Inspection Report
Annual Inspection
Deficiencies: 2
Jan 29, 2025
Visit Reason
The Adult Care Licensure section conducted an annual survey on 01/28/25-01/29/25 to assess compliance with regulations related to nutrition and food service, specifically therapeutic diets in adult care homes.
Findings
The facility failed to maintain an accurate therapeutic diet list for residents with physician-ordered diets and failed to serve therapeutic diets as ordered for several residents, including failure to serve ground meat diets as prescribed, which posed a risk to resident safety.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain an accurate therapeutic diet list for guidance of food service staff for 2 of 4 sampled residents with physician-ordered therapeutic diets. | — |
| Failed to serve therapeutic diets as ordered for 3 of 3 sampled residents with orders for a regular diet with ground meat, including serving unground meat to residents requiring ground meat diets. | Type B Violation |
Report Facts
Residents with inaccurate therapeutic diet list: 2
Residents served incorrect therapeutic diet: 3
Date of survey: Jan 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Responsible for updating the therapeutic diet list and instructing kitchen staff. | |
| Health and Wellness Director | Responsible for copying new diet orders and giving them to the Dietary Manager. | |
| Administrator | Oversaw dietary compliance and expected proper diet order implementation. | |
| SCU Activities Director | Observed and reported issues with therapeutic diet implementation. | |
| Cook | Prepared meals and failed to grind meat as ordered. | |
| Personal Care Aide | Provided observations related to residents' meals and diet compliance. |
Inspection Report
Follow-Up
Deficiencies: 2
Aug 24, 2023
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies related to physical plant compliance.
Findings
The facility was found not in compliance with code requirements for automatic smoke detection in rooms open to corridors and housekeeping standards, including walls, ceilings, and floor coverings not being kept clean and in good repair, with specific issues noted in the employee lounge/copy room and kitchen area.
Deficiencies (2)
| Description |
|---|
| Rooms open to the corridor are required to be protected by automatic smoke detection; the employee lounge/copy room corridor door was removed leaving the room open and the smoke detector is not connected to the fire alarm system. |
| Walls, ceilings, and floor coverings were not kept clean and in good repair; specifically, kitchen paint is bubbling around the supply vent and there is a crack in the patching material due to humidity. |
Inspection Report
Annual Inspection
Deficiencies: 3
May 4, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Forest City from 05/02/23 through 05/04/23 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure proper referral and follow-up for acute health care needs related to missed and incorrect doses of warfarin and failure to complete ordered PT/INR labs for Resident #3. Additionally, the facility failed to administer medications as prescribed for Residents #1 and #3, including incorrect and missed doses of anticoagulant and blood pressure medications. The electronic medication administration records (eMAR) were also found to be inaccurate for Resident #1.
Severity Breakdown
Type B Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure referral and follow-up to meet acute health care needs related to missed and incorrect doses of warfarin and failure to complete PT/INR labs as ordered for Resident #3. | Type B Violation |
| Failure to administer medications as prescribed for Residents #1 and #3, including incorrect and missed doses of anticoagulant and blood pressure medications. | Type B Violation |
| Failure to ensure electronic medication administration records (eMARs) were complete and accurate for Resident #1 related to a medication used to treat high blood pressure. | Type B Violation |
Report Facts
Missed warfarin doses: 16
Medication cart audits: 4
Remaining warfarin tablets: 6
Remaining warfarin tablets: 2
Remaining warfarin tablets: 8
Remaining warfarin tablets: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Notified of missed warfarin doses on 04/14/23 and notified Nurse Practitioner on 04/17/23; responsible for continuing warfarin orders on 04/15/23. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for processing medication orders and communicating with Nurse Practitioner; aware of warfarin order stoppage and missed doses. |
| Nurse Practitioner | Nurse Practitioner | Ordered warfarin and PT/INR labs; notified late about missed doses; provided clinical context on risks for Resident #3. |
| Medication Aide | Medication Aide | Responsible for administering medications and auditing medication carts; failed to identify missing warfarin order and administered incorrect medication to Resident #1. |
| Administrator | Administrator | Oversaw communication and audit processes; acknowledged failures in medication order tracking and audits. |
| Pharmacy Representative | Contracted Pharmacy Representative | Provided information on medication orders, dispensing, and refill responsibilities. |
| Primary Care Provider | Primary Care Provider | Discontinued Resident #1's amlodipine/benazepril and ordered benazepril/hydrochlorothiazide; explained clinical rationale. |
Inspection Report
Annual Inspection
Deficiencies: 5
Feb 11, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 02/09/22 to 02/11/22 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure proper notification and follow-up for residents' health care needs, including bloodwork and eye appointments. Medication administration errors were found for 4 of 6 sampled residents, including failure to administer insulin as ordered, missed medications due to pharmacy delays, and late administration of Parkinson's medication. Additionally, medication records were inaccurate and staff training and competency documentation were incomplete.
