Deficiencies per Year
16
12
8
4
0
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Feb 18, 2026 | 95 | 3 | 8 | Annual Inspection | |
| Mar 3, 2025 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Aug 15, 2023 | 102.5 | 4.5 | 2 | Annual Inspection | |
| Dec 7, 2021 | 98.5 | 2.5 | 4 | Annual Inspection | |
| Sep 19, 2017 | 99.5 | 2.5 | 0 | Follow-Up Inspection | |
| May 19, 2017 | 97 | 2.5 | 5.5 | Annual Inspection | |
| May 1, 2015 | 102.25 | 1.25 | 0 | Follow-Up Inspection | |
| Dec 3, 2014 | 101 | 4.5 | 3.5 | Annual Inspection | |
| Dec 1, 2014 | 104.5 | 0 | 0 | Re-Issued | |
| Jan 8, 2014 | 87 | 7 | 0 | Annual Inspection | |
| Dec 10, 2012 | 82.5 | 2.5 | 0 | Follow-Up Inspection | |
| Oct 24, 2012 | 80 | 0 | 10 | Annual Inspection | |
| Oct 2, 2012 | 88.5 | 2.5 | 0 | Monitoring Visit | |
| Aug 13, 2012 | 86 | 0 | 10 | Monitoring Visit | |
| Nov 30, 2011 | 96 | 0 | 4 | Annual Inspection | |
| Jul 14, 2010 | 98.5 | 2.5 | 4 | Annual Inspection | |
| Jun 18, 2009 | 102.25 | 1.25 | 0 | Follow-Up Inspection | |
| Apr 15, 2009 | 101 | 4.5 | 3.5 | Annual Inspection |
Inspection Report
Capacity: 76
Deficiencies: 15
Aug 10, 2023
Visit Reason
The facility was surveyed for conformance with applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, North Carolina State Building Codes, and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure. This was a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited related to physical plant and fire safety code compliance, including delayed egress door issues, corridor obstructions, outside premises maintenance, housekeeping and furnishings cleanliness and repair, improper oxygen bottle storage, incomplete fire safety rehearsal records, fire safety equipment maintenance failures such as holes and gaps in fire-resistant ceilings and walls, malfunctioning smoke barrier doors, mechanical equipment hazards, and electrical emergency lighting failures.
Deficiencies (15)
| Description |
|---|
| Delayed egress exit doors required two pressure applications to release locks. |
| Delayed egress exit door missing required signage. |
| Magnetic lock door missing emergency on/off release switches at required locations. |
| Corridors were obstructed by benches reducing corridor width below required 6 feet. |
| Outside premises not maintained in a clean and safe condition; worn and damaged armchair on stoop. |
| Walls and ceilings not kept clean and in good repair; dust, cobwebs, lint, water stains, and ceiling damage observed. |
| Facility not maintained free from hazards; oxygen bottles improperly stored without restraint. |
| Fire rehearsal records lacked short descriptions of what the rehearsals involved. |
| Fire safety systems not maintained in safe condition; holes and gaps in fire-resistant ceilings and walls. |
| Smoke barrier doors did not close or latch properly to limit spread of smoke or fire. |
| Mechanical equipment not maintained safely; lint buildup from disconnected dryer exhausts creating fire hazard. |
| Resident room doors had holes or gaps compromising fire safety. |
| Sprinkler heads obstructed by items within 18 inches, limiting fire suppression ability. |
| Radiation dampers blocked open preventing closure, allowing spread of smoke or fire. |
| Electrical emergency/exit lighting not functioning properly; some exit signs did not illuminate on test. |
Report Facts
Licensed bed capacity: 76
Special Care Unit beds: 24
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 6, 2023
Visit Reason
The Adult Care Licensure section conducted an annual and follow-up survey from 07/05/23 through 07/06/23 to assess compliance with medication administration regulations.
Findings
The facility failed to administer medications as ordered for 2 of 5 sampled residents (#3 and #5). Resident #3 did not receive scheduled trazodone due to a lapse in prescription refills, and Resident #5 missed doses of coenzyme Q10 because the medication was not requested or available at the facility.
