Inspection Report
Annual Inspection
Capacity: 76
Deficiencies: 2
Sep 18, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from September 16, 2025 through September 18, 2025 to assess compliance with regulations.
Findings
The facility failed to ensure food items were protected from contamination due to unlabeled, undated, expired food and improper storage of raw meat. Additionally, the facility failed to administer medications according to provider orders for one resident, administering medication despite parameters to hold it based on heart rate.
Deficiencies (2)
| Description |
|---|
| Food items stored by the facility were not protected from contamination due to unlabeled, undated, expired food and inappropriate storage of raw meat. |
| Failed to administer medications according to provider orders for 1 of 5 sampled residents, including administering Toprol XL when resident's heart rate was below the ordered threshold. |
Report Facts
Licensed capacity: 76
Kitchen sanitation score: 98.5
Demerits deducted: 2
Times medication administered below heart rate parameter: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Admitted mistake in storing raw corned beef over cooked sweet potatoes and acknowledged staff had been busy and neglected proper food storage and labeling. |
| Health and Wellness Director | Health and Wellness Director | Conducted training for medication aides on following medication parameters and holding medications when required. |
| Health and Wellness Coordinator | Health and Wellness Coordinator | Placed reminders and visual aids for medication parameters and provided education to medication aides. |
| Executive Director | Executive Director | Acknowledged medication aides should follow PCP orders and that training was conducted on medication parameters. |
| Medication Aide | Medication Aide | Admitted to mistakenly administering medication when resident's heart rate was below the ordered threshold. |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 1
Sep 10, 2024
Visit Reason
A complaint investigation was conducted due to an allegation of a sprinkler leak causing damage at the facility.
Findings
The complaint was substantiated with findings of a leak in the main sprinkler line in the attic causing damage near the dining room. Deficiencies were noted requiring a plan of correction.
Complaint Details
The complaint alleging a sprinkler leak with damage was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the building's fire safety systems in a safe condition due to a leak in the main sprinkler line causing damage. |
Report Facts
Total licensed capacity: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Meyer | Conducted the Construction Section Biennial Complaint survey |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 9, 2023
Visit Reason
The Adult Care Licensure Section conducted a Follow Up Survey on 11/08/23 to 11/09/23 to verify correction of previous deficiencies related to Licensed Health Professional Support and medication orders.
Findings
The facility failed to ensure Licensed Health Professional Support (LHPS) evaluations were completed for 2 of 5 sampled residents (#3 and #4) and failed to maintain medication orders in the residents' records for 1 of 5 sampled residents (#4) related to controlled medication. Interviews revealed staff were unaware of certain LHPS tasks and medication reconciliation deficiencies.
Deficiencies (3)
| Description |
|---|
| Failed to ensure Licensed Health Professional Support review and evaluation was completed for 2 of 5 sampled residents related to suppository medication and oxygen orders. |
| Failed to ensure medication orders were maintained in the residents' records for 1 of 5 sampled residents related to orders for controlled medication. |
| Failed to provide pharmaceutical services that ensured accurate records of the receipt of medications were maintained in the facility for 1 of 5 sampled residents. |
Report Facts
Number of sampled residents with LHPS deficiencies: 2
Number of sampled residents with medication order deficiencies: 1
Dispensed tablets: 36
Dispense date: Apr 10, 2019
Discard date: Apr 9, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Registered Nurse | Responsible for completing LHPS reviews and medication reconciliation; interviewed regarding deficiencies |
| Health and Wellness Coordinator | Licensed Practical Nurse | Interviewed regarding awareness of LHPS and medication reconciliation tasks |
| Medication Aide | Interviewed regarding medication administration and documentation | |
| Administrator | Interviewed regarding responsibility and awareness of LHPS and medication reconciliation |
Inspection Report
Annual Inspection
Deficiencies: 5
Sep 8, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 09/06/23 through 09/08/23 to assess compliance with regulations for Brookdale Elizabeth City.
