Inspection Reports for Brookdale Chapel Hill
2220 Farmington Dr, Chapel Hill, NC 27517, Unites States, NC, 27517
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jan 14, 2025 | 87.5 | 3.5 | 16 | Annual Inspection | |
| Sep 28, 2023 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Dec 13, 2021 | 95.5 | 3.5 | 8 | Annual Inspection | |
| Dec 18, 2017 | 101.25 | 1.25 | 0 | Follow-Up Inspection | |
| Jul 6, 2017 | 100 | 3.5 | 3.5 | Annual Inspection | |
| Jan 22, 2015 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Dec 21, 2012 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Oct 13, 2011 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Jul 14, 2010 | 99 | 3 | 4 | Annual Inspection | |
| Sep 11, 2009 | 101 | 3 | 2 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 2, 2025
Visit Reason
Report of a Construction Section Biennial Follow Up Survey conducted to verify correction of previous deficiencies.
Findings
Deficiencies have been corrected. No further action is needed.
Inspection Report
Follow-Up
Deficiencies: 4
Mar 4, 2025
Visit Reason
The visit was a biennial follow-up construction survey to assess correction of previously identified deficiencies.
Findings
Deficiencies remain uncorrected related to the lack of current fire and building safety inspection reports and failure to maintain the building's fire safety systems in a safe condition, including unsealed penetrations and use of non-approved fire-resistant materials.
Deficiencies (4)
| Description |
|---|
| Facility did not have current fire and building safety inspection reports available for review. |
| Failure to maintain building's fire safety systems in a safe condition; sprinkler head not centered leaving gaps. |
| Use of non-approved fire rated materials (orange foam) sealing penetrations, potentially delaying fire detector activation. |
| Unsealed hole cut in side wall in laundry storage; penetrations sealed with yellow foam not meeting fire-resistant rating. |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 9
Dec 5, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Chapel Hill AL from December 3, 2024 through December 5, 2024 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure exit doors had sounding devices for residents at risk of wandering, improper assignment of food service duties to personal care aides, failure to implement physician orders for medications and treatments, failure to document medication administration accurately and timely, failure to ensure safe storage of self-administered medications, and failure to maintain accurate self-administration medication assessments and medication reconciliation.
Deficiencies (9)
| Description |
|---|
| Exit doors accessible by residents, including a resident intermittently disoriented, were not equipped with sounding devices that activated when doors were opened. |
| Personal care aides were routinely assigned food service duties such as serving meals and cleaning dining rooms, which is not compliant with staffing rules. |
| Failure to implement physician's orders for thrombo-embolic deterrent (TED) hose for two residents, including wearing TED hose without an order and not ordering TED hose as prescribed. |
| Failure to clarify and follow physician orders for vitamin B-12 supplementation and daily blood pressure checks for a resident. |
| Failure to administer medications as ordered for three residents, including pain medication, memory loss medication, and allergy medication. |
| Failure to document medication administration immediately following administration for two residents, including PRN medications. |
| Failure to have a physician order for a resident to self-administer medications, despite the resident having medications for pain, inhaler, and allergy in her room. |
| Failure to ensure medications self-administered by a resident were stored safely and securely; resident's room was unlocked and medications were accessible. |
| Failure to implement procedures to ensure medications were administered in accordance with physician orders for a resident who self-administered medications; lack of medication reconciliation and communication of medication changes. |
Report Facts
Census: 47
Medication doses unaccounted: 26
Medication doses remaining: 16
Medication doses remaining: 3
Medication doses unaccounted: 6
Medication doses remaining: 24
Inspection Report
Follow-Up
Deficiencies: 12
Apr 23, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building safety, sanitation, and physical plant conditions.
Findings
Multiple deficiencies were found including lack of current fire and building safety inspection reports, improper use of bathrooms for storage, absence of a designated soil utility room, damaged walls and ceilings, failure to maintain fire safety systems and emergency lighting, doors not closing or latching properly, exposed electrical hazards, blocked electrical panels, and non-functioning exhaust ventilation fans.
