Inspection Report
Follow-Up
Deficiencies: 3
Aug 20, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies remain uncorrected including broken automatic door closer on smoke-tight corridor doors, non-operational mechanical system climate control device, and trouble indicated on the fire alarm panel with a smoke detector.
Deficiencies (3)
| Description |
|---|
| Smoke-tight corridor doors are not maintained in a safe and operating condition; the automatic door closer is broken. |
| Building's mechanical system is not maintained in a safe manner; the above ceiling VAV climate control device is not operational. |
| Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; fire alarm panel indicated trouble with the Clarebridge Hall Rear Exit smoke detector. |
Inspection Report
Follow-Up
Deficiencies: 5
May 6, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies related to sanitation, fire, and building safety inspection reports and equipment maintenance.
Findings
Deficiencies remain uncorrected including lack of current sanitation and fire safety inspection reports, broken automatic door closer, non-operational climate control device, multiple fire alarm system deficiencies, and fire suppression system components failing testing.
Deficiencies (5)
| Description |
|---|
| Facility failed to maintain current sanitation and fire and building safety inspection reports available for review. |
| Smoke-tight corridor doors not maintained in safe and operating condition; automatic door closer broken in AL-Dining Room right side. |
| Building's mechanical system not maintained in a safe manner; above ceiling VAV climate control device not operational on 2nd Floor Azalea Spa. |
| Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; multiple smoke detectors, initiating devices, and batteries failed testing. |
| Fire suppression system not maintained in safe and operating condition; dry pipe valve and two tamper switches failed testing. |
Report Facts
Number of tamper switches failed testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Surveyor | Conducted the Construction Section Biennial Follow Up Survey |
| Executive Director | Interviewed regarding lack of current sanitation and fire safety inspection reports | |
| Maintenance Director | Interviewed regarding lack of current sanitation and fire safety inspection reports |
Inspection Report
Capacity: 80
Deficiencies: 6
Nov 5, 2024
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with building, fire safety, and sanitation regulations for an adult care home licensed for 80 beds.
Findings
The facility failed to maintain current sanitation and fire safety inspection reports, had multiple deficiencies in building equipment including broken automatic door closers, non-operational climate control devices, fire alarm system failures, fire suppression system deficiencies, and hazards obstructing evacuation routes.
Deficiencies (6)
| Description |
|---|
| Failed to maintain current sanitation and fire and building safety inspection reports available for review. |
| Smoke-tight corridor doors not maintained in a safe and operating condition; automatic door closer broken. |
| Building's mechanical system not maintained in a safe manner; VAV climate control device not operational. |
| Failure to maintain emergency fire alarm system devices and equipment in a safe operating condition; multiple smoke detectors, initiating devices, and batteries failed testing. |
| Fire suppression system not maintained in a safe and operating condition; dry pipe valve and two tamper switches failed testing. |
| Facility not maintained free from hazards obstructing or delaying evacuation; items stored in stairwell near Room 101. |
Report Facts
Licensed bed capacity: 80
Number of tamper switches failed testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Construction Section Biennial Survey. | |
| Executive Director | Interviewed regarding failure to maintain current sanitation and fire safety inspection reports. | |
| Maintenance Director | Interviewed regarding failure to maintain current sanitation and fire safety inspection reports. |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 15, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale MacArthur Park on November 14-15, 2023 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in serving therapeutic diets as ordered, medication administration errors including late or incorrect medication administration, crushing medications that should not be crushed, and failure to hold blood pressure medications as ordered based on residents' blood pressure readings.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a therapeutic diet was served as ordered for 1 of 2 sampled residents with a texture modified diet order. |
| Failed to administer medications as ordered and in accordance with facility policies for multiple residents, including errors with pain medication, iron supplement, and blood pressure medications. |
Report Facts
Medication error rate: 8
Medication supply: 3.5
Blood pressure readings range: Resident #2's blood pressure ranged from 98/53 to 181/95 during September 2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Aide (PCA) | Mistakenly served the wrong plate to Resident #2 during breakfast service on 11/15/23. | |
| Dining Services Manager | Did not place Resident #2's therapeutic diet plate on the food cart due to belief resident was hospitalized. | |
| Medication Aide (MA) | Prepared and administered medications including errors with Tramadol and Ferrous Sulfate; did not use Do Not Crush list. | |
| Resident Care Coordinator (RCC) | Reported pharmacy did not send Tramadol on time and MAs should not crush medications labeled 'Do Not Crush'. | |
| Health and Wellness Director (HWD) | Discussed medication administration errors, documentation issues, and training of MAs. | |
| Administrator | Confirmed medication administration and documentation deficiencies. | |
| Pharmacy Technician | Confirmed dispensing of Tramadol on 11/14/23 after receiving prescription. | |
| Primary Care Provider (PCP) | Expressed concerns about medication errors and confirmed orders for residents. |
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 7, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale MacArthur Park from October 5-7, 2021 to assess compliance with personal care and supervision regulations.
