Inspection Report
Capacity: 76
Deficiencies: 4
Nov 6, 2024
Visit Reason
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.
Findings
Deficiencies were cited related to physical plant requirements including failure to properly operate doors with special locking, lack of ground fault circuit interrupter (GFCI) protection on electrical outlets in wet locations, cracked glass in fire doors, and non-operable exhaust fan in the Special Care Unit chemical room.
Deficiencies (4)
| Description |
|---|
| Fire Alarm Control Panel's Special Locking System lacks informational wiring diagram and system components location diagram. |
| Electrical outlets behind washer machines in laundry rooms are not GFCI protected. |
| Cracked glass in the right leaf of the set of fire doors nearest the courtyard in the Special Care Unit. |
| Exhaust fan in the Special Care Unit chemical room is not working. |
Report Facts
Licensed bed capacity: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Meyer | Conducted the Construction Section Biennial Survey | |
| Maintenance Director | Interviewed regarding Special Locking System wiring diagrams |
Inspection Report
Annual Inspection
Deficiencies: 4
Jan 4, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 01/03/24 and 01/04/24 to assess compliance with regulations for Brookdale Dickinson Avenue.
Findings
The facility failed to ensure that care plans for sampled residents were certified by physicians, medications were administered as ordered, medication administration records were accurate, and infection control practices were followed during medication administration.
Deficiencies (4)
| Description |
|---|
| Care plans for 2 of 5 sampled residents were not certified by the residents' physician and lacked the physician's dated signature. |
| Failed to administer medications as ordered for 2 of 5 residents during medication pass, including errors with a pain control medication and a medication to prevent constipation. |
| Medication administration records were inaccurate for 1 of 5 residents, documenting administration of a medication that was not available. |
| Medication administration was not performed in accordance with infection control measures; a medication aide did not sanitize hands between preparation and administration of medications to multiple residents. |
Report Facts
Medication error rate: 6
Residents sampled for care plan certification: 5
Medication administration observations: 29
Residents with COVID outbreak: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for completing care plans and ensuring physician signatures; interviewed regarding care plan certification and medication administration oversight |
| Executive Director | Executive Director (ED) | Interviewed regarding facility oversight and awareness of care plan and medication issues |
| Medication Aide | Medication Aide (MA) | Observed administering medications with infection control violations and interviewed about medication administration practices |
| Administrator | Administrator | Interviewed regarding medication refill processes and infection control expectations |
Inspection Report
Follow-Up
Census: 51
Capacity: 76
Deficiencies: 7
Jan 27, 2022
Visit Reason
Follow-up survey conducted to assess correction of previous deficiencies related to healthcare, medication administration, infection control, and compliance with COVID-19 protocols.
Findings
The facility failed to notify primary care providers timely about missed medications and follow-up appointments for residents, failed to implement physician orders accurately, and failed to ensure proper infection control during medication administration. Additionally, the facility did not properly screen visitors and residents for COVID-19 symptoms and temperatures, failed to maintain social distancing in dining areas, and did not notify the local health department or residents' families about COVID-19 positive cases among staff and residents.
Deficiencies (7)
| Description |
|---|
| Failed to notify primary care providers of missed doses and follow-up appointments for residents #4 and #5. |
| Failed to ensure implementation of physician orders for compression stockings, weekly weights, and valproic acid level for residents #1 and #5. |
| Failed to administer medications as ordered to residents #1 and #4, including missed antidepressant and pain medication doses. |
| Failed to perform hand hygiene between medication administrations by a medication aide, risking cross-contamination. |
| Failed to implement COVID-19 infection prevention guidance including proper visitor and resident screening, social distancing in dining areas, and documentation of resident symptom screening. |
| Failed to report staff members testing positive for COVID-19 to the local health department. |
| Failed to inform residents and their representatives within 24 hours of confirmed COVID-19 cases among residents or staff. |
Report Facts
Facility licensed capacity: 76
Resident census: 16
Resident census: 35
COVID-19 positive staff count: 8
Medication doses missed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Named in findings related to medication ordering and follow-up appointment scheduling |
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in findings related to infection control training, medication oversight, and COVID-19 protocols |
| Administrator | Facility Administrator | Named in findings related to oversight of medication management, infection control, and COVID-19 reporting |
| Medication Aide | Medication Aide (MA) | Observed failing to perform hand hygiene during medication administration |
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 7, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 10/05/21 through 10/07/21 to assess compliance with health care regulations and resident care standards.