Deficiencies (12)
| Description |
|---|
| Facility did not have current fire and building safety inspection reports available for review. |
| Community bathrooms were being utilized for storage of maintenance supplies. |
| Facility did not have a Soil Utility Room for cleaning and sanitizing bed pans; utility sink removed. |
| Walls and ceilings were not kept in good repair, including stress cracks, damaged ceiling grids, and mildew spots. |
| Failure to maintain building's fire safety systems; holes or gaps at penetrations through fire resistant rated ceilings and walls. |
| Electrical emergency/safety lighting equipment not maintained in safe operating condition; multiple exit signs and lights not illuminating on test. |
| Fire safety doors not closing or latching properly, including unsynchronized doors and gaps allowing smoke passage. |
| Emergency fire alarm system devices not maintained in safe operating condition; heat detector hanging from wiring. |
| Unapproved devices and obstructions preventing doors from closing during fire alarm activation. |
| Electrical equipment not maintained safely; missing light fixtures leaving wires exposed. |
| Facility not maintained free from hazards; electrical breaker panels blocked by boxes and equipment. |
| Facility did not maintain exhaust ventilation in specified spaces; none of the fans were working. |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 10, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 11/08/21 through 11/10/21 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to complete required staff background checks prior to hire, failure to ensure timely physician notification and medication administration for a resident, failure to provide appropriate snacks to residents, and multiple medication administration issues including lack of medication availability and incomplete medication administration records.
Deficiencies (5)
| Description |
|---|
| Failure to ensure 1 of 3 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. |
| Failure to ensure physician notification for 1 of 5 sampled residents related to not starting an ophthalmic antibiotic in a timely manner. |
| Failure to offer or make available three snacks per day to residents as required. |
| Failure to administer medications as ordered for 2 of 5 residents related to arthritis pain medication and eye drops. |
| Failure to ensure medication administration records were complete and accurate for 2 of 5 residents including medications for moderate pain and an oral mouth rinse. |
Report Facts
Residents sampled: 5
Staff sampled: 3
Norco administrations: 21
Norco administrations: 20
Norco administrations: 18
Peridex doses: 53
Peridex doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in deficiency for lack of HCPR check prior to hire |
| Business Office Manager | Responsible for completing HCPR checks prior to hire | |
| Health and Wellness Coordinator | Named in findings related to medication administration and audits | |
| Medication Aide | Named in medication administration deficiencies and failure to reorder medications | |
| Administrator | Interviewed regarding multiple deficiencies and facility responsibilities |
Inspection Report
Capacity: 70
Deficiencies: 20
Oct 23, 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 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, building equipment, and safety systems. These include lack of required fire detection in some areas, missing hand grips in tubs, storage in bathrooms, corridor obstructions, lack of current fire safety inspections, fire extinguisher maintenance issues, incomplete fire safety rehearsals, electrical hazards, fire alarm troubles, smoke door issues, sprinkler system deficiencies, obstructed sprinkler heads, doors held open improperly, ventilation failures, and call system failures for residents unable to evacuate without assistance.