Findings
The facility failed to provide timely personal care to Resident #4, who waited between 13 and 56 minutes for staff assistance after using the pendant call system, resulting in episodes of incontinence and a fall with injury. Staff response times were inconsistent and often delayed, especially during evening and night shifts, with insufficient staffing and equipment issues contributing to the problem.
Severity Breakdown
Type B Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide personal care for Resident #4 who waited 29 minutes for toileting assistance and 56 minutes after a fall before staff responded to her pendant call. | Type B Violation |
Report Facts
Response time: 56
Response time: 29
Response time: 13
Response time: 25
Response time: 44
Response time: 14
Response time: 17
Response time: 40
Number of residents in AL unit: 34
Percentage incontinent residents: 50
Staff on second shift: 3
Staff on second shift previously: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Reported on call bell and pendant system issues and staff response delays |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for staff assignments and training on pager use; acknowledged response time issues |
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for ensuring staff respond to calls within 5-7 minutes; aware of Resident #4's fall and injury |
| Administrator | Facility Administrator | Set expectations for staff response times; acknowledged lack of formal policy; investigated complaints |
| Second shift personal care aide | Personal Care Aide (PCA) | Described staffing and response time challenges on second shift |
| Second shift medication aide | Medication Aide (MA) | Described training and expectations for call response times |
| Third shift medication aide | Medication Aide (MA) | Reported response time expectations and issues with staff carrying pagers and radios |
Inspection Report
Capacity: 80
Deficiencies: 12
Oct 23, 2019
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant and safety regulations for an adult care home licensed for 80 beds.
Findings
Multiple deficiencies were cited related to physical plant maintenance including unsafe outside premises, unclean and unrepaired housekeeping and furnishings, hazards from unsecured oxygen bottles, electrical outlets lacking ground fault interrupters, fire safety system failures, plumbing issues, and non-functioning exhaust ventilation in required areas.
Deficiencies (12)
| Description |
|---|
| Outside premises not maintained in a clean and safe condition; 3" hole in exterior veneer with pest nest. |
| Ceilings and equipment not kept clean and in good repair; lint accumulation on exhaust fans, water stains, rust, and mildew stains in various rooms. |
| Floors and walls not kept clean; lint coating and debris behind dryer in laundry. |
| Furnishings not kept in good repair; unsecured handrail near exit door. |
| Facility not maintained free from hazards; unsecured oxygen bottles in resident rooms. |
| Electrical outlets near sinks not equipped with ground fault circuit interrupters (GFCI). |
| Failure to maintain building fire safety systems; unsealed conduit sleeves, missing sprinkler escutcheon plates, damaged ceilings, loose door hinges, doors not closing or latching properly, and other fire safety hazards. |
| Electrical emergency/safety lighting equipment not maintained; emergency light failed to illuminate on test. |
| Resident room doors with gaps or holes compromising smoke resistance. |
| Unapproved devices used to keep doors open, impeding fire safety. |
| Plumbing equipment not maintained; dried out sink trap causing unpleasant odor. |
| Exhaust ventilation not working in multiple required areas including hallways, soiled linen, housekeeping, laundry, guest toilet, and resident rooms. |
Report Facts
Licensed bed capacity: 80
Inspection Report
Follow-Up
Deficiencies: 3
Nov 9, 2017
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies related to building construction and safety.
Findings
The facility had unresolved deficiencies including failure to provide exhaust ventilation in some bathrooms and toilet rooms, and issues with fire safety such as an emergency pull station being obstructed and doors that do not latch properly, potentially compromising fire and smoke containment.
Deficiencies (3)
| Description |
|---|
| Facility failed to provide exhaust ventilation in certain bathrooms and toilet rooms, which could affect occupants if odors permeate occupied areas. |
| Emergency pull station at the front door is not easily accessible due to being located behind furnishings. |
| Doors that do not latch properly, including Private Dining Room Entry Door and Unisex Bathrooms on First and Second Floors, may not prevent spread of fire and smoke. |
Inspection Report
Capacity: 80
Deficiencies: 14
Aug 17, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with the 1996 Rules for the Licensing of Adult Care Homes and applicable building codes for the facility licensed for 80 beds.