Findings
The facility failed to ensure appropriate health care referral and follow-up for residents with significant medical needs, failed to implement physician orders including weekly vital signs and daily weights with parameters, and failed to administer medications as ordered, including errors in medication administration and documentation.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure health care referral and follow-up for residents with vaginal bleeding and failure to schedule an echocardiogram as ordered. | Type A2 Violation |
| Failure to implement physician orders for weekly vital signs and daily weights with parameters and fluid restrictions. | Type B Violation |
| Failure to administer medications as ordered including errors with inhaler rinsing, blood thinner administration, and missed doses of medications. | — |
| Failure to maintain accurate medication administration records (eMAR), including documenting medications as administered while resident was hospitalized. | — |
Report Facts
Medication error rate: 5
Missed doses: 7
Weight gain: 5.1
Weight gain: 4.1
Weight gain: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Interviewed regarding missed orders, medication administration, and oversight responsibilities. | |
| Administrator | Interviewed regarding expectations for medication administration, order implementation, and oversight. | |
| Resident Care Coordinator | Mentioned as responsible for following up on orders and resident care coordination. | |
| Medication Aide | Observed administering medications and interviewed about medication administration practices and errors. | |
| Primary Care Provider | Interviewed regarding concerns about missed orders and medication administration. |
Inspection Report
Capacity: 76
Deficiencies: 9
Oct 3, 2017
Visit Reason
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.
Findings
Multiple deficiencies were identified including improper storage of oxygen bottles presenting hazards, failure to maintain fire safety systems and equipment in safe operating condition, blocked fire sprinkler heads, obstructed emergency egress pathways, electrical safety hazards including overloaded circuits and missing outlet cover plates, and failure to maintain required exhaust ventilation equipment in several areas.
Deficiencies (9)
| Description |
|---|
| Oxygen bottles were stored sitting upright on the floor and could be knocked over, presenting a hazard. |
| Holes or gaps at penetrations through fire resistant rated ceilings could allow fire and smoke to spread beyond the area of origin. |
| Doors between kitchen and living areas do not have latching hardware, failing to limit spread of smoke or fire. |
| Fire sprinkler heads were blocked by pillows, diapers, and cleaning materials; corrected during survey. |
| Emergency egress pathways were obstructed by unattended medication carts and wheelchairs; corrected during survey. |
| Power strips without overload protection were plugged into each other, creating a fire hazard. |
| Electrical outlet above microwave oven missing cover plate, posing shock hazard. |
| GFCI outlet did not trip when tested, posing shock hazard. |
| Exhaust ventilation equipment failed to operate in multiple locations including resident bathroom, laundry, storage closets, visitor bathroom, and maintenance room. |
Report Facts
Total licensed beds: 76
Special Care Unit beds: 24
Clear passage width: 48
Inspection Report
Capacity: 76
Deficiencies: 12
Nov 18, 2015
Visit Reason
The report documents a Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including non-operational mechanical ventilation in bathrooms, excessive particulate buildup in exhaust grilles, deteriorated exterior building components, damaged floor surfaces creating trip hazards, breaches in fire/smoke barrier construction compromising safety, plumbing fixtures not maintained safely, and unfinished ceiling sheet-rock at various locations.
Deficiencies (12)
| Description |
|---|
| Mechanical ventilation is not operational in several resident and spa bathrooms. |
| Excessive particulate buildup in exhaust grilles in all facility bathrooms. |
| Exterior porch bug screen torn and excessive stored materials present. |
| Sink faucet heavily rusted and leaking in Room 402. |
| Exterior wood trim and door frame rotten near Exit Hall door adjacent to Room 206; siding has large holes; double patio doors rotten on exterior finish faces. |
| Damaged and disrepair floor finishes creating trip hazards in multiple locations including employee locker room and laundry rooms. |
| Breaches of one-hour roof/ceiling assembly construction compromising fire/smoke containment. |
| Dropped sprinkler head escutcheons in multiple locations. |
| Kitchen ice machine drain line improperly installed with insufficient clearance. |
| Resident entry doors have 3/8" gaps at top of door jambs allowing smoke passage. |
| Toilets not secured to floor bases with leakage and slippery floors in guest bathrooms. |
| Ceiling sheet-rock unfinished at butt-joints in hallways and parlor areas. |
Report Facts
Licensed bed capacity: 76
Survey date: Nov 18, 2015
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 5, 2015
Visit Reason
The Adult Care Licensure Section and the Pitt County Department of Social Services conducted an annual and follow-up survey from November 3, 2015 to November 5, 2015.
Findings
The facility failed to assure proper medication administration for 3 of 11 residents observed during medication passes, resulting in a 13% medication error rate with 5 errors out of 36 opportunities. Errors included improper insulin administration technique, failure to administer medications with meals as ordered, and incorrect medication timing.
Deficiencies (1)
| Description |
|---|
| Failure to assure administration of medications, including insulin, acetaminophen, effexor, metformin, and flomax, in accordance with prescribing practitioner's orders and manufacturer's directions for 3 of 11 residents observed during medication pass. |
Report Facts
Medication error rate: 13
Medication errors: 5
Medication opportunities: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Observed administering medications improperly and interviewed regarding medication administration practices | |
| Health and Wellness Director | Interviewed regarding medication administration practices and training; acknowledged lack of knowledge about 'air shots' and initiated retraining | |
| Health and Wellness Coordinator | Interviewed about ongoing training and in-services for medication administration | |
| Pharmacy Provider Pharmacist | Provided expert opinion on proper insulin administration and medication timing |
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