Inspection Reports for Brookdale Durham

The Adult Care Licensure Section conducted an Annual and Follow-up survey on 09/16/25 to 09/18/25 to assess compliance with state regulations for assisted living and special care units.

The facility was cited for multiple deficiencies including failure to maintain hot water temperatures within safe limits, malfunctioning call bell system with delayed staff response, incomplete tuberculosis testing and health care personnel registry checks for staff, incomplete resident assessments and care plans, medication administration errors, improper infection control during medication administration, unsecured medications in resident rooms, and failure to follow up on pharmacy medication review recommendations.

Biennial Construction Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable building codes and licensing rules in effect at the time of initial licensure.

Multiple deficiencies were cited including failure to comply with building and fire safety codes, inadequate physical plant conditions, housekeeping hazards, non-operational equipment, and improper maintenance of fire safety and mechanical systems.

The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to medication orders.

The facility failed to clarify a medication order for one sampled resident related to Levothyroxine administration. The medication label on the punch card did not match the electronic medication administration record (eMAR), leading to inconsistent medication dispensing and documentation. Multiple opportunities to clarify the order were missed, and the pharmacy was not alerted to changes in the eMAR system.

The Adult Care Licensure Section conducted an annual and follow up survey on May 28-30, 2024.

The facility failed to assure 8 ounces of milk or equivalent dairy products were served three times daily to residents in Assisted Living and Special Care Unit. Additionally, the facility failed to clarify a medication order for one resident and failed to ensure medication administration compliance and proper self-administration oversight for two residents.

The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies.

The facility did not have records of fire rehearsals conducted quarterly on each shift as required, and staff was unable to retrieve the fire drill logs.

This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies related to physical plant and safety compliance.

The facility was found to have multiple deficiencies including lack of proper signage on delayed egress doors, missing current sanitation and fire safety inspection reports, unclean and unrepaired walls, ceilings, floors, and furniture, hazards blocking electrical panels, failure to conduct required fire safety rehearsals on each shift quarterly, malfunctioning emergency lighting and exit signs, gaps in fire-resistant rated ceilings due to dropped sprinkler heads and holes, missing smoke detectors, doors not closing properly, and non-functioning exhaust ventilation fans in specified areas.

The Adult Care Licensure Section conducted a follow-up survey from 02/28/23 to 03/02/23 with an exit conference via telephone on 03/02/23.

The facility failed to provide personal care according to residents' care plans related to showering for 2 of 6 sampled residents, failed to ensure diets were served as ordered for 1 of 5 sampled residents with thickened liquid orders, failed to ensure medications were administered as ordered for 2 of 5 sampled residents including failure to check blood pressure before administering medication and failure to reorder medication timely, failed to accurately document medication administration for 1 of 5 residents, and failed to ensure medications were stored securely for 1 of 1 sampled residents.

The Adult Care Licensure Section conducted a follow-up survey from November 29, 2022 to December 2, 2022 to verify correction of previous deficiencies and assess compliance with regulations.

The facility was found deficient in multiple areas including staff qualifications, tuberculosis testing, personal care and supervision, health care notifications, medication administration, nutrition and food service, medication storage, and medication aide training and competency. Several residents did not receive care or medications as ordered, and staff training and documentation were incomplete.

Annual, follow-up and complaint investigation conducted to assess compliance with regulations including housekeeping, staff qualifications, staffing levels, resident care, and medication administration.

The facility had multiple deficiencies including unsecured oxygen tanks, failure to verify staff qualifications, inadequate staffing levels on third shifts in assisted living and special care units, incomplete tuberculosis testing, failure to provide personal care as per care plans, incomplete health care referrals and follow-ups, medication administration errors, inaccurate medication records, failure to follow infection control protocols, inadequate medication storage for self-administering residents, and failure to report and respond to COVID-19 cases per guidelines.

The visit was a Biennial Follow Up Construction Survey conducted to assess compliance with physical plant and safety regulations.

Multiple deficiencies were identified including corridors obstructed by benches, missing door pushbar endcaps exposing sharp metal edges, failure to maintain fire safety systems and equipment in safe operating condition, and non-functioning exhaust fans in various facility areas.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on November 6-8 and 12, 2019.

