Deficiencies per Year
24
18
12
6
0
High
Moderate
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 3
Feb 12, 2025
Visit Reason
The Adult Care Licensure Section and the Gaston Department of Social Services conducted an annual survey from February 12, 2025 through February 13, 2025 to assess compliance with regulatory requirements.
Findings
The facility failed to maintain hot water temperatures within the required range at resident bathroom fixtures, had deficiencies in resident care plan physician signatures within required timeframes, and failed to ensure proper food labeling, dating, and kitchen sanitation.
Deficiencies (3)
| Description |
|---|
| Hot water temperatures exceeded the maximum of 116°F at 4 of 4 resident bathroom fixtures accessible for resident use. |
| Two of five sampled residents had care plans not signed by the Primary Care Provider within 15 days of assessment. |
| Food items in the kitchen refrigerator were not labeled or dated, and the kitchen had sanitation and maintenance issues including sticky floors, debris buildup, damaged walls, and black spots above sinks. |
Report Facts
Water temperature: 120
Water temperature: 121
Residents sampled: 5
Residents with unsigned care plans: 2
Food items unlabeled and undated: 4
Demerits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Aware of elevated hot water temperatures and kitchen wall damage; responsible for maintenance and water temperature monitoring. | |
| Administrator | Interviewed regarding awareness and notification of hot water temperature issues and kitchen conditions. | |
| Nurse Manager | Responsible for completing resident care plans after Health and Wellness Director left; interviewed about care plan processes. | |
| Dietary Manager | Responsible for assuring kitchen staff labeled and dated food; reported environmental needs to administration. |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 23, 2021
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 06/23/21 to 06/24/21 to verify correction of previous deficiencies.
Findings
The facility failed to administer medications as ordered for 1 of 5 sampled residents due to seven missed doses of Klonopin for anxiety disorder caused by medication unavailability from the pharmacy. The facility had ongoing issues with obtaining timely medication refills and lacked documentation of communication with the pharmacy.
Deficiencies (1)
| Description |
|---|
| Failed to administer medications as ordered by a licensed prescribing practitioner for 1 of 5 sampled residents related to not administering a medication to treat anxiety disorder. |
Report Facts
Missed medication doses: 7
Medication quantities dispensed: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #5 | Resident affected by missed medication doses | |
| Administrator | Administrator | Provided information about medication refill procedures and facility staffing |
| Medication aide | Medication aide | Interviewed regarding medication reorder process and communication with pharmacy |
Inspection Report
Annual Inspection
Deficiencies: 9
Apr 9, 2021
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services conducted an annual survey and complaint investigation on April 6-9, 2021. The complaint investigation was initiated on April 1, 2021 by the Gaston County Department of Social Services.
Findings
The facility failed to maintain clean and well-repaired ceilings and floor coverings, maintain a clean and orderly environment, ensure tuberculosis testing and FL2 documentation for residents, complete initial resident assessments timely, ensure physician notification for medication and treatment issues, administer medications as ordered, and properly document medication administration and self-administration assessments.
Complaint Details
Complaint investigation initiated on April 1, 2021 by Gaston County Department of Social Services related to facility conditions and care.
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure ceilings and floor coverings were kept clean and in good repair in multiple locations throughout the facility. | — |
| Facility failed to maintain a clean and orderly environment as evidenced by overflowing trashcans, dirty clothes on floors, unclean bathrooms, and clutter. | — |
| Facility failed to ensure 1 of 7 residents had been tested for tuberculosis disease prior to admission (Resident #4). | — |
| Facility failed to ensure FL2 was in the facility before admission or accompanied the resident upon admission and reviewed by the facility before admission for 2 of 7 sampled residents (Residents #5 and #6). | — |
| Facility failed to ensure an initial assessment of each resident was completed within 72 hours of admission using the Resident Register for 3 of 6 residents (Residents #3, #5, and #6). | — |
| Facility failed to ensure physician notification for 2 of 5 residents related to renewal of a pain medication prescription (Resident #3) and a resident not wearing compression stockings or geri sleeves as ordered (Resident #1). | — |
| Facility failed to administer medications as ordered for 3 of 7 residents related to not administering an antifungal medication (Resident #6), not administering a medication to treat chronic pain (Resident #3), and not administering medications to treat a rash and pain (Resident #1). | Type B |
| Facility failed to ensure resident who self-administered medications had physician orders indicating competency to do so for Residents #1, #6, and #8. | — |
| Facility failed to ensure all residents were free from neglect related to medication administration. | — |
Report Facts
Sanitation score: 98
Number of residents sampled: 7
Number of residents with missing initial assessments: 3
Number of residents with medication administration issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Responsible for TB testing, medication administration oversight, and self-administration assessments | |
| Resident Care Coordinator | Responsible for resident records, medication cart checks, and admission packet processing | |
| Administrator | Facility administrator interviewed regarding multiple deficiencies and oversight | |
| Maintenance Director | Provided information on housekeeping and facility maintenance issues | |
| Medication Aide | Involved in medication administration and documentation | |
| Pharmacist | Contracted pharmacy representative interviewed regarding medication orders and refills |
Inspection Report
Capacity: 78
Deficiencies: 24
Nov 14, 2019
Visit Reason
Biennial Construction Survey conducted to assess compliance with applicable building codes and adult care home rules for the facility licensed for 78 residents.
