Inspection Reports for Brookdale East Broad

NC, 28625

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Inspection Report Follow-Up Deficiencies: 0 Apr 29, 2025
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Follow Up Construction Survey conducted to verify correction of previously cited deficiencies from the Biennial Construction Survey.
Findings
All previously cited deficiencies from the Biennial Construction Survey were noted as corrected based on the acceptable Plan of Correction received on December 3, 2024. No further action is required.
Inspection Report Capacity: 58 Deficiencies: 1 Aug 21, 2024
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The document is a Construction Section Biennial Survey conducted to assess compliance with building and ventilation standards for an adult care home facility.
Findings
The facility was found to have deficiencies related to exhaust ventilation, specifically that exhaust fans in the employee restroom and housekeeping closet were not operational, potentially causing odors and mildew.
Deficiencies (1)
Description
Exhaust fans in the Service Hall Employee Restroom and Hall #2 Housekeeping Closet were not working.
Report Facts
Total licensed beds: 58
Inspection Report Annual Inspection Deficiencies: 3 Jun 15, 2022
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The Adult Care Licensure Section and the Iredell County DSS conducted an annual and follow-up survey from 06/14/22 to 06/15/22 to assess compliance with health care regulations.
Findings
The facility failed to ensure proper referral and follow-up for routine and acute health care needs, including failure to administer prescribed medications to Resident #1, failure to document vital signs and implement orders timely for Resident #2, and failure to properly track and start allergy medications for Resident #3. Deficiencies were related to medication administration, order processing, and documentation.
Deficiencies (3)
Description
Failed to ensure referral and follow-up to meet routine and acute health care needs for Resident #1 related to not receiving prescribed medications azithromycin and benzonatate.
Failed to ensure documentation and implementation of physician orders for vital signs, temperature, and oxygen saturation every shift for Resident #2.
Failed to ensure timely implementation and tracking of allergy medications Claritin and Flonase for Resident #3.
Report Facts
Number of sampled residents with deficiencies: 3 Survey dates: Survey conducted from 2022-06-14 to 2022-06-15.
Employees Mentioned
NameTitleContext
Resident Care CoordinatorResident Care Coordinator (RCC)Named in findings related to failure to follow up on medication orders and documentation.
Health and Wellness DirectorHealth and Wellness Director (HWD)Responsible for monitoring fax machine, processing orders, and auditing charts; named in deficiencies.
AdministratorAdministratorInterviewed regarding responsibilities and expectations for order processing and compliance.
Inspection Report Annual Inspection Capacity: 58 Deficiencies: 11 Oct 2, 2019
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The inspection was a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, fire safety, sanitation, and building codes applicable to the facility.
Findings
Multiple deficiencies were cited including failure to provide all required exits or exit access doors, unresolved deficiencies from prior annual fire sprinkler inspections, plumbing system devices not in good repair, unsecured portable medical oxygen cylinders, lack of ground fault interrupters on electrical outlets in wet locations, unsafe and non-operating electrical and fire safety equipment, obstructed fire sprinkler heads, corridor doors not maintained properly, and failure to maintain required exhaust ventilation systems.
Deficiencies (11)
Description
Dining room back exit door lock installed backwards, preventing egress without key.
Unresolved deficiencies cited on current annual Fire Sprinkler System Inspection.
Loose connection of commode to floor and loose commode seat in spa.
Portable medical oxygen cylinders not physically secured in racks or chained in multiple locations.
Electrical outlets in wet locations near sinks not equipped with ground fault interrupters.
Electrical panel clearance blocked by stored boxes; GFCI receptacle in bedroom 2 bathroom does not trip when tested.
Firestopping missing on cables and holes penetrating fire-resistance-rated ceiling assemblies in multiple locations.
Fire sprinkler heads obstructed by stored items violating minimum clearance requirements.
Smoke tight corridor doors not maintained properly: doors hitting frames, missing latch bolts, or not latching.
Corridor doors blocked open by unapproved devices such as trashcan holding door open.
Facility failed to maintain required exhaust ventilation system; fan not operating and price obtained for replacement fans.
Report Facts
Total licensed beds: 58 Date of last Fire Sprinkler System Inspection: Jan 22, 2019 Number of portable oxygen cylinders unsecured in Bedroom 14: 8 Number of portable oxygen cylinders unsecured in Nurse Station: 3 Number of portable oxygen cylinders unsecured in Activity area: 3 Minimum clearance required below fire sprinkler deflector: 18 Number of replacement fans price obtained for: 32
Inspection Report Annual Inspection Deficiencies: 2 Jul 18, 2018
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The Adult Care Licensure Section conducted an annual and follow-up survey on 07/17/18-07/18/18 to assess compliance with regulations related to housekeeping, furnishings, and medication administration.
Findings
The facility was found to have deficiencies in housekeeping and furnishings, specifically failure to keep ceilings and floor coverings clean and in good repair in multiple resident rooms. Additionally, medication administration errors were identified involving failure to administer prescribed medications correctly for two residents, including pain medication and eye drops.
Deficiencies (2)
Description
Facility failed to keep ceilings (resident rooms #20 and #26) and floor coverings (resident rooms #1, #3, #4, #5, #7, #12, #21, and #30) clean and in good repair.
Facility failed to administer medications as prescribed by a licensed prescribing practitioner for two residents, including errors related to pain medication (Resident #1) and eye drops (Resident #5).
Report Facts
Professional carpet cleaning dates: 10 Medication administration errors: 2 Missed doses: 6 Medication administrations: 16
Employees Mentioned
NameTitleContext
