Inspection Reports for Twin Lakes Memory Care
3810 Heritage Drive Burlington, NC 27215, Burlington, NC, 27215
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Capacity: 32
Deficiencies: 4
Date: Apr 19, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 2005 Rules for Adult Care Homes of Seven or More Beds and the 2006 North Carolina State Building Code Section 407.1-Institutional Group I-2 Occupancy.
Findings
Deficiencies were cited related to physical plant requirements including failure of emergency release switches on special locking doors, lack of current sanitation and fire safety inspection reports, building equipment not maintained in safe operating condition due to smoke barrier doors not latching properly, and failure to provide working exhaust ventilation in required spaces.
Deficiencies (4)
The on/off emergency release switch at the Sandpiper Cove front exit near Bedroom 214 did not interrupt power to the electromagnetic locking device and unlock the door.
The facility failed to maintain current (within last twelve months) building safety inspection reports, including the NFPA 25 report which was last dated 4-11-23.
Doors protecting the opening in the smoke barrier did not close completely and latch to restrict fire and smoke, specifically the right leaf of the double-egress cross-corridor doors near the FACP Room.
The facility did not provide working exhaust ventilation in required spaces; exhaust systems in non-residential rooms were not exhausting air.
Report Facts
Licensed bed capacity: 32
Date of last NFPA 25 inspection: Apr 11, 2023
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The Adult Care Licensure Section and the Alamance Department of Social Services conducted an annual and follow-up survey on August 8th and 9th, 2023.
Findings
The facility failed to ensure readily retrievable records that accurately reconciled the receipt and administration of controlled substances for one of three sampled residents. Specifically, the nurse administered Norco 5-325mg for pain but did not document each administration on the electronic medication administration record (eMAR), although the controlled substance count sheet (CSCS) was signed.
Deficiencies (1)
Failed to ensure readily retrievable records that accurately reconciled the receipt and administration of controlled substances for one resident, with missing documentation on the eMAR for administered Norco 5-325mg.
Report Facts
Medication administrations documented on eMAR: 18
Controlled substance count sheet sign-outs: 29
Medication dispensed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for documentation of controlled substances on eMAR and CSCS |
| Administrator | Administrator | Interviewed regarding expectations for documentation and tracking of controlled substances |
Inspection Report
Original Licensing
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
The Adult Care Licensure conducted an Initial Survey on 02/17/22 to assess compliance with physical environment and safety regulations.
Findings
The facility failed to ensure that hazardous materials in the environmental storage rooms and resident laundry rooms were properly secured and locked, posing safety risks to residents. Multiple observations and interviews confirmed that doors to chemical storage and laundry rooms were often unlocked, allowing potential resident access to harmful substances.
Deficiencies (1)
The facility failed to ensure the environmental storage room containing hazardous materials was locked and not accessible to residents.
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