Inspection Reports for Waltonwood Lake Boone
3560 Horton Street Raleigh, NC 27607, Raleigh, NC, 27607
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 6, 2025, identified deficiencies related to environmental safety, staffing shortages, personal care, and meal service issues. Earlier inspections showed a pattern of medication administration errors and maintenance problems, including issues with fire safety equipment and ventilation. Inspectors cited concerns with medication management, resident care, and environmental hazards across multiple reports. Complaint investigations were mostly unsubstantiated, with the exception of substantiated medication-related deficiencies in early 2024. The facility’s inspection history shows ongoing challenges without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 5
Date: May 6, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual, follow-up, and state involved complaint investigation from 05/06/25 to 05/08/25.
Findings
The facility failed to maintain a safe and clean environment on the Special Care Unit, including unsecured personal care items and a hair dryer accessible to residents, and failed to maintain cleanliness in a resident's bathroom. Additionally, the facility was understaffed, resulting in delayed personal care and call pendant responses, and failed to provide meals in a timely manner and with proper non-disposable place settings.
Deficiencies (5)
Failed to maintain an environment free of hazards including personal care items and a hair dryer accessible to residents on the Special Care Unit and a clean environment related to a resident's bathroom.
Failed to ensure adequate staff was available to provide personal care services needed by residents, resulting in delayed assistance and unmet care needs.
Failed to provide personal care according to the resident care plan for a resident needing assistance with toileting and personal hygiene.
Failed to ensure mealtime service consisted of non-disposable place settings for residents eating in their rooms.
Failed to provide meals in a timely manner for residents, with documented delays in meal delivery and resident complaints.
Report Facts
Residents in Special Care Unit: 19
Facility census: 41
Call pendant response times: 15
Call pendant response times: 30
Call pendant response times: 10
Call pendant response times: 4
Call pendant response times: 26
Call pendant response times: 7
Call pendant response times: 3
Inspection Report
Capacity: 68
Deficiencies: 4
Date: Mar 12, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 2012 North Carolina State Building Code, Institutional Occupancy, and the 2005 Adult Care Home Rules for the facility licensed for 68 Adult Care Home beds including 23 Special Care Unit beds.
Findings
Deficiencies were cited related to building equipment maintenance and exhaust ventilation. Specifically, smoke-tight corridor doors were not maintained in a safe and operating condition due to missing door hardware and gaps around cable penetrations in fire-rated walls. Additionally, exhaust fans in the men's guest bathrooms on the 2nd and 3rd floors were not working, potentially causing odors and mildew.
Deficiencies (4)
Smoke-tight corridor doors not maintained in a safe and operating condition; door hardware missing on 2nd Floor Network Room door allowing passage of smoke/fire.
Holes or gaps at penetrations through fire resistant rated walls in 2nd Floor Electrical/Mechanical Room allowing fire and smoke to spread.
Exhaust fans not maintained in operable condition; 2nd Floor Men's Guest Bathroom exhaust fan not working.
Exhaust fans not maintained in operable condition; 3rd Floor Men's Guest Bathroom exhaust fan not working.
Report Facts
Licensed beds: 68
Special Care Unit beds: 23
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 7, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation from 02/06/24 to 02/07/24. The complaint investigation was initiated by the Wake County Department of Social Services on 01/30/24.
Complaint Details
Complaint investigation was initiated by the Wake County Department of Social Services on 01/30/24 and included follow-up to a previous Type B violation related to medication administration.
Findings
The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents (#1 and #4), including errors with controlled substances for pain management and a potassium supplement. Issues included delayed medication refills, medication administration errors, and failure to update medication orders in the system.
Deficiencies (2)
Failed to ensure medications were administered as ordered for Resident #1, including delayed refill and incorrect dosage administration of controlled substances Xtampza ER and Lyrica.
Failed to ensure medications were administered as ordered for Resident #4, including failure to update and administer increased dosage of Potassium Chloride following hospital discharge.
Report Facts
Medication doses: 2
Controlled substance capsules dispensed: 60
Controlled substance capsules dispensed: 60
Controlled substance capsules dispensed: 60
Controlled substance capsules dispensed: 60
Potassium Chloride dosage: 10
Potassium Chloride dosage: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Responsible for ordering medications, faxing refill requests, and involved in medication administration errors for Resident #1 | |
| Assisted Living Wellness Coordinator (ALWC) | Notified of medication refill issues and responsible for contacting providers | |
| Resident Care Manager (RCM) | Oversaw medication administration process and identified medication errors | |
| Pharmacist | Provided information on medication dispensing and prescription receipt | |
| Pharmacy Technician | Provided information on prescription faxing and communication with facility |
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted an annual survey and complaint investigation on 12/06/23 to 12/07/23.
Complaint Details
The visit included a complaint investigation as indicated by the report stating it was an annual survey and complaint investigation conducted on 12/06/23 to 12/07/23.
Findings
The facility failed to serve water to each resident in the Special Care Unit during meals and failed to administer medications as ordered for multiple residents, including critical medications for Parkinson's disease and blood clots. Medication administration errors and delays in medication refills were documented, posing risks to resident health and safety.
Deficiencies (2)
Facility failed to serve water to each resident in the Special Care Unit at each meal.
Facility failed to ensure medications were administered as ordered for multiple residents, including errors with medications for heartburn, acid reflux, low blood potassium, depression, Parkinson's disease, blood clots, and constipation.
Report Facts
Residents in dining room at breakfast: 12
Residents in dining room at lunch: 13
Medication error rate: 10
Missed doses of Carbidopa-Levodopa: 4
Missed doses of Eliquis: 3
Missed doses of Sertraline: 2
Missed doses of Bupropion: 2
Missed doses of Hydroco/APAP: 3
Missed dose of Ropinirole: 1
Missed dose of Buspirone: 1
Missed doses of Azelastine/Systane: 7
Inspection Report
Initial Licensing
Deficiencies: 3
Date: Sep 26, 2019
Visit Reason
The Adult Care Licensure Section conducted an initial survey of Waltonwood Lake Boone on September 24, 25 and 26, 2019 to assess compliance with state regulations.
Findings
The facility failed to provide adequate supervision for a resident with frequent falls, resulting in multiple falls and injuries. Additionally, the facility failed to discontinue a medication as ordered by the physician, administering ibuprofen after it was discontinued. The facility also failed to obtain a physician's order for a resident self-administering medications.
Deficiencies (3)
Failed to provide supervision for Resident #1 with frequent falls, resulting in 9 falls and injuries including a broken wrist and scalp abrasion.
Failed to discontinue administration of Ibuprofen to Resident #2 after physician ordered discontinuation, resulting in 123 doses administered.
Failed to obtain physician's order for Resident #1 to self-administer medications.
Report Facts
Number of falls: 9
Ibuprofen doses administered: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Manager | Resident Care Manager (RCM) | Responsible for reviewing falls, ensuring interventions, and medication order processing. |
| Medication Aide | Medication Aide (MA) | Responded to Resident #1's falls and documented incident reports. |
| Physical Therapist | Physical Therapist (PT) | Provided therapy and fall prevention training to Resident #1. |
| Assisted Living Wellness Coordinator | Wellness Coordinator | Investigated falls and participated in at-risk meetings. |
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