Findings
Multiple deficiencies were identified including failure to provide mechanical ventilation in bathrooms and housekeeping closets, damaged ceiling tiles, grease buildup on kitchen equipment, inaccessible emergency pull stations, interior doors that do not latch properly, incomplete fire protection for electrical conduit penetrations, breaches in fire-rated assemblies, restricted access to electrical panels, combustible material storage issues, unsecured electrical junction boxes, sprinkler heads out of position, and improper storage of oxygen cylinders.
Deficiencies (14)
| Description |
|---|
| Failure to provide mechanical ventilation in bathrooms and housekeeping closets leading to odors affecting residents and staff. |
| Damaged lay-in ceiling tile and grid in the First Floor Laundry. |
| Kitchen range and exhaust hood with grease buildup and grease dripping on the floor. |
| Emergency pull station not easily accessible, located more than 5 feet from front door and behind furniture. |
| Interior doors do not latch properly, preventing containment of fire and smoke. |
| Furniture blocking smoke-barrier doors preventing them from closing and latching. |
| Unisex bathroom doors out of square and do not fit tightly to resist smoke/fire passage. |
| Incomplete fire protection for electrical conduit penetrations in data closets and mechanical room. |
| Ceiling sheet-rock has voids and water damage compromising fire/ smoke containment. |
| Restricted working clearance in front and sides of electrical service panels due to washing machine placement. |
| Excessive combustible material stored in the First Floor Mechanical Room. |
| Electrical junction box without cover in First Floor Mechanical Room ceiling. |
| Sprinkler heads missing escutcheons or out of position in Dogwood Stair Tower and Spa on Second Floor. |
| Oxygen bottles in Room 208 not secured to structure or stored in approved racks. |
Report Facts
Licensed bed capacity: 80
Inspection Report
Follow-Up
Deficiencies: 5
Feb 10, 2016
Visit Reason
Follow-up survey conducted to verify completion of deficiencies identified in the 09/24/2016 Biennial Inspection.
Findings
The facility failed to maintain fire safety equipment including fire rated cross-corridor doors that did not close or latch properly, doors wedged open, and many corridor doors not closing or latching to resist fire and smoke passage. Additionally, the central exhaust system was not working on both the 1st and 2nd floors.
Deficiencies (5)
| Description |
|---|
| Failed to maintain one pair of 3 hour fire rated cross-corridor doors to the main dining room; doors did not close completely and latch. |
| Fire safety components not maintained in a safe operable manner; doors were blocked or held open by unapproved methods. |
| Many corridor doors not closing, fitting well, or latching to resist fire and smoke passage. |
| Central exhaust system not working for all of the 2nd floor. |
| Central exhaust system not working for all of the 1st floor. |
Inspection Report
Capacity: 80
Deficiencies: 14
Sep 24, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable adult care home licensing rules and North Carolina State Building Code requirements.
Findings
The facility was found to have multiple deficiencies including non-compliance with delayed egress door requirements, damaged furnishings and cabinetry in resident rooms, dry drain traps, inadequate fire safety rehearsals and record keeping, obstructed exit paths, compromised fire rated walls and doors, unsecured kitchen doors, lack of proper lighting, broken exit lights, loose toilets, unsupervised energized cooking equipment, and non-functioning exhaust ventilation systems.
Deficiencies (14)
| Description |
|---|
| Delayed Egress exit process was reversible and lacked required signage. |
| Damaged cabinets, bathroom door, door casings, and removed bathroom vanity in room 209. |
| Drain traps in soiled linen room and main mechanical room were dry. |
| Insufficient fire plan rehearsals and incomplete records. |
| Exterior exit path obstructed by PVC chiller pipes. |
| Compromised one-hour fire rated walls and ceilings with holes and missing sprinkler escutcheon. |
| Cross-corridor fire rated doors failed to close and latch properly. |
| Kitchen fire rated doors wedged open. |
| Corridor doors not closing, fitting well, or latching to resist fire and smoke passage. |
| No working light in clean linen room. |
| Exit light near room 237 broken and hanging by wires. |
| Toilet loosely mounted to floor in bathroom off room 209. |
| Energized range in Cafe unsupervised by staff. |
| Central exhaust system not working on 2nd floor; no exhaust fan in housekeeping closet near room 124. |
Report Facts
Licensed bed capacity: 80
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