Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 2
Apr 30, 2025
Visit Reason
The Adult Care Licensure Section and the Catawba County Department of Social Services conducted an annual survey on April 29-30, 2025.
Findings
The facility was found deficient in ensuring tuberculosis testing compliance for one of five sampled residents and in maintaining accurate Medication Administration Records (MAR) for one resident related to prednisone medication documentation.
Deficiencies (2)
| Description |
|---|
| Failed to ensure one of five sampled residents was tested for tuberculosis disease in compliance with control measures within ninety days of admission. |
| Failed to ensure the Medication Administration Records (MAR) were accurate for one resident related to inaccurate documentation of prednisone medication administration. |
Report Facts
Sampled residents: 5
Prednisone tablets dispensed: 10
Prednisone administration days documented: 11
Prednisone non-administration days documented: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health & Wellness Director | Interviewed regarding tuberculosis testing process and medication order entry | |
| Administrator | Interviewed regarding admission procedures and medication order discrepancies | |
| Resident Care Coordinator (RCC) | Interviewed regarding medication order entry and auditing | |
| Contracted Pharmacist Consultant | Interviewed regarding prednisone medication dispensing |
Inspection Report
Follow-Up
Capacity: 88
Deficiencies: 3
Oct 22, 2024
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to assess compliance with building, fire safety, electrical, mechanical, and plumbing equipment regulations for an adult care home.
Findings
Deficiencies were cited related to failure to maintain the emergency fire alarm system, electrical emergency/safety lighting, and mechanical equipment in safe operating condition. Specific issues included trouble with the fire alarm control panel tamper switch, a failed sealed lead acid battery voltage test, and radiation dampers propped open in the mechanical/maintenance office.
Deficiencies (3)
| Description |
|---|
| Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition, including trouble with the tamper switch on the Fire Alarm Control Panel. |
| Electrical emergency/safety lighting equipment not maintained in safe operating condition; sealed lead acid battery did not pass voltage test. |
| Mechanical equipment not maintained in safe and operating condition; radiation dampers propped open so they could not close during a fire. |
Report Facts
Licensed capacity: 88
Inspection Report
Follow-Up
Deficiencies: 6
Jan 30, 2019
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to assess the facility's compliance with physical plant regulations and to verify correction of previously cited deficiencies.
Findings
The survey found multiple deficiencies including ceilings not kept clean and in good repair, emergency exit signs not illuminating on backup power, fire safety issues such as improperly covered holes in fire-resistance-rated ceilings, electrical hazards from improper use of power taps, missing or damaged fire sprinkler components, and smoke tight corridor doors that do not latch properly.
Deficiencies (6)
| Description |
|---|
| Building ceilings are not kept clean and in good repair; textured ceiling detaching near Bedroom 8. |
| Emergency exit signs near Bedrooms 12 and 21 did not illuminate on backup power. |
| Exit sign base near Bedroom 1 does not completely cover hole penetrating fire-resistance-rated ceiling assembly. |
| Oxygen concentrator plugged into a power tap in Bedroom 3, creating a fire hazard (corrected before surveyors departed). |
| Fire sprinkler components missing or in disrepair, including FDC inlet connection area sign not visible. |
| Smoke tight corridor doors near Bedroom 11 and Bistro do not latch into their frames when closed. |
Inspection Report
Capacity: 88
Deficiencies: 12
Nov 21, 2018
Visit Reason
Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety regulations for an adult care home.
Findings
Multiple deficiencies were cited including issues with delayed egress locking system, housekeeping and furnishings not clean or in good repair, fire extinguishers not properly maintained, emergency lighting and exit signs not functioning on backup power, fire safety doors not closing properly, obstructed fire sprinkler heads, and electrical hazards such as improper use of power taps. Several deficiencies were corrected before surveyors departed.
