Inspection Report
Capacity: 69
Deficiencies: 21
Date: Sep 6, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1991 Homes for the Aged Minimum and Desired Standards and Regulations, applicable portions of the 2005 Licensing of Adult Care Homes of Seven or More Beds, and the 1991 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including failure to meet building code requirements for smoke barrier doors, lack of current sanitation and fire safety inspection reports, inadequate hand grips in bathrooms, exit door locks not operable by single hand motion, poor housekeeping and maintenance issues, electrical outlets without ground fault protection, fire safety equipment and sprinkler system deficiencies, and ventilation system failures.
Deficiencies (21)
Smoke Barrier Doors near Bedroom 110 lacked vision panels.
Facility failed to maintain current annual fire alarm and sprinkler system inspection reports.
Bathroom commode in Bedroom 220 had a loose side hand grip.
Exit door handles at multiple locations did not provide single hand motion operation.
Facility failed to keep walls, ceilings, floors, and furniture clean and in good repair.
Facility failed to maintain building free of obstructions and hazards; excessive dust/lint on HVAC returns.
Electrical outlets in wet locations lacked ground fault interrupters or were non-functional.
Fire rated doors of hazardous areas not maintained; bio-hazard room door not self-closing or automatic closing.
Exit doors had signage deterring emergency exit; one exit had caution tape blocking usage (corrected before departure).
Smoke barrier doors near Bedroom 110 did not close completely or provide smoke tight seal.
Exit signs near Bedrooms 110 and 216 did not work on backup power.
Fire sprinkler heads obstructed with lint and debris.
Interior doors not maintained properly; door coordinator and closures malfunctioning.
Building components such as exit door and corridor doors required excessive force to operate.
Commercial kitchen hood fire extinguishing system lacked required inspections and documentation.
Fire safety compromised by holes and gaps in fire-resistance-rated ceiling assemblies and missing firestopping.
Corridor doors did not latch properly, failing to resist passage of smoke.
Corridor doors held open by wedges preventing proper closure and latching.
Fire sprinkler escutcheon plates missing or improperly installed, allowing spread of fire and smoke.
Electrical system unsafe due to missing weatherproof cover on GFCI outlet at loading dock.
Exhaust ventilation system failed to operate properly in soiled linen room, bathroom, and staff toilet room.
Report Facts
Licensed capacity: 69
Date of inspection: Sep 6, 2016
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 25, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on June 23-25, 2015 to assess compliance with medication administration regulations.
Findings
The facility failed to assure medications were administered as ordered by the licensed prescribing practitioner for one resident (#3), with errors related to medications for hypertension, urinary tract infection symptoms, nasal allergies, low vitamin D levels, cough, and congestion. Multiple discrepancies were found between physician orders, medication administration records, and actual medication administration.
Deficiencies (1)
Failed to assure medications were administered as ordered by the licensed prescribing practitioner for Resident #3, including errors with Metoprolol, Vitamin D, Guaifenesin, Chromolyn Nasal Spray, and AZO.
Report Facts
Date of survey: Jun 25, 2015
Number of residents sampled: 5
Medication administration errors: 1
Blood pressure readings: 13296
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