Inspection Reports for Brekenridge Retirement Center
2500 Hunter Hill Road Rocky Mount, NC 27804, Rocky Mount, NC, 27804
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 02/28/24 to 02/29/24 to assess compliance with medication administration regulations.
Findings
The facility failed to administer medications as ordered for 1 of 5 sampled residents, specifically failing to administer metolazone as prescribed to prevent fluid overload, despite documented weight gains that met the criteria for administration.
Deficiencies (1)
Failed to administer metolazone 5mg as ordered for weight gain greater than 3 lbs in 24 hours or 5 lbs in a week for Resident #1.
Report Facts
Weight gain: 6.4
Weight gain: 4.4
Weight gain: 3.2
Medication doses remaining: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Responsible for audits of the eMAR and ensuring all medication orders were followed |
| Administrator | Administrator | Interviewed regarding medication administration policies and responsibilities |
| Medication Aide | Medication Aide (MA) | Responsible for obtaining daily weights and administering metolazone; failed to administer medication as ordered |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 24, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brekenridge Retirement Center from 03/23/22 through 03/24/22 to assess compliance with state regulations.
Findings
The facility failed to provide adequate supervision for 3 of 5 sampled residents, resulting in multiple falls with injuries including fractures. Additionally, the facility failed to ensure medications were administered as ordered for 1 resident related to a vasodilator medication, risking serious health consequences.
Deficiencies (2)
Failed to provide supervision for 3 of 5 residents (#1, #2, and #3) related to multiple falls resulting in injuries including fractures and unwitnessed falls.
Failed to ensure medications were administered as ordered for 1 of 5 residents (#3) related to a vasodilator medication (Nitroglycerin patch).
Report Facts
Unwitnessed falls: 8
Falls for Resident #2: 8
Falls for Resident #1: 6
Nitroglycerin patch doses missed: 2
Nitroglycerin patches remaining: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Personal Care Aide (PCA) | Interviewed regarding resident supervision and fall monitoring |
| Not provided | Medication Aide (MA) | Interviewed regarding medication administration and resident monitoring |
| Not provided | Registered Nurse for Resident Supervision (RNRS) | Interviewed regarding supervision policies and fall interventions |
| Not provided | Administrator | Interviewed regarding expectations for resident supervision and medication administration |
| Not provided | Primary Care Provider (PCP) for Resident #1 | Interviewed regarding resident care and fall injury |
| Not provided | Primary Care Provider (PCP) for Resident #3 | Interviewed regarding medication administration and supervision |
| Not provided | Pharmacy Technician | Interviewed regarding medication dispensing and refill delays |
| Not provided | Hospice Nurse | Interviewed regarding resident #3's condition and medication needs |
Inspection Report
Capacity: 64
Deficiencies: 9
Date: Oct 2, 2019
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1991 (1995 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1994 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The survey identified multiple deficiencies related to housekeeping and furnishings, maintenance of fire safety systems, mechanical and electrical equipment, and exhaust ventilation. Specific issues included damaged furnishings, ceilings not kept clean or in good repair, unsecured oxygen bottles, gaps in fire-rated ceilings, doors that do not latch properly, accumulation of dust on mechanical equipment, missing electrical outlet cover plates, and non-functioning exhaust fans in several toilet areas.
Deficiencies (9)
Furnishings were not kept in good repair, including splintered door veneer and damaged bathroom doors.
Ceilings were not kept clean and in good repair, including damp and bubbling ceiling near closets and dust accumulation on A/C grille and exhaust fan.
Facility was not maintained free from hazards; unsecured oxygen bottles were observed.
Failure to maintain building's fire safety systems in a safe condition; gaps at penetrations through fire resistant rated ceilings or walls.
Fire safety doors did not completely close and latch, limiting ability to contain smoke or fire.
Mechanical equipment was not maintained in a safe and operating condition; dust accumulation noted.
Use of materials not fire resistant rated could allow fire and smoke to spread beyond area of origin.
Electrical equipment was not maintained in a safe and operating condition; missing cover plate on electrical outlet.
Facility did not provide working exhaust ventilation in required areas; multiple exhaust fans were not working.
Report Facts
Total licensed capacity: 64
Inspection Report
Capacity: 64
Deficiencies: 11
Date: Oct 12, 2017
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1991 (1995 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1994 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The facility did not meet several physical plant and safety requirements including building code requirements for special locking, housekeeping and furnishings maintenance, fire safety equipment operation, electrical safety, and exhaust ventilation. Specific deficiencies included missing schematic wiring diagrams, cracks in ceilings, obstructions to electrical panels, fire sprinkler system issues, smoke compartment door malfunctions, emergency lighting failures, and non-functioning exhaust fans.
Deficiencies (11)
A schematic wiring diagram and system components location map for the special locking system was not displayed adjacent to the fire alarm panel.
Cracks in the gypsum board ceiling adjacent to the sky light at the Nurses' Station.
The Code required clearance of 36" for access to the electrical panels is obstructed by items stored in front of the panels.
Fire sprinkler's accelerator pressure gauges indicated zero pressure and valves were in the off position.
Items stored on the top shelf of Storage Room #117 closet were not a minimum of 18" below the fire sprinkler head.