Severity Breakdown
Type B Violation: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure primary care provider was notified for refusal of bloodwork and missed eye appointment for Resident #3. | — |
| Failed to ensure physician's orders were implemented for Resident #4 related to urinalysis. | — |
| Failed to administer medications as ordered for 4 of 6 sampled residents (#1, #2, #3, #6) including insulin, anxiety, depression, pain, and Parkinson's medications. | Type B Violation |
| Failed to ensure electronic medication administration records (eMAR) were accurate for Resident #7 related to fingerstick blood sugar documentation. | — |
| Failed to ensure medication aides completed required training and competency evaluation prior to administering medications. | Type B Violation |
Report Facts
Missed insulin doses: 38
Thiothixene doses not administered: 6
Weight gain: 4
Weight gain: 7.1
Late medication administrations: 5
Late medication administrations: 5
Late medication administrations: 5
Medication administration discrepancies: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Documented administering insulin inconsistently and lacked documentation of completing 10-hour and 15-hour medication administration training. |
| Staff B | Medication Aide | Completed 15-hour training but lacked documentation of passing medication aide exam prior to administering medications. |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 12, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Forest City on November 12 and 13, 2019 to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to provide required diabetic care training to a Medication Aide prior to insulin administration, improper food storage and labeling in the kitchen, and failure to prepare weekly menus with specified serving quantities in accordance with Adult Care Licensure requirements.
Deficiencies (3)
| Description |
|---|
| Failure to ensure 1 of 5 sampled Medication Aides received training on the care of diabetic residents prior to insulin administration. |
| Food stored in the produce cooler and freezer was not protected from contamination due to unlabeled and undated food and food stored on the floor in boxes. |
| Failure to prepare weekly menus with serving quantities specified and in accordance with daily food requirements. |
Report Facts
Environmental Health Sanitation Score: 99
Dates insulin administered by untrained Medication Aide: 11/04/19 to 11/07/19 and 11/09/19 to 11/12/19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to receive diabetic training prior to administering insulin |
| Corporate Nurse | Responsible for diabetic training; did not complete Staff A's training | |
| Business Office Manager | Responsible for auditing personnel records and reporting missing or expired training | |
| Health and Wellness Director | Responsible for scheduling diabetic training; accepted responsibility for failure to schedule Staff A's training | |
| Dietary Manager | Responsible for food labeling, storage, and menu preparation; acknowledged issues with food storage and menu planning | |
| Administrator in Training | Unaware of food safety and menu planning deficiencies; responsible for verifying dietary compliance | |
| District Director of Operations | Unaware of food safety and menu planning deficiencies; responsible for oversight of dietary compliance |
Inspection Report
Capacity: 76
Deficiencies: 13
Sep 18, 2019
Visit Reason
The facility was surveyed for conformance with applicable licensing and building code requirements as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited including failure to meet building code requirements for delayed egress door signage, inadequate smoke detection in dining area, lack of current fire sprinkler inspection, corridor obstructions, poor housekeeping and maintenance issues, fire extinguisher maintenance lapses, incomplete fire safety rehearsals, fire safety and electrical system deficiencies, and failure to maintain required exhaust ventilation systems.
Deficiencies (13)
| Description |
|---|
| Delayed egress locked doors missing required visible signage. |
| MCU Dining area open to corridor without adequate smoke detection. |
| Facility failed to maintain current annual fire sprinkler system inspection report. |
| Corridors obstructed by equipment and furniture, impeding egress. |
| Building mechanical systems not kept clean and in good repair; wet leak in ceiling. |
| Portable medical oxygen cylinders not secured in bedrooms. |
| Fire extinguishers not properly maintained; missing monthly inspection documentation. |
| Fire safety rehearsals not performed regularly on all shifts and not fully documented. |
| Building fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition, including unsealed penetrations and door issues. |
| Fire sprinkler heads obstructed and missing escutcheon plates, compromising fire containment. |
| Corridor doors blocked open by unapproved devices, preventing proper closure. |
| Electrical system deficiencies including unsecured light fixture and improper junction box cover. |
| Exhaust ventilation system failed to operate in required rooms. |
Report Facts
Total licensed beds: 76
Fire sprinkler system last inspection date: Jan 22, 2018
Fire extinguisher maintenance last annual date: Jan 1, 2019
Inspection Report
Follow-Up
Deficiencies: 2
Oct 18, 2017
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
The facility failed to maintain building equipment in a safe and operating condition due to malfunctioning exit signs, including an unilluminated exit sign in the therapy room and a non-working emergency light/exit sign near the maintenance office.
