Inspection Reports for Brookdale Chapel Hill

The Adult Care Licensure Section completed a follow-up survey from 08/26/25 to 08/27/25 to verify correction of previous deficiencies related to medication administration.

The facility failed to administer medications as ordered for one of five sampled residents, specifically Resident #1, involving a Symbicort inhaler and polyethylene glycol for constipation. The facility had not reordered these medications since May 2025 despite ongoing administration, and there was uncertainty among staff about medication cart audits and reordering responsibilities due to the absence of a Responsible Care Coordinator (RCC).

Report of a Construction Section Biennial Follow Up Survey conducted to verify correction of previous deficiencies.

Deficiencies have been corrected. No further action is necessary.

This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies.

Deficiencies remain uncorrected related to the physical environment; specifically, the outside premises were not maintained in a clean and safe condition, with roofing shingles approximately 1' x 6' detached and sliding down the roof.

The Adult Care Licensure Section conducted an annual and follow-up survey from 05/28/25 to 05/30/25 to assess compliance with adult care home regulations.

The facility was found deficient in multiple areas including unsecured oxygen cylinders posing safety hazards, medication aides lacking required training and employment verification, failure to notify mental health providers of resident behavioral incidents, incomplete documentation and administration of medications, and failure to report a resident's fall resulting in a lumbar compression fracture to the county Department of Social Services.

This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies.

Deficiencies remain uncorrected related to the physical plant including outside premises maintenance, housekeeping and furnishings, electrical outlets in wet locations, and building equipment safety. Specific issues include missing escutcheon rings on sprinkler heads, peeling finishing tape, detached roofing shingles, trip hazards from carpet, and non-functioning ground fault interrupters.

The Adult Care Licensure Section conducted an annual and follow-up survey of Brookdale Chapel Hill to assess compliance with medication administration and staff qualifications.

The facility failed to ensure medication aides completed required training, administer medications as ordered for multiple residents, and maintain accurate medication administration records (eMAR). Deficiencies included missing medication aide training documentation, medication administration errors for three residents, and incomplete eMAR documentation for medication administration and effectiveness.

The Adult Care Licensure Section conducted an annual and follow-up survey on May 19-20, 2022 to assess compliance with regulations related to resident care, medication administration, nutrition, infection control, and other facility operations.

The facility was found deficient in multiple areas including failure to implement physician orders for TED hose application, failure to serve therapeutic diets as ordered for multiple residents, failure to administer a lidocaine patch as ordered, and failure to conduct daily resident temperature screenings as required by infection control policies during the COVID-19 pandemic.

The Adult Care Licensure section conducted an annual and follow-up survey on 05/23/19 - 05/24/19 to assess compliance with regulations related to nutrition, food safety, medication administration, and therapeutic diets.

The facility failed to ensure food safety by not properly labeling, dating, or covering food items in storage. Additionally, the facility did not serve nutritional supplements as ordered to one resident and had inaccuracies in the electronic Medication Administration Record (eMAR) related to trazadone dosage for the same resident.

This facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revision) 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.

Multiple deficiencies were cited including failure of magnetically locking exit doors to release upon fire alarm activation, damaged interior walls and ceilings, excessive particulate build-up on return-air grilles, stored items preventing adequate sprinkler coverage, rusted door and frame in exterior storage room, and non-operational bathroom exhaust ventilation in 'B' Hall.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1997 Revision) 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.

The survey identified deficiencies related to physical plant maintenance including hazards such as a floor drain grate below floor level creating a tripping hazard, gaps and penetrations in fire resistant rated ceilings compromising fire safety, doors that do not close and latch properly to contain fire and smoke, and unsafe electrical equipment use such as a power strip used as an extension cord.

The Adult Care Licensure Section conducted an annual survey of the facility on 06/14/16 - 06/15/16 to assess compliance with infection prevention requirements for medication aides.

The facility failed to ensure that 2 of 2 medication aides completed the required annual state medication aide infection control training. Observations, record reviews, and interviews confirmed lack of documentation of recent infection control training for Staff A and Staff B.

This report is of a follow-up survey conducted to verify correction of previously identified deficiencies at the facility.

The follow-up survey revealed that not all deficiencies were corrected. Specifically, the facility failed to maintain HVAC ventilation grilles and associated dampers, with excessive dust accumulation and activated radiation dampers noted.

This report is of a follow-up survey conducted to verify correction of previously identified deficiencies at the facility.

The follow-up survey revealed that not all deficiencies were corrected; specifically, the facility failed to maintain HVAC ventilation grilles and associated dampers, which had an excessive accumulation of dust and lint throughout the facility.

Biennial Construction Survey conducted to assess compliance with physical plant requirements, fire safety, housekeeping, and other regulatory standards for an adult care home.

Multiple physical plant deficiencies were identified including lack of proper delayed egress signage, incomplete fire sprinkler coverage, loose hand grips in bathrooms, obstructed corridors, inadequate housekeeping, missing fire extinguisher inspection documentation, incomplete fire safety rehearsals, electrical safety issues, fire door malfunctions, ventilation problems, and presence of prohibited portable electric heaters.