Inspection Reports for Brookdale Smithfield

Report of a Construction Section Biennial Follow-Up Survey conducted on May 15, 2025.

All deficiencies identified in the previous survey have been corrected. No further action is required.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 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.

Multiple deficiencies were cited including lack of delayed egress signage, absence of current fire and building safety inspection reports, missing hand grips in bathrooms, unsafe and unclean physical environment, fire safety rehearsals not conducted on all shifts quarterly, failure to maintain fire safety equipment and emergency lighting in safe operating condition, unsecured oxygen bottles, obstructed exit paths, and non-functioning exhaust ventilation in specified areas.

The Adult Care Licensure Section conducted an annual and follow-up survey on September 18 and 19, 2024 to assess compliance with adult care home regulations.

The facility was found deficient in multiple areas including medication staff qualifications, tuberculosis testing compliance, care plan completion and physician signatures, nutrition and food service standards, and medication administration errors involving incorrect dosages, timing, and documentation.

The Adult Care Licensure Section conducted an annual and follow-up survey on June 14-15, 2022 to assess compliance with health care and medication administration regulations.

The facility failed to ensure proper referral and follow-up for a resident's orthopedic appointment after a fall, failed to notify the primary care provider of blood pressure and weight loss outside ordered parameters, and failed to ensure medications were available and administered as ordered, with inaccurate medication documentation on the electronic medication administration record (eMAR).

The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to tuberculosis testing of staff.

The facility failed to assure that 1 of 2 sampled staff (Staff A) completed a two-step tuberculosis skin test as required. Staff A had documentation of TB skin tests in 2017 and 2019, but the first test could not be counted for employment purposes, so a second valid test was missing.

The report documents a Biennial Follow Up Construction Survey conducted to assess the correction of previously cited deficiencies related to building equipment and fire safety in the facility.

The facility failed to maintain electrical emergency/safety lighting and fire safety equipment in safe operating condition, including non-illuminating emergency lights, fire doors that do not latch properly, and storage obstructing sprinkler heads.

This is a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies related to physical plant and fire safety compliance.

The facility had multiple deficiencies including non-operational soiled utility room equipment, failure to maintain electrical emergency lighting, fire safety equipment issues such as fire door latch failures, gaps allowing smoke passage, holes around sprinkler heads, improper storage obstructing sprinkler heads, lack of required fire safety inspections, and absence of exhaust ventilation in required areas.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 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.

Multiple deficiencies were identified related to physical plant and safety including missing signage on exit doors, obstructions in corridors, unclean and damaged walls, floors, and ceilings, unsecured oxygen bottles, malfunctioning fire safety equipment, inadequate emergency lighting, fire door latch failures, holes in fire-rated ceilings, improper storage below sprinkler heads, overdue kitchen hood suppression inspection, plumbing issues, gaps in resident room doors, and lack of required exhaust ventilation in certain areas.

Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.

The facility's fire safety equipment, specifically the fire sprinkler system, was found not to be maintained in operating condition. The valve for the pipe to the fire sprinkler system accelerator was in the off position and the pressure gauge indicated no pressure on the line.

The visit was a biennial follow-up construction survey to verify correction of previously identified deficiencies related to building safety and physical plant requirements.

The facility had deficiencies including lack of current fire sprinkler inspection reports due to incomplete repairs, and absence of required exhaust ventilation in certain areas such as the Memory Care laundry room. Plans for corrective actions were in place but not yet completed at the time of inspection.

The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 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.

The survey identified multiple deficiencies including lack of current fire sprinkler inspection reports, dirty and dusty HVAC grilles, storage obstructing emergency exit paths and electrical panels, disabled dry fire sprinkler system, gaps and holes in fire resistant ceilings, malfunctioning smoke resistant doors, non-illuminated emergency exit signs and emergency lighting, presence of prohibited portable electric heaters, and absence of required exhaust ventilation in the laundry room.

The Adult Care Licensure Section conducted an annual and follow-up survey of Brookdale Smithfield from 1/11/17 to 1/13/17 to assess compliance with state regulations for adult care homes, including personal care training, supervision, licensed health professional support, nutrition and food service, resident rights, special care unit admission, staff orientation and medication aide training.

The facility failed to ensure staff completed required personal care training, failed to provide adequate supervision for a resident with multiple falls, did not complete timely licensed health professional support reviews, had cleanliness issues in the kitchen and food storage areas, lacked sufficient staff to assist residents with feeding, failed to maintain resident dignity related to clothing and treatment during meals, did not document pre-admission screenings for special care unit residents, failed to provide required special care unit staff training, and did not verify medication aide training and competency for at least one medication aide.

The Adult Care Licensure Section conducted an annual and follow-up survey on June 23 - 25, 2015 to assess compliance with state regulations for the adult care home.

The facility was found deficient in multiple areas including failure to ensure tuberculosis testing compliance, failure to notify physicians of abnormal vital signs, failure to implement oxygen treatments per orders, failure to complete licensed health professional support evaluations timely, failure to clarify and administer medication orders correctly, failure to complete resident care plans within required timeframes, and failure to ensure medication aides completed required competency testing.