Holes or gaps at penetrations through fire resistant rated ceilings could allow fire and smoke to spread beyond the area of origin, including gaps and removed sections in the Sprinkler Room, Room 101, Porte Cochere, and Mechanical Room 115.
Duct detector sampling tube in Mechanical Room 115 is clogged with dust.
Doors in various locations (Common Bath #107, 100 Hall Cross Corridor, Room #13, Kitchen Housekeeping Closet) do not completely close and latch to help limit the spread of smoke or fire.
Ceiling mounted emergency lights at the nurse's station did not operate when tested.
GFCI electrical outlet in Room 181 did not trip when tested, posing a potential shock hazard.
The facility failed to maintain exhaust ventilation equipment in working order; central exhaust system for East and South Halls and the exhaust fan in Main Laundry were not working.
Report Facts
Total licensed capacity: 64
Required clearance: 36
Minimum clearance below sprinkler head: 18
Size of removed ceiling section: 432
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 7, 2016
Visit Reason
This report documents a follow-up survey conducted to verify correction of previously identified deficiencies at Brekenridge Retirement Center.
Findings
The follow-up survey revealed that not all deficiencies had been corrected. Specifically, the facility had not submitted required plans for changes to the magnetic locking system on exit doors to comply with the NC State Building Code. Deficiencies included lack of on/off emergency override switches within 3 feet of exit doors and absence of an on/off release switch at the nurse's station capable of interrupting power to all electromagnetically locked doors.
Deficiencies (2)
No on/off emergency override switches located within 3 feet of the EXIT doors.
No on/off release switch capable of interrupting power to all electromagnetically locked doors located and identified at the nurse's station serving the unit.
Inspection Report
Census: 64
Capacity: 64
Deficiencies: 10
Date: Dec 11, 2015
Visit Reason
This is a Biennial Construction Survey conducted to ensure the facility meets the 1994 Rules for the Licensing of Domiciliary Homes, the 1991 North Carolina State Building Code, and applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds.
Findings
The facility failed to maintain the building and furnishings in good repair and clean, including peeling vinyl wall coverings and loose grab bars. The building equipment was not maintained safe and operating, with issues such as lack of air gap at ice machines, non-functioning GFCI receptacle, gaps compromising fire resistance, non-latching corridor doors, non-illuminating exit signs, plumbing without vacuum breakers, and inadequate mechanical exhaust ventilation in several areas.
Deficiencies (10)
Vinyl wall covering peeling in several locations in common bathrooms including Bathrooms 163 and 107.
Grab bar in Handicap Suite 120 is loose at the toilet, posing a fall hazard.
Condensate pipe for the ice machine in the Main Kitchen is resting on top of the floor drain, failing to maintain an air gap.
GFCI receptacle in Room 107 did not trip when tested, risking electrical shock.
Gaps around water pipes in Room 115 Mechanical Room and dropped flange around duct penetrating ceiling exposing holes, compromising fire resistance.
Corridor doors to Rooms 154 and 183 do not latch.
EXIT sign at the Laundry does not illuminate on battery power.
Sink in the Beauty Shop is not equipped with a vacuum breaker/anti-siphon device.
Soiled Utility Room at the Laundry is not equipped with mechanical exhaust fan.
Exhaust fans in Rooms 122, 168, and 173 are not exhausting air.
Report Facts
Licensed capacity: 64
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 4, 2015
Visit Reason
The Adult Care Licensure Section conducted an Annual Survey and Complaint Investigation on 11/4/15 and 11/5/15 at Brekenridge Retirement Center and on 10/27/15 - 10/28/15 at Brookdale Wake Forest.
Complaint Details
The visit included a complaint investigation as part of the annual survey at Brekenridge Retirement Center on 11/4/15 and 11/5/15.
Findings
At Brekenridge Retirement Center, the facility failed to maintain cleanliness and protection from contamination in the kitchen, dining, and food storage areas, including issues with rust, stains, dirt, and improperly stored food. At Brookdale Wake Forest, the facility failed to maintain cleanliness in the kitchen and dining areas, including floors, walls, equipment, and food storage, and failed to provide a gluten-free therapeutic diet menu for a resident with Celiac disease.
Deficiencies (3)
The kitchen, dining and food storage areas were not clean or protected from contamination, including rust spots, stains, dirt, and improperly dated open food.
The walk-in cooler and freezer, shelves, stove/oven, fryer, and floors and walls in the kitchen and dining area were not clean and free of contamination.
The facility failed to assure there was a gluten-free therapeutic diet menu for a resident with a physician-ordered gluten-free regular diet.
Report Facts
Cleaning frequency: 2
Cleaning frequency: 2
Cleaning frequency: 2
Inspection dates: 2
Inspection dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding cleaning responsibilities and schedules at Brekenridge Retirement Center. | |
| Dietary Aide | Interviewed about cleaning duties and schedules at Brekenridge Retirement Center. | |
| Administrator | Interviewed about cleaning responsibilities and dietary management at Brekenridge Retirement Center and Brookdale Wake Forest. | |
| Maintenance Employee | Interviewed about cleaning the ice machine and other kitchen areas at Brekenridge Retirement Center. | |
| Temporary Cook | Interviewed about kitchen cleaning duties at Brookdale Wake Forest. | |
| Fill-in Cook | Interviewed about kitchen cleaning duties at Brookdale Wake Forest. |
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