Deficiencies (20)
| Description |
|---|
| Facility failed to meet NC State Building Code for delayed egress exit doors lacking required fire detection and signage. |
| Facility failed to maintain current sanitation and fire safety inspection reports; last fire sprinkler inspection was over 12 months old. |
| Tubs accessible to residents lacked required hand grips (grab bars). |
| Resident toilet rooms and bathrooms were used for storage, obstructing fixtures and space. |
| Corridors were obstructed by unattended medication and housekeeping carts. |
| Soil utility room was not properly equipped; clinical sink removed. |
| Building mechanical systems and plumbing devices were not kept clean or in good repair; commode removed, shower head missing, ice machine drain line improperly installed. |
| Building was not maintained free of hazards; multiple portable oxygen cylinders unsecured in various locations. |
| Fire extinguishers lacked monthly in-house inspection documentation since last annual maintenance. |
| Fire safety rehearsals were not performed regularly on each shift quarterly and lacked adequate documentation. |
| Building emergency equipment including exit signs failed to illuminate on backup power. |
| Fire safety features including firestopping, fire alarm panel, cable penetrations, and fire alarm duct detectors were deficient or not maintained. |
| Electrical hazards observed including damaged baseboard heater, unsecured light fixture, multiple plug adaptors without overcurrent protection, blocked electrical panel access, and missing cover plates. |
| Smoke tight corridor walls and doors were not maintained; missing plates, broken handles, doors not latching or fitting properly. |
| Corridor doors had unacceptable gaps allowing smoke passage. |
| Fire sprinkler escutcheon plates missing or improperly installed allowing smoke and heat spread. |
| Fire sprinkler heads obstructed by stored items violating clearance requirements. |
| Corridor doors were blocked open or held open by unapproved devices or methods. |
| Ventilation system failed to provide required exhaust in specified rooms. |
| Call system did not provide ability for persons unable to evacuate without staff assistance to call for help. |
Report Facts
Total licensed capacity: 70
Number of portable oxygen cylinders unsecured: 20
Minimum clearance below fire sprinkler heads: 18
Inspection Report
Capacity: 70
Deficiencies: 9
Nov 9, 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 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant conditions including damaged and moldy ceilings due to moisture, improperly stored oxygen bottles presenting hazards, obstructed electrical panels, holes and gaps in fire resistant rated ceilings and walls, failure of fire safety doors to latch properly, non-functioning emergency lighting and exit signs, exposed electrical wiring, damaged GFCI receptacles, and failure of exhaust ventilation systems in several wings.
Deficiencies (9)
| Description |
|---|
| Ceilings not kept in good repair; fire resistant rated ceiling damaged and moldy due to moisture damage. |
| Oxygen bottles improperly stored without restraint, presenting hazard. |
| Code required clearance of 36" in front of electrical breaker panels not maintained due to obstruction. |
| Holes or gaps at penetrations through fire resistant rated ceilings and walls allowing potential fire and smoke spread. |
| Fire safety doors held open improperly, missing hardware, or obstructed preventing proper closing and latching. |
| Electrical emergency/safety lighting and exit signs not maintained in safe operating condition; many exit signs failed to illuminate on battery power. |
| Exterior emergency exit light missing with exposed wiring creating potential shock hazard. |
| Damaged and non-operable GFCI receptacle near water source. |
| Exhaust ventilation equipment failed to operate in several wings. |
Report Facts
Licensed capacity: 70
Exit signs tested: 24
Exit signs failed: 20
Required clearance: 36
Hole size: 4
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 1, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey on May 31, 2017 and June 1, 2017 to assess compliance with health care regulations.
Findings
The facility failed to assure the implementation of a Primary Care Provider order for supplemental oxygen for Resident #1, who had dementia and was hospitalized for breathlessness on exertion. The resident was not prompted to wear oxygen when ambulatory, adequate portable oxygen supply was not ensured, and non-usage was not reported to the PCP. Additionally, the facility failed to ensure one medication aide had completed a medication skills competency prior to administering medications.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assure implementation of PCP order for supplemental oxygen for Resident #1, including failure to prompt oxygen use when ambulatory, ensure adequate portable oxygen supply, and report non-usage to PCP. | Type B Violation |
| Failure to assure one medication aide had completed a medication skills competency prior to administering medications. | — |
Report Facts
Date of survey completion: 2017
Oxygen tank PSI: 1000
Date of resident hospitalization: May 24, 2017
Date of oxygen refill request: May 31, 2017
Date of hire for medication aide: Jul 12, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide/Supervisor | Failed to have documented medication skills competency prior to administering medications |
| Unnamed Medication Aide | Medication Aide | Placed oxygen refill order on 5/24/17 and reported refill request to oncoming shift |
| Facility RN | Registered Nurse | Responsible for calling oxygen refills and monitoring oxygen use; signed evaluation and faxed PCP |
| Administrator | Facility Administrator | Acknowledged gap in oxygen monitoring system and planned staff training and care plan updates |
| Business Office Manager | Business Office Manager | Responsible for employee training documentation; acknowledged occasional documentation gaps |
| Resident #1's Primary Care Provider | Primary Care Provider | Ordered supplemental oxygen and clarified oxygen use; expected staff to prompt resident |
Inspection Report
Follow-Up
Deficiencies: 4
Aug 31, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale Chapel Hill AL.
