Inspection Report
Follow-Up
Deficiencies: 0
May 14, 2025
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previous deficiencies.
Findings
All deficiencies have been corrected. No further action necessary.
Inspection Report
Follow-Up
Deficiencies: 8
Mar 27, 2025
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies and to identify any new deficiencies related to construction, physical plant, and safety compliance.
Findings
The facility has several outstanding deficiencies including failure to meet licensure and code requirements for emergency release switches on locked doors, lack of keys carried by staff for emergency release, failure to submit construction documents for recent remodeling, poor maintenance of outside premises, housekeeping issues with walls and ceilings, fire safety system deficiencies such as gaps around sprinkler heads, mechanical equipment not maintained safely, and non-functioning exhaust ventilation in specified areas.
Deficiencies (8)
| Description |
|---|
| Facility does not meet licensure and code requirements for emergency release switches on locked doors; emergency release switches must be within 3 feet of the door. |
| Staff working in locked unit do not carry keys for emergency release switches and do not know where keys are located. |
| Facility failed to submit Construction Documents and specifications to the Division of Health Service Regulation when construction or remodeling was planned. |
| Outside premises not maintained in a clean condition; exterior trim is rotting and paint is flaking below the eave vent. |
| Walls, ceilings, and floors not kept clean and in good repair; ceiling finish flaking and peeling in dining area. |
| Failure to maintain building's fire safety systems in a safe condition; holes or gaps at penetrations through fire resistant rated ceilings could allow fire and smoke to spread. |
| Mechanical equipment not maintained in safe and operating condition; broken or open exhaust vents allow pests to enter. |
| Facility did not maintain exhaust ventilation in specified spaces; exhaust fans in SCU Housekeeping Closet, SCU Laundry, and 200 Hall Spa are not working. |
Inspection Report
Capacity: 64
Deficiencies: 14
Oct 31, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and building code requirements for the licensed adult care home.
Findings
Multiple deficiencies were cited including failure to meet code requirements for physical plant and fire safety, lack of current fire and building safety inspection reports, failure to submit construction documents for recent remodeling, issues with exit door locks and outside premises maintenance, housekeeping and furnishings in disrepair, inadequate fire safety rehearsals, fire safety equipment not maintained or operating properly, gaps in fire resistant ceilings, and non-functioning exhaust ventilation in specified areas.
Deficiencies (14)
| Description |
|---|
| Stairs used for storage of furniture, equipment, and other items, violating means of egress requirements. |
| Electromagnetic locks lacked proper emergency release switch; override key did not release gate in SCU Courtyard. |
| Facility did not have current fire and building safety inspection reports available for review. |
| Failure to submit construction documents and specifications to the Division for review and approval for recent fire alarm panel replacement. |
| Outside exit doors not easily operable by single hand motion; excessive force required and bungee cords preventing gate opening. |
| Outside premises not maintained in clean condition; exterior trim rotting and paint flaking. |
| Walls, ceilings, and floors not kept clean and in good repair; water leaks, stains, microbial growth, holes in walls, and peeling paint observed. |
| Fire safety rehearsals not conducted quarterly on each shift as required; missing records for multiple shifts in 2024. |
| Fire safety, electrical, mechanical, and plumbing equipment not maintained in safe and operating condition; gaps in fire resistant ceilings, missing escutcheon rings on sprinkler heads, burst sprinkler head causing damage, corrosion on sprinkler heads, emergency lights not illuminating. |
| Fire extinguishers last serviced in May 2023, potentially outdated. |
| Resident room doors had gaps and did not close or latch properly, compromising smoke and fire containment. |
| Unapproved devices used to keep doors open, impeding fire safety door closure. |
| Mechanical equipment not maintained; broken or open exhaust vents allowing pest entry. |
| Exhaust ventilation not maintained or functioning in specified areas including SCU housekeeping closet, SCU laundry, and 200 Hall Spa. |
Report Facts
Licensed capacity: 64
Fire extinguisher last service date: 2023
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 7
Jul 10, 2019
Visit Reason
The inspection was a Division of Health Service Regulation Construction Section Biennial survey conducted on July 10, 2019, to assess compliance with physical plant requirements and building codes for the adult care home facility.
Findings
Multiple deficiencies were cited related to building code compliance, housekeeping, fire safety rehearsals, building equipment maintenance, and exhaust ventilation. The facility was found not in compliance with several physical plant and safety requirements, requiring a Plan of Correction.