Findings
The facility failed to provide adequate supervision and post-fall evaluations for a resident with multiple falls, failed to ensure proper health care referral and follow-up for two residents, failed to complete quarterly licensed health professional support evaluations for three residents, failed to maintain accurate medication administration records for two residents, and failed to complete required disclosures and pre-admission screenings for two residents admitted to the Special Care Unit.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide supervision and post-fall evaluations with interventions for a resident who had 14 falls within 5 months resulting in injuries and ER visits. | Type A2 Violation |
| Failed to ensure health care referral and follow-up for residents including failure to notify provider of blood glucose levels less than 90 and failure to notify mental health provider of gait changes and falls. | — |
| Failed to ensure quarterly licensed health professional support evaluations were completed for residents with specific care tasks. | — |
| Failed to ensure medication administration records were accurate including missing parameters for notification of blood glucose readings and side effects for medications. | — |
| Failed to ensure disclosures and pre-admission screenings were completed upon admission for residents admitted to the Special Care Unit. | — |
Report Facts
Falls: 14
ER visits: 2
Lorazepam administrations: 34
FSBS checks: 2
Residents requiring LHPS evaluations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Personal Care Aide (PCA) | Mentioned in relation to supervision and care of Resident #5. |
| Not provided | Medication Aide (MA) | Mentioned in relation to medication administration and supervision of Resident #5 and Resident #4. |
| Not provided | Hospice Nurse | Provided care and medication adjustments for Resident #5. |
| Not provided | Health and Wellness Coordinator (HWC) | Responsible for care coordination and entering orders in eMAR. |
| Not provided | Executive Director (ED) | Interviewed regarding facility policies and deficiencies. |
| Not provided | Clinical Specialist | Conducted LHPS evaluations and assisted with compliance. |
| Not provided | Mental Health Provider | Prescribed Lorazepam and expected notification of side effects and falls. |
| Not provided | Primary Care Provider (PCP) | Expected notification of blood glucose levels and falls for residents. |
| Not provided | Licensed Practical Nurse (LPN) or Registered Nurse (RN) | Responsible for entering orders into eMAR and completing LHPS evaluations. |
| Not provided | Special Care Coordinator (SCC) | Responsible for pre-admission screening and disclosures. |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 3
Sep 10, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 09/08/21 to 09/10/21 to assess compliance with health care, medication administration, and related regulations.
Findings
The facility failed to ensure proper health care referral and follow-up for one resident related to dental and wound care appointments. Additionally, medications were not administered within the required time frames for five residents, and medication administration records were found inaccurate for two residents.
Deficiencies (3)
| Description |
|---|
| Failed to ensure health care referral and follow-up for 1 of 3 sampled residents related to scheduling dental and primary care follow-up appointments. |
| Failed to ensure medications were administered within one hour before or after the prescribed or scheduled times for 5 of 5 residents observed. |
| Failed to ensure medication administration records were accurate for 2 of 3 residents sampled related to pain medication and anxiety medication documentation. |
Report Facts
Residents in assisted living side: 14
Residents in special care unit: 8
Residents observed for medication administration: 5
Doses of Tramadol not documented as administered: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding medication administration timing and procedures | |
| Health and Wellness Director | Interviewed regarding follow-up care and medication administration record accuracy | |
| Executive Director/Administrator | Interviewed regarding expectations for follow-up care and medication administration policies |
Inspection Report
Follow-Up
Census: 76
Deficiencies: 8
Jan 10, 2019
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies related to building construction and physical plant compliance.
Findings
The survey found multiple deficiencies including failure to submit remodeling plans for approval, lack of required accessible bathrooms with roll-in showers for many residents, use of bathrooms for storage, unsafe and non-operational life safety and fire safety equipment, and inadequate exhaust ventilation in required areas.