Deficiencies (2)
| Description |
|---|
| Exit sign in the therapy room was not illuminated. |
| Combination emergency light/exit sign near the maintenance office did not work on battery when tested. |
Inspection Report
Capacity: 76
Deficiencies: 8
Aug 23, 2017
Visit Reason
The facility was surveyed for conformance with applicable licensing rules and building codes as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified including failure to comply with building code signage requirements for delayed egress doors, unsafe storage of portable medical oxygen cylinders, improper storage near fire sprinkler heads, inadequate documentation of fire safety rehearsals, malfunctioning exit signs and emergency lights, corridor doors not closing or latching properly to resist fire and smoke, and compromised one-hour fire rated walls and ceilings with unsealed holes and lint buildup.
Deficiencies (8)
| Description |
|---|
| Egress exit doors lacked required signage adjacent to release devices as per Section 1012.6.2 of the 1996 NC State Building Code. |
| Improper handling and storage of portable medical oxygen cylinders, including 11 cylinders stored in unapproved containers and one stored without container. |
| Storage stacked too close to fire sprinkler head, negating sprinkler effectiveness; linens stacked to ceiling in laundry closet. |
| Fire safety rehearsal records lacked adequate description of what the rehearsals involved. |
| Exit signs and emergency lights not functioning properly, including unilluminated exit sign in therapy room and emergency light near maintenance office not working on battery. |
| Battery powered emergency light near room 306 failed to work when tested, risking resident and staff safety. |
| Corridor doors failed to close completely and latch, including damaged fire barrier doors in Special Care and doors to dining room and rooms 407 and 408 not fitting openings properly to resist smoke passage. |
| One-hour fire rated walls and ceilings compromised by holes and penetrations not sealed with approved materials, including holes in mechanical room ceiling, storage room ceiling, wall in room 202, and lint buildup on radiation damper in resident laundry exhaust vent. |
Report Facts
Licensed beds: 76
Portable medical oxygen cylinders improperly stored: 12
Survey completion date: Aug 23, 2017
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 11, 2017
Visit Reason
The Adult Care Licensure Section and the Rutherford County Department of Social Services conducted an annual survey on January 11, 12, 13 with a phone exit on 1/18/17.
Findings
The facility failed to test 1 of 5 sampled residents for tuberculosis disease, failed to provide appropriate supervision for 1 of 5 sampled residents related to decline in condition and falls, and failed to follow-up for 1 resident requiring referral to a Gero-psychiatric unit for agitation and aggression.
Severity Breakdown
Type B Violation: 2
Type A2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to test 1 of 5 sampled residents (Resident #3) for tuberculosis disease in compliance with control measures. | Type B Violation |
| Failed to provide appropriate supervision for 1 of 5 sampled residents (Resident #2) related to decline in condition and falls, resulting in 22 falls over six months including a fractured clavicle. | Type A2 Violation |
| Failed to follow-up for 1 resident (Resident #3) requiring referral to a Gero-psychiatric unit for agitation and aggression, despite physician orders and documented aggressive behaviors. | Type B Violation |
Report Facts
Falls: 22
PRN Ativan administrations: 31
PRN Ativan administrations: 44
PRN Ativan administrations: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for assuring TB skin tests were done and for assuring facility followed regulations. | |
| Executive Director | Provided information on Resident #2's falls and interventions, and Resident #3's behaviors and placement attempts. | |
| Medication Aide | Interviewed regarding Resident #3's medication administration and Resident #2's fall prevention. | |
| Physician | Provided medical notes and orders for Resident #2 and Resident #3, including medication adjustments and placement recommendations. |
Inspection Report
Capacity: 76
Deficiencies: 8
Aug 19, 2015
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 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The survey identified multiple deficiencies related to physical plant safety including obstructions in emergency egress pathways, doors lacking automatic latching hardware, holes in fire resistant ceilings, unsafe electrical equipment, non-functioning emergency lighting, and failure to provide required mechanical exhaust ventilation in designated areas.
Deficiencies (8)
| Description |
|---|
| Stored items obstructing the path of egress in exit vestibules adjacent to rooms #409 and #412 in the Special Care Unit. |
| Doors in Employee's Lounge and Kitchen Service Corridor do not have hardware to latch and remain closed to resist smoke passage. |
| Open sleeve for data cables in Storage Room allowing access to attic space. |
| Electrical power strip in Activity Room lacks overload protection. |
| GFCI electrical outlet in Room #110 did not reset when tested. |
| Combination illuminated directional exit sign and emergency light in Physical Therapy Room is not working. |
| Illuminated directional exit sign not visible at double doors adjacent to Special Care Unit entrance. |
| Failure to provide required mechanical exhaust ventilation in Bio-Hazard Room and non-working exhaust fan in resident bathroom Room 101. |
Report Facts
Licensed capacity: 76
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