Inspection Reports for Zebulon House

The facility was found not in compliance with code requirements for electromagnetic locks on exit doors, and fire safety equipment was not maintained in a safe and operating condition. The fire alarm system showed multiple trouble signals, and a portion of the sprinkler system was out of service with the control valve closed. The facility had not notified required authorities about the sprinkler impairment as required by new rules effective June 1, 2025, and fire watch documentation was incomplete but resumed at the direction of the Fire Marshal.

Complaint investigation was part of the visit, focusing on referral and follow-up for ordered laboratory tests and refund of personal funds.

The facility failed to ensure referral and follow-up for ordered laboratory tests for one resident, and failed to refund personal funds and advance payments within 14 days for several discharged residents. Multiple interviews and record reviews confirmed delays in lab work and refund processing.

The facility failed to administer medications as ordered for one resident during the medication pass, including errors with medications for constipation and phosphate control in dialysis patients. Additionally, the medication administration record was inaccurate for the same resident, documenting medication administration that did not occur.

The complaint investigation was initiated by the Wake County Department of Social Services on November 19, 2021.

The facility failed to administer medications as ordered for 4 of 5 residents observed during medication passes, including errors related to medication omission, crushing extended-release medication, and incorrect medication administration timing. The medication error rate was 6% based on 2 errors out of 30 opportunities during the 8:00am medication pass on 12/08/21.

This was a complaint investigation focused on COVID-19 infection control related to staff screening. The complaint was substantiated based on findings of inconsistent and incomplete staff COVID-19 screening documentation and procedures.

The facility failed to ensure implementation of CDC, North Carolina Department of Health and Human Services, and local health department guidance for COVID-19 staff screening. Multiple staff members did not consistently sign the COVID-19 Screening Log at the beginning of their shifts, and the facility was unable to locate screening logs for several dates. Staff screening was conducted by others rather than self-screening, and documentation was incomplete or inconsistent.

Multiple deficiencies were cited including poor housekeeping with walls and ceilings not kept in good repair or clean, facility hazards such as loose handrails, failure to conduct required fire safety rehearsals quarterly on each shift, and fire safety equipment and building components not maintained in safe operating condition including malfunctioning magnetic locks, gaps in fire-resistant ceilings, doors not latching, and non-working exhaust fans in multiple areas.

The facility was found to have multiple deficiencies related to physical plant maintenance including damaged wall coverings due to water damage, malfunctioning interior doors, removed attic insulation, fire safety equipment not maintained in operating condition, smoke detectors removed due to water damage, exit signage not illuminated, blocked electrical panel, and damaged fencing around the secured courtyard.

The facility failed to ensure that one of six sampled staff had completed the required two-step tuberculosis (TB) test in compliance with state TB control measures. Specifically, Staff F had only one documented TB test upon hire, and the facility accepted a prior TB test given five months before employment, which was not valid as the first step test.

The followup survey revealed that not all deficiencies have been corrected. Specifically, the building was not maintained in a safe manner due to a dropped sprinkler escutcheon in the supply storage room near room 301, and the exhaust fan in room 204 bathroom was not working.

The followup survey revealed that not all deficiencies had been corrected. Deficiencies were found in housekeeping and furnishings, building equipment safety and operation, and exhaust ventilation, including furniture in poor repair, fire protection equipment not maintained, electrical system issues, unprotected fire barrier penetrations, and a non-working exhaust fan in a bathroom.

Multiple deficiencies were noted including unsecured hand grips in bathrooms, unsafe outside premises, poor housekeeping and furnishings, malfunctioning fire protection equipment, doors that do not close or latch properly, electrical system issues, inadequate exit signage, compromised fire-resistance of building components, plumbing equipment lacking vacuum breakers, obstructed corridors, and non-functioning exhaust ventilation fans.

The facility was found deficient in housekeeping and furnishings, nutrition and food service cleanliness, and medication administration practices. Observations revealed stained and damaged furniture, unclean food storage and kitchen areas, and medication administration errors including insulin timing, inhaler use, and incomplete medication orders.