Deficiencies (8)
| Description |
|---|
| Facility remodeled and did not submit plans to DHSR/Construction for review and approval. |
| Facility does not provide at least one bathroom opening off the corridor with a roll-in shower, accessible bathtub, lavatory, and toilet for 54 of the 76 residents. |
| Facility is using a bathroom for purposes other than those indicated in licensure rules (bathroom converted to maintenance office and storage). |
| Life safety equipment not maintained in safe and operating condition; exit doors are difficult to open or blocked. |
| Failure to maintain building's fire safety systems; holes or gaps at penetrations through fire resistant ceilings. |
| Non-rated access panels in fire rated ceilings not secure and leaving gaps. |
| Fire safety doors do not completely close and latch, risking smoke or fire spread. |
| Exhaust ventilation not maintained in required areas; exhaust fan in chemical storage not working. |
Report Facts
Residents without accessible bathroom: 54
Total residents present: 76
Inspection Report
Capacity: 76
Deficiencies: 16
Oct 10, 2018
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 (1997 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant and safety issues including lack of current sanitation and fire safety inspection reports, remodeling without plan submission, inadequate bathroom facilities, storage of items in bathrooms, corridor obstructions, poor housekeeping and maintenance, unsafe building equipment and fire safety systems, non-operating exhaust ventilation, and electrical and mechanical equipment issues.
Deficiencies (16)
| Description |
|---|
| Facility did not have current sanitation and fire safety inspection reports available for review. |
| Facility remodeled and did not submit plans to DHSR/Construction for review and approval. |
| Facility does not provide at least one bathroom opening off the corridor with a roll-in shower, accessible bathtub, lavatory, and toilet for 54 of the 76 residents. |
| Facility is using a bathroom for purposes other than those indicated in licensure rules (converted to maintenance office). |
| Corridors were not free of equipment and obstructions, restricting minimum clearance for egress. |
| Furnishings were not kept in good repair (e.g., closet bifold door off track, loose bathroom door hinge). |
| Ceilings were not kept clean (mildew, water stains, mold patches). |
| Facility was not maintained free of all obstructions and hazards (e.g., vinyl floor threshold indentation causing trip hazard). |
| Life safety equipment and building equipment were not maintained in safe and operating condition (e.g., rotted doors, fire safety system issues, holes/gaps in fire rated ceilings). |
| Fire safety doors did not close and latch properly, compromising smoke and fire containment. |
| Mechanical equipment not maintained in safe and operating manner (e.g., disconnected dryer duct). |
| Items stored within 18 inches of sprinkler heads, potentially hindering fire suppression. |
| Electrical equipment not maintained in safe and operating condition (e.g., broken cable box cover, loose electrical box). |
| Electrical emergency/safety lighting equipment not maintained in safe operating condition (emergency light did not illuminate on battery test). |
| Fire safety equipment such as rated corridor doors lacked closers to ensure automatic closing. |
| Exhaust ventilation was not maintained in required areas (multiple fans not working, chemical odor present). |
Report Facts
Total licensed capacity: 76
Residents without accessible bathroom: 54
Number of med carts obstructing corridor: 3
Number of sprinkler head clearance violations: 2
Inspection Report
Annual Inspection
Deficiencies: 6
Feb 22, 2017
Visit Reason
The Adult Care Licensure Section and the Pasquotank County Department of Social Services conducted an annual and follow-up survey and complaint investigation on February 22, 23, 24, 2017, with an exit conference via telephone on February 28, 2017.
Findings
The facility failed to assure the front exit door was equipped with a sounding device that activated when the door was opened, resulting in residents with dementia and disorientation exiting the facility unsupervised, including Resident #1 who was found deceased. The facility also failed to provide adequate supervision for residents with dementia and disorientation, resulting in elopements and safety risks. Additionally, the facility failed to obtain physician signatures on care plans within 15 days of assessment for all sampled residents, failed to obtain physical therapy evaluation for a resident's walker use, and failed to administer medications as ordered, including errors with iron supplement dosing, nasal spray omission, laxative omission, incorrect cholesterol medication timing, and antipsychotic medication transcription errors.