Deficiencies (2)
| Description |
|---|
| Failure to administer trazodone as ordered for Resident #3 due to prescription refill issues and medication unavailability. |
| Failure to administer coenzyme Q10 as ordered for Resident #5 due to medication not being requested or available. |
Report Facts
Sampled residents: 5
Residents with medication administration issues: 2
Missed doses for Resident #3: 10
Missed doses for Resident #5: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in relation to medication refill and administration issues for Residents #3 and #5 |
| Administrator | Administrator | Interviewed regarding medication administration expectations and awareness of deficiencies |
| Medication Aide | Medication Aide | Interviewed about medication administration and refill requests for Residents #3 and #5 |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 4, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on November 3-4, 2021.
Findings
The facility failed to develop care plans within 30 days of admission for 2 of 5 sampled residents and failed to ensure Licensed Health Professional Support (LHPS) assessments were completed for 2 of 5 sampled residents for specific personal care tasks. Staffing shortages and absence of a Health and Wellness Director contributed to delays in documentation and care plan completion.
Complaint Details
The visit included a complaint investigation as noted in the initial comments, but specific substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a care plan was developed for 2 of 5 sampled residents within 30 days following admission. |
| Failed to ensure a Licensed Health Professional Support (LHPS) assessment was completed for 2 of 5 sampled residents for identified tasks including finger stick blood sugars, insulin injections, and physical assistance with ambulation. |
Report Facts
Sampled residents: 5
Residents with care plan deficiencies: 2
Residents with LHPS assessment deficiencies: 2
Inspection Report
Capacity: 76
Deficiencies: 11
Apr 5, 2018
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 North Carolina State Building Codes and Minimum Standards for Homes for the Aged, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited related to physical plant and fire safety, including lack of current fire alarm testing report, obstructed exit passageways, disabled sprinkler system switches, unsecured smoke-barrier door hold open device, unsecured exit signs, ceiling openings near sprinkler heads, and unsupervised stove operation adjacent to residents.
Deficiencies (11)
| Description |
|---|
| Facility failed to have current fire alarm testing report on site for review. |
| Exit vestibule in the Memory Care Unit adjacent to Room 412 blocked by excessive stored items obstructing exit passageway. |
| OS&Y temper switches disabled at the sprinkler riser. |
| Sprinkler system gauges due for calibration or replacement. |
| Fire-rated door entry for Laundry in Azalea Court Wing held open with coat hanger. |
| Excessive particulate build-up on return-air grilles at radiation dampers. |
| Smoke-barrier door hold open device box in wall not secure adjacent to Laundry Room in SCU. |
| Exit sign at 100/200 Hall intersection not secure to ceiling. |
| Exit sign at double corridor doors in 400 Hall/Spa lacks battery back-up. |
| Ceiling openings adjacent to sprinkler heads at multiple locations including Storage Closet near Room 210, Residential Laundry Room Closet in 300 Hall, Spa/Shower Room in 400 Hall, and Entrance into Activity Room. |
| Stove energized adjacent to residents at dining tables without staff supervision; stove was de-energized during inspection. |
Report Facts
Total licensed beds: 76
Inspection Report
Annual Inspection
Deficiencies: 5
Apr 6, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from April 4-6, 2017 to assess compliance with state regulations.
Findings
The facility failed to assure that medications including alendronate, vitamin D3, Novolog insulin, and Tylenol were administered as ordered by licensed practitioners for multiple residents. Deficiencies included improper timing of medication administration, missed medications, and incorrect transcription of medication orders in the electronic medication administration record (eMAR).