The facility failed to assure electronic medication administration records (eMAR) were accurate and complete for 2 of 8 sampled residents, including inaccurate documentation of narcotic and anti-anxiety medications. Additionally, the facility failed to ensure medications were administered in accordance with infection control measures to prevent disease transmission and cross-contamination.

The visit included a complaint investigation as indicated by the follow-up survey and complaint investigation conducted on November 6-8 and 12, 2019.

The report documents a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building and physical plant conditions.

The survey found multiple deficiencies remaining uncorrected, including damaged exit doors, ceilings and walls in disrepair, missing or damaged fire safety equipment, electrical hazards, plumbing issues, and non-functioning exhaust ventilation in several areas.

The Adult Care Licensure Section conducted an annual survey from 07/09/19 to 07/11/19 to assess compliance with state regulations for Brookdale Durham.

The facility was found to have multiple deficiencies including failure to maintain odor-free environment, inadequate hot water temperatures in resident rooms, incomplete medical examinations for residents, failure to implement physician orders such as weekly weights, unsanitary kitchen and food storage conditions, insufficient dining space causing crowding and difficulty for residents, medication order clarifications not obtained, improper medication administration, failure to refrigerate medications properly, failure to notify social services of reportable incidents, and failure to treat residents with dignity and respect during meals.

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 North Carolina Building Code and related regulations, as part of a Biennial Construction Survey.

The survey identified multiple deficiencies related to physical plant and safety code compliance including issues with delayed egress door labeling and operation, lack of smoke detection in certain areas, missing fire safety inspection reports, obstructions in corridors, damaged exit doors, poor housekeeping and maintenance with mildew and water damage, improper storage of oxygen bottles, electrical hazards, fire safety equipment not maintained or operating properly, missing or damaged sprinkler escutcheon plates, doors not latching or closing properly, use of portable electric heaters, and non-functioning exhaust ventilation in multiple areas.

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 North Carolina Building Code and licensing rules, as part of a Biennial Construction Survey.

The survey identified multiple deficiencies including failure to comply with delayed egress exit door requirements, housekeeping and maintenance issues such as leaks, mold, tripping hazards, and chronic odors, storage hazards obstructing emergency egress and electrical panels, improperly stored oxygen bottles, fire safety equipment and fire resistant ceiling penetrations not maintained in safe operating condition, doors propped open impairing fire safety, emergency lighting failures, electrical equipment safety issues, and failure to provide required exhaust ventilation in multiple areas.

The visit was a Follow-Up Construction Survey to assess whether previously cited deficiencies had been satisfactorily corrected.

The facility was found to have unresolved deficiencies including improper storage of oxygen cylinders, compromised fire-resistance rating of building components due to leaks and unprotected ceiling penetrations, doors that did not close or latch properly, and electrical system issues such as a falling light fixture escutcheon.

This is a follow-up survey conducted to verify correction of previously cited deficiencies at Brookdale Durham.

Most previously cited deficiencies have been corrected; however, some deficiencies remain uncorrected, including issues with corridor obstructions, housekeeping, hazard-free maintenance, building safety, electrical system maintenance, and exhaust ventilation.

This is a follow-up construction survey conducted to verify correction of previously cited deficiencies related to facility ventilation.

Most of the previously cited deficiencies have been corrected; however, some ventilation deficiencies remain uncorrected, including lack of ventilation in the Maintenance Director's Office/Work Room and non-functioning spot exhaust fans in Bedroom 104 Bathroom, Right Front Elevator Room, and 2nd Floor Nursing Office Bathroom.

Biennial Construction Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for Licensing of Adult Care Homes and the 1996 North Carolina State Building Code, Section 409 - Institutional.

Multiple physical plant deficiencies were identified including unsecured hazardous substance storage, obstructed corridors, HVAC and ventilation issues, fire safety equipment and door malfunctions, electrical hazards, improper storage of oxygen cylinders, inadequate lighting, and insufficient exhaust ventilation.