Complaint Details
The visit included a complaint investigation triggered by the elopement and death of Resident #1 who left the facility unsupervised and was found deceased off the property. The investigation revealed multiple failures in supervision and safety measures.
Severity Breakdown
Type A1 Violation: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| The facility failed to assure the front exit door was equipped with a sounding device that activated when the door was opened, resulting in residents with dementia and disorientation exiting the facility unsupervised, including Resident #1 who was found deceased. | Type A1 Violation |
| The facility failed to provide supervision for residents with diagnoses of dementia and disorientation, resulting in residents leaving the facility unsupervised, including one resident death. | Type A1 Violation |
| The facility failed to assure the residents' physicians certified their care by signing and dating care plans within 15 days of assessment for 6 sampled residents. | — |
| The facility failed to obtain physical therapy / occupational therapy evaluation and treatment for the use of a rollator walker and failed to notify two physicians of the resident's refusal to use the walker for Resident #2. | — |
| The facility failed to assure daily weights were obtained and documented for Resident #3 as ordered by the physician. | — |
| The facility failed to administer medications as ordered for multiple residents, including errors with liquid iron supplement dosing, omission of nasal spray and laxative, incorrect timing of cholesterol medication, and transcription errors with antipsychotic and supplement medications. | — |
Report Facts
Medication errors observed: 6
Missing documented weights: 9
Medication doses missed: 3
Medication doses missed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Named in multiple interviews related to supervision failures, medication errors, and care plan deficiencies. | |
| Business Office Coordinator | Mentioned in relation to front desk supervision and resident observations. | |
| Administrator | Named in interviews regarding facility policies, supervision, and incident investigations. | |
| District Director of Clinical Services | Named in interviews regarding complaint investigation and supervision policies. | |
| Medication Aide | Mentioned in relation to medication administration observations and errors. | |
| Personal Care Aide | Mentioned in relation to resident supervision and observations. |
Inspection Report
Capacity: 76
Deficiencies: 10
Dec 6, 2016
Visit Reason
The facility underwent a Construction Section Biennial Survey to assess conformance with applicable licensing rules and building codes, including the 2005 Rules for Licensing of Adult Care Homes and the 1996 North Carolina Building Code.
Findings
Multiple deficiencies were cited related to physical plant safety and maintenance, including failure to maintain current sanitation and fire safety inspection reports, housekeeping issues, plumbing hazards, improperly maintained fire extinguishers, missing or damaged fire safety and evacuation equipment, malfunctioning emergency lighting, fire sprinkler system deficiencies, fire door and smoke barrier issues, and non-functioning exhaust ventilation systems.
Deficiencies (10)
| Description |
|---|
| Facility failed to maintain current annual sanitation and fire safety inspection reports. |
| Walls, ceilings, floors, and furniture were not kept clean and in good repair; ceiling tiles in employee break room were stained. |
| Building plumbing equipment was not maintained safely; loose commode connection and lack of vacuum breaker on spa tub shower wand. |
| Fire extinguishers and associated equipment were not properly maintained; last maintenance check was 15 months prior. |
| Fire evacuation plans were not properly posted or maintained; evacuation maps in Special Care Unit were missing after painting. |
| Building sprinkler system was not maintained in safe and operating condition; painted sprinkler head, missing escutcheon plates, and openings in fire-resistance-rated ceilings. |
| Emergency equipment including emergency lights and exit signs were not maintained or functioning properly. |
| Fire rated doors of hazardous areas were not maintained; doors propped open, missing fire-resistance labels, and self-closing doors not latching. |
| Smoke barrier doors did not close completely or latch properly, allowing smoke passage. |
| Exhaust ventilation systems in laundry and restroom areas were not functioning, causing odor buildup. |
Report Facts
Total licensed capacity: 76
Time since last fire extinguisher maintenance: 15
Date of last fire alarm system inspection: Oct 13, 2015
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