Deficiencies (7)
| Description |
|---|
| Facility was not in compliance with building code requirements; delayed egress doors not properly labeled and bistro doors removed making room open to corridor without smoke detector. |
| Ceilings were not kept clean and in good repair; walls were damaged; chronic unpleasant odors present; furnishings not kept in good repair. |
| Facility was not maintained free of hazards; transition strip at bathroom door loose creating trip hazard. |
| Facility was not conducting fire safety rehearsals quarterly on each shift as required. |
| Failure to maintain building and fire safety equipment in safe and operating condition; holes and gaps in fire resistant ceilings and doors not closing properly. |
| Electrical equipment not maintained in safe and operating condition; emergency light did not illuminate on battery test. |
| Facility did not provide exhaust ventilation in required areas; exhaust fan in second floor spa not working. |
Report Facts
Licensed residents: 64
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Biennial Institutional Engineering Surveyor | Conducted the Division of Health Service Regulation Construction Section Biennial survey. |
| Joyce Jones | Executive Director | Signed the Statement of Deficiencies as facility representative. |
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 21, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Meadowmont on June 19-21, 2019 to assess compliance with state regulations for adult care homes.
Findings
The facility failed to ensure that 3 of 5 sampled residents received the required two-step tuberculosis (TB) skin test upon admission. Additionally, the facility did not develop an annual care plan for 1 of 5 sampled residents and failed to complete quarterly resident profiles for 1 of 2 residents admitted to the Special Care Unit.
Deficiencies (3)
| Description |
|---|
| Failure to assure 3 of 5 residents sampled (#1, #4, and #5) were tested upon admission for tuberculosis disease with the required two-step TB skin test. |
| Failure to assure an annual care plan was developed for 1 of 5 sampled residents (#1). |
| Failure to ensure 1 of 2 sampled residents admitted to the Special Care Unit had a resident profile completed quarterly. |
Report Facts
Residents sampled for TB testing: 5
Residents with deficient TB testing: 3
Residents sampled for care plan: 5
Residents sampled for Special Care Unit profile: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Coordinator | Responsible for completion of two-step TB skin tests and resident profiles; unaware of two-step TB skin test requirement | |
| Administrator | Responsible for assuring residents had first step TB skin test prior to admission and second step 2-3 weeks later; unaware of deficiencies | |
| Registered Nurse Case Manager | Responsible for auditing care plans and resident profiles | |
| Special Care Unit Program Coordinator | Provided information about resident care needs | |
| Hospice Aide | Provided observations about Resident #1's care needs |
Inspection Report
Plan of Correction
Census: 64
Capacity: 64
Deficiencies: 10
Aug 16, 2017
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant, fire safety, and building code requirements for an adult care home licensed to serve 64 residents, including a Special Care Unit for 16 residents.
Findings
Multiple deficiencies were cited including failure to meet code requirements for delayed egress and special locking doors, lack of current annual sprinkler inspection report, irregular fire safety rehearsals, unsafe and obstructed exit paths, malfunctioning emergency lighting and exit signs, corridor doors not latching properly, firestopping deficiencies in electrical rooms, and inadequate exhaust ventilation in several areas.
Deficiencies (10)
| Description |
|---|
| Delayed egress doors did not release properly under force and lacked required visible signage. |
| Special locking doors had emergency release issues and lacked proper labeling. |
| Facility failed to maintain current annual sprinkler system inspection report. |
| Fire drill rehearsals were not performed regularly on all shifts each quarter and records lacked descriptions. |
| Exterior exit paths were obstructed and stairwells contained stored equipment. |
| Emergency lighting and exit signs failed to illuminate on backup power in multiple locations. |
| Corridor doors were held open improperly or did not latch, compromising smoke containment. |
| Firestopping was incomplete or missing around cable penetrations and gypsum enclosures in electrical rooms. |
| Egress from walk-in refrigerator/freezer required keys due to padlock without override device. |
| Exhaust ventilation systems failed or were insufficient in multiple soiled linen, housekeeping, and bedroom areas causing odors. |
Report Facts
Licensed residents: 64
Special Care Unit capacity: 16
Fire drill rehearsal shifts missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Construction Section Surveyor | Conducted the biennial survey on August 16, 2017 |
| Maintenance Technician | Interviewed regarding sprinkler inspection and fire drill rehearsals | |
| Executive Director/Administrator/Maintenance Director/Technician Manager | Interviewed regarding fire drill rehearsals |
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