Deficiencies (12)
| Description |
|---|
| Delayed egress door's releasing device did not initiate irreversible release process when force applied over 15 pounds for more than three seconds. |
| Ventilation system throughout facility had excessive accumulation of dust/lint on radiation dampers. |
| Plumbing system devices not kept clean and in good repair; loose commode connections and dirty shower seats in shared bathrooms. |
| Textured ceilings detaching in Bedroom 1 and Laundry near Bedroom 8. |
| Oxygen cylinders not physically secured, posing hazard if they fall and break valves. |
| Fire extinguishers lacked documentation of monthly inspections; last annual maintenance checks outdated. |
| Emergency lights and exit signs did not illuminate on backup power during testing. |
| Fire-rated doors propped open or not closing/latching properly, compromising smoke and fire containment. |
| Commercial kitchen hood fire suppression system lacked required inspections and maintenance; nozzle not correctly aimed at deep fryer. |
| Fire-resistance-rated ceiling penetrations not properly firestopped. |
| Electrical hazards due to power taps plugged into other power taps and medical equipment plugged into power taps. |
| Fire sprinkler system components missing or in disrepair; sprinkler heads obstructed by stored items. |
Report Facts
Licensed capacity: 88
Inspection Report
Follow-Up
Deficiencies: 1
Mar 15, 2017
Visit Reason
The report documents a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant requirements.
Findings
The survey found that deficiencies cited during the previous Biennial Follow Up Construction Survey have not been satisfactorily corrected, specifically the smoke barrier doors near bedroom 18 lacking required vision panels of wire reinforced or fire rated glass.
Deficiencies (1)
| Description |
|---|
| Smoke barrier doors near bedroom 18 failed to comply with NC State Building Code Section 409.1.2.4 requiring vision panels of wire reinforced or fire rated glass. |
Inspection Report
Follow-Up
Deficiencies: 4
Jan 5, 2017
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies at Brookdale Hickory Northeast.
Findings
Several deficiencies related to physical plant safety were observed, including missing vision panels in smoke barrier doors near bedroom 18, a missing sprinkler head in bedroom 28, corridor doors that do not close and latch properly, and a missing top on an outside light fixture at the dining room.
Deficiencies (4)
| Description |
|---|
| Smoke barrier doors near bedroom 18 lacked required vision panels of wire reinforced or fire rated glass. |
| A sprinkler head was missing in bedroom 28, compromising fire safety. |
| Many corridor doors failed to close quickly and latch, including double doors to the living room and door to bedroom 11. |
| Top of the outside light fixture was missing at the dining room, allowing rain water to enter. |
Report Facts
Inspection dates: 2
Inspection Report
Capacity: 88
Deficiencies: 17
Dec 1, 2016
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and building code requirements for the licensed adult care home facility.
Findings
The survey identified multiple deficiencies including non-compliance with delayed egress door force requirements, missing vision panels on smoke barrier doors, lack of required signage on exit doors, outstanding fire marshal deficiencies without correction documentation, missing monthly inspection documentation for fire suppression systems, various fire safety and building maintenance issues such as missing sprinkler heads, non-functioning emergency lights, compromised fire rated walls and ceilings, corridor doors not closing or latching properly, malfunctioning exit signs, broken tiles and switch plates, and combustible storage hazards.
Deficiencies (17)
| Description |
|---|
| Delayed Egress door near room 34 required 40 pounds to open instead of the maximum 15 pounds. |
| Smoke barrier doors near bedroom 18 lacked required vision panels of wire reinforced or fire rated glass. |
| Exit door from Dining room lacked required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.' |
| No documentation of monthly inspections on range hood fire suppression system tag. |
| No documentation of monthly inspections since June 2016 for fire extinguisher in laundry. |
| Ceiling radiation dampers in bathroom exhaust ducts were very dirty, potentially impairing fire safety function. |
| Exit sign in corridor near living room directed exiting in wrong directions. |
| Combustible storage found behind commercial dryer. |
| Fire safety rehearsal records lacked adequate description of what the rehearsals involved. |
| Sprinkler head missing in bedroom 28. |
| Battery powered emergency light in physical therapy room did not work when tested. |
| One-hour fire rated walls and ceilings compromised by holes and unsealed penetrations in multiple locations including mop closet, laundry, basement, and rooms. |
| Many corridor doors failed to close completely and latch, including doors to bedrooms, copier room, living room, and others, compromising fire and smoke resistance. |
| Exit sign near living room would not work on battery back-up. |
| Broken tiles in Spa on Elm Lane presented laceration hazard. |
| Broken switch plate in oxygen room exposed energized parts and wires. |
| Top of outside light missing at Dining room allowing rain water entry. |
Report Facts
Licensed capacity: 88
Force required to open delayed egress door: 40
Force allowed to open delayed egress door: 15
Date of last Fire Marshal inspection: Jan 27, 2016
Month of last fire extinguisher inspection documentation: 6
Loading inspection reports...