Maintenance DirectorResponsible for shampooing carpet on an as-needed basis and repairing water leaks in ceilings.
AdministratorResponsible for walk-throughs to determine carpet cleaning needs and overseeing maintenance and medication administration processes.
Health and Wellness DirectorHWDResponsible for reviewing resident orders and assuring tracking forms were completed.
Medication AideMAResponsible for faxing new medication orders to the pharmacy and completing tracking forms; multiple MAs interviewed regarding medication order errors.
Resident #1's PhysicianOrdered to hold Norco and start tramadol for Resident #1.
Resident #5's Primary Care ProviderPCPCommented on potential risks of missed doses of artificial tears for Resident #5.
Inspection Report Follow-Up Deficiencies: 1 Nov 1, 2017
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Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to building safety and fire rated construction.
Findings
The required one-hour fire rated walls and/or ceilings were found compromised in several locations, including a hole in the ceiling of the water heater room, indicating that the deficiency was not corrected and further action is required.
Deficiencies (1)
Description
Hole in the ceiling of the water heater room compromising one-hour fire rated construction.
Inspection Report Follow-Up Deficiencies: 5 Sep 21, 2017
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This is a biennial follow-up construction survey to verify correction of previously identified deficiencies.
Findings
Several deficiencies were found related to housekeeping hazards, incomplete fire safety rehearsals documentation, and building equipment maintenance issues including corridor doors not closing properly, compromised fire-rated walls and ceilings, and exposed energized wiring due to missing switch plates.
Deficiencies (5)
Description
Floor squeegee left in exit path causing trip hazard; later replaced by two chairs obstructing exit path.
Fire safety rehearsals records lacked adequate description of activities performed during the fire plan rehearsals.
Many corridor doors prevented from closing and latching properly, risking fire and smoke spread.
Required one-hour fire rated walls and ceilings compromised with holes and penetrations not sealed properly.
Switch plates removed for painting had not been re-installed, exposing energized parts and wires.
Report Facts
Date of survey completion: Sep 21, 2017
Inspection Report Capacity: 58 Deficiencies: 8 Aug 2, 2017
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This document is a Statement of Deficiencies and Plan of Correction following a Construction Section Biennial Survey conducted on 08/02/2017 at Brookdale East Broad, a licensed adult care home.
Findings
The survey identified multiple deficiencies related to physical plant and safety standards including lack of hand grips in the spa tub, corridor obstructions creating trip hazards, housekeeping issues such as lack of vacuum breakers and fungal contamination risks, inadequate fire safety rehearsals documentation, and compromised fire safety doors and walls with multiple penetrations and propped open doors.
Deficiencies (8)
Description
No hand grip provided at the tub in the spa.
Corridor was not maintained free of obstructions including chairs, boxes, and an electrical cord creating trip hazards.
Shower wand hose in bedroom 20 was long enough to reach the basin without a vacuum breaker, risking water contamination.
Fungus growth from ice machine drain line contacting floor drain, risking ice contamination.
Floor squeegee left in exit path near kitchen creating a significant trip hazard.
Fire safety rehearsal records lacked sufficient description of what the rehearsals involved.
Many corridor doors failed to close and latch properly, including smoke barrier doors and fire rated doors, some propped open or held open with hooks.
Required one-hour fire rated walls and ceilings were compromised with holes and penetrations in multiple mechanical and storage rooms.
Report Facts
Total licensed beds: 58 Chairs stored in corridor: 4 Boxes stored in corridor: 3 Gap between Dutch door halves: 0.5
Inspection Report Annual Inspection Deficiencies: 2 Mar 2, 2016
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The Adult Care Licensure Section conducted an annual survey of the facility on March 2-3, 2016 to assess compliance with adult care home regulations.
Findings
The facility failed to maintain clean floor coverings in hallways, activity room, and 13 of 29 resident rooms, with numerous stains and spots on carpets. Additionally, the facility failed to notify the County Department of Social Services of accidents requiring emergency medical evaluation for 3 of 4 residents with injuries after incidents.
Deficiencies (2)
Description
Facility failed to keep floor coverings clean in hallways, activity room, and 13 of 29 resident rooms with numerous dark splotches, stains, smears, and spots.
Facility failed to notify the County Department of Social Services of accidents requiring emergency medical evaluation for 3 of 4 residents with injuries after incidents.
Report Facts
Resident rooms with unclean floor coverings: 13 Residents with unreported accidents: 3
Employees Mentioned
NameTitleContext
Associate Executive DirectorInterviewed regarding carpet cleaning and incident reporting.
HousekeeperOnly housekeeper in facility; responsible for vacuuming and shampooing carpets.
Health and Wellness DirectorInterviewed regarding incident reporting to DSS.
Inspection Report Census: 58 Deficiencies: 4 Sep 30, 2015
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This is a Biennial Construction Survey conducted to assess compliance with the 1987 Minimum Standards and Regulations for Homes for the Aged and Disabled, the 1978 North Carolina State Building Code, and the 2005 Rules for Adult Care Homes of Seven or More Beds.
Findings
The facility failed to maintain plumbing systems in working condition, maintain fire resistance of building components, ensure stoves are used only under staff supervision, and maintain mechanical exhaust systems in working condition.
Deficiencies (4)
Description
Water leak in the Housekeeping/Dietary Supply Closet spreading into the hallway, soaking the carpet.
One-hour rated ceilings not sealed due to a large hole in the Maintenance Shop and unprotected penetrations around piping above water heaters.
Stove in Activity/Therapy Room not properly locked and accessible to unsupervised persons.
Exhaust fan in bathroom of Room 1 not exhausting air.
Report Facts
Residents licensed: 58 Hole size: 12 Hole size: 18

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