Severity Breakdown
Type B Violation: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident #2 was not served nectar thick liquids as ordered by the physician due to staff not properly thickening liquids according to instructions. | — |
| Resident #8 received alendronate 70 mg with other medications at mealtime instead of 30 minutes before food or other medications as ordered. | Type B Violation |
| Resident #7 did not receive vitamin D3 2000 IU as ordered during medication administration on 04/05/17. | Type B Violation |
| Resident #2 received rapid-acting insulin (Novolog) after meals and at inconsistent times not aligned with sliding scale parameters, risking hypoglycemia. | Type B Violation |
| Resident #1 did not receive scheduled Tylenol 325 mg every 6 hours as ordered; medication was incorrectly entered as 'as needed' in the eMAR. | Type B Violation |
Report Facts
Medication pass error rate: 5
Tylenol tablets on hand: 198
FSBS documented: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for entering medication orders into eMAR and educating staff on medication administration |
| Facility Nurse | Facility Nurse (FN) | Responsible for weekly eMAR audits and medication order transcription |
| Health and Wellness Director | Health and Wellness Director | Responsible for training staff on thickened liquids |
| Food Service Manager | Food Service Manager | Educated staff on safe food service but not on thickening liquids |
| Corporate Nurse | Corporate Nurse | Provided consultation and training oversight on medication administration |
| Medication Aide | Medication Aide (MA) | Involved in medication administration and reported issues with medication timing and availability |
| Medication Aide/Supervisor | Medication Aide/Supervisor (MAS) | Administered insulin and aware of timing issues with Novolog insulin |
Inspection Report
Follow-Up
Deficiencies: 2
Sep 8, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies at Brookdale Asheboro.
Findings
Deficiencies were found related to housekeeping and furnishings, specifically dust accumulation on HVAC devices, and failure to maintain fire safety equipment as several doors did not close or latch properly.
Deficiencies (2)
| Description |
|---|
| Facility failed to keep ceilings clean by allowing HVAC devices to collect dust and particulate. |
| Failure to maintain fire safety equipment in safe operating condition as evidenced by doors that do not completely close and latch. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Strickland | Conducted the follow-up survey on 09/08/2016. |
Inspection Report
Capacity: 76
Deficiencies: 12
May 19, 2016
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 1996 North Carolina State Building Codes, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure. This was a Biennial Construction Survey.
Findings
Multiple deficiencies were identified including failure to meet building code requirements for delayed egress special locking systems, inadequate housekeeping with dust accumulation on HVAC devices, unsafe storage of gas cylinders and combustible items, obstructions in emergency egress pathways, failure to maintain fire safety systems including gaps in fire resistant ceilings and malfunctioning doors, non-operational emergency exit signs, exposed electrical wiring, and lack of required exhaust ventilation in laundry areas.
Deficiencies (12)
| Description |
|---|
| Special Care Unit exit door lacks required signage for delayed egress special locking system and entrance door lacks manual override and remote release for magnetic lock. |
| HVAC return air and exhaust fan grilles clogged with dust and particulate; HVAC duct radiation dampers coated with dust; lint accumulation from dryer exhaust duct. |
| Hole in resident's bathroom door in Room #304. |
| Helium gas tank stored upright without restraint in Special Care Unit Program Coordinator's Office. |
| Items stored in front of electrical panels in 200 Hall, Dale's Office. |
| Combustible items such as cardboard and used air filters stored in attic above mechanical room. |
| Path of egress from Special Care Unit corridor exit door impeded by stored items; med carts stored in corridor narrowing required egress width. |
| Gaps and open penetrations approximately ¾" diameter in fire resistant rated ceilings in Programs and Dining area and Mechanical Room adjacent to Kitchen. |
| Doors failing to completely close and latch including cross corridor door adjacent to Room #102, laundry door dragging and loose hinges, Room #206 corridor door not latching, and kitchen door held open by twine (corrected on site). |
| Emergency exit signs not working at Dining Room entrance door to Special Care Unit and within Special Care Unit. |
| Exposed electrical wiring connections at electrical motor and junction box near PRV in Mechanical Room adjacent to Kitchen. |
| Laundry rooms on 300 Hall and Special Care Unit lack required exhaust fans. |
Report Facts
Licensed capacity: 76
Hole diameter: 0.75
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