Findings
The facility failed to correct several deficiencies related to physical plant safety, including inadequate sprinkler coverage in closets, a sprung double door coordinator on a corridor door, and non-functioning exhaust fans in C wing.
Deficiencies (4)
| Description |
|---|
| Facility failed to meet NC State Building Code requirements for special locking on exit doors due to lack of approved supervised automatic smoke detection or sprinkler system in certain areas. |
| Closets in resident room bathrooms and linen closets in Spa Bathrooms throughout the building are not equipped with sprinkler heads inside the closets. |
| Facility failed to maintain fire resistance of building components, allowing possible spread of smoke beyond compartment of origin; specifically, the double door coordinator for the Living Room corridor door on C Hall is sprung. |
| Facility failed to maintain mechanical exhaust systems in working condition; exhaust fans located in C wing are not moving air, preventing exhausting of odors and moisture. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Conducted the follow-up survey on August 31, 2016. | |
| Maintenance Director | Interviewed regarding facility's failure to meet building code requirements for special locking on exit doors. |
Inspection Report
Follow-Up
Deficiencies: 7
May 4, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale Chapel Hill AL.
Findings
The facility failed to correct several deficiencies including incomplete sprinkler coverage in resident room closets and linen closets, unsafe building conditions such as fire resistance issues with doors and ceiling damage, and malfunctioning exhaust ventilation systems that blow air instead of exhausting it.
Deficiencies (7)
| Description |
|---|
| Closets in resident room bathrooms throughout the building are not sprinkled. |
| Linen closets in the Spa Bathrooms throughout the building are not sprinkled. |
| F-Hall EXIT corridor door does not latch when closed. |
| Large hole in the ceiling of the Club Room HVAC Closet. |
| Double door coordinator for the Living Room corridor door on C Hall is sprung and doors are not smoke resisting due to broken astragal. |
| Exhaust fans located in D wing are blowing air instead of exhausting. |
| Exhaust fans located in C wing are blowing air instead of exhausting. |
Inspection Report
Capacity: 70
Deficiencies: 6
Jan 20, 2016
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with physical plant and safety regulations applicable to the facility.
Findings
The facility was found deficient in multiple areas including failure to fully sprinkle enclosed spaces, exit doors not operable by single hand motion, improper storage of oxygen containers, failure to maintain fire resistance of building components, unsafe electrical receptacles, and malfunctioning exhaust ventilation systems.
Deficiencies (6)
| Description |
|---|
| Facility failed to sprinkle all enclosed spaces as required of a fully sprinkled building, including closets in resident bathrooms and linen closets in Spa Bathrooms. |
| Exit doors are not single-motion exiting; specifically, the Physical Therapy Room exit door is equipped with a dead bolt lock. |
| Oxygen bottles in Room E3 are not secured to prevent falling or rolling, creating a hazard. |
| Failure to maintain fire resistance of building components, including doors that do not close or latch properly, a large hole in the HVAC closet ceiling, and a kick-down hold open device on a kitchen door. |
| Electrical system unsafe due to a GFCI receptacle in Room C10 that did not trip when tested. |
| Mechanical exhaust systems not maintained in working condition; exhaust fans in D and C wings are blowing air instead of exhausting. |
Report Facts
Licensed bed capacity: 70
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