Findings
The survey identified multiple deficiencies including delayed egress doors not functioning properly, housekeeping and mechanical systems not maintained, unsafe storage and handling of oxygen cylinders, electrical outlets lacking ground fault protection or power, fire safety equipment and building components compromised, and ventilation systems not working in specified areas.
Deficiencies (24)
| Description |
|---|
| Delayed Egress exit near room 53 would not release and open after force exceeding 100 pounds was applied. |
| Delayed Egress exit door in Dining room lacked required legible sign. |
| Delayed Egress doors were hard to reset, including kitchen exit and dining room exit requiring weighted umbrella stand. |
| HVAC exhaust grills and radiation dampers in laundry and housekeeping closet had excessive dust/lint accumulation. |
| Strong unpleasant odor present in room 6A/B. |
| Portable medical oxygen cylinders stored without racks or containers in oxygen storage room and room 33A/B. |
| Extension cord used in place of permanent wiring in dining room. |
| Weighted umbrella stand leaning against dining room exit door creating trip hazard. |
| Electrical outlet expander used in bathroom off room 52, not approved for institutional occupancies. |
| Leaking toilet in bathroom off room 12 A/B causing slip and fall hazard. |
| Dining room exit door was hard to open due to dragging on rubber mat (corrected during survey). |
| No key onsite to allow entry into housekeeping near medication room for hazard survey. |
| Electrical outlets in wet locations lacked ground fault circuit protection and some had no power. |
| Corridor smoke detector DO38 failed to activate when tested with smoke. |
| Battery packs and test buttons for most emergency lights could not be located; lights not tested. |
| One-hour fire rated walls and ceilings compromised by unsealed penetrations, damage, missing outlet covers, and holes in multiple locations. |
| Improperly fitted or missing sprinkler escutcheons in laundry and drive through portico. |
| Corridor doors to employee break room and multiple resident rooms would not latch when closed. |
| Glass and steel framed wall holding exit door near Activities room was unsecure and moved significantly. |
| Active significant leak at main valve in sprinkler riser room with water damage. |
| Storage stacked within 3 inches of ceiling in Administrator's office, violating clearance below sprinkler heads. |
| No documentation of required monthly inspections for several fire extinguishers for October. |
| Ice machine drain line only 1/2 inch above floor drain, risking contamination. |
| Exhaust ventilation not working in mop closet off kitchen and bathroom off room 16A/B. |
Report Facts
Licensed capacity: 78
Portable medical oxygen cylinders improperly stored: 4
Sprinkler escutcheons improperly fitted: 3
Storage clearance below sprinkler head: 3
Force applied to delayed egress door: 100
Required force for delayed egress door release: 15
Inspection Report
Follow-Up
Deficiencies: 0
Aug 22, 2019
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services conducted a follow-up survey on 08/21/19-08/22/19.
Findings
The document is a statement of deficiencies and plan of correction related to a follow-up survey conducted at Brookdale Union.
Inspection Report
Follow-Up
Deficiencies: 1
May 1, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on May 1-2, 2019 to assess correction of previous deficiencies related to medication administration.
Findings
The facility failed to assure administration of medications as ordered by a licensed prescribing practitioner for 1 of 6 sampled residents (#3), specifically related to Parkinson's medication dosage changes, resulting in a fall with head injury. Medication aides administered outdated medication packs and did not return old medications to the pharmacy as required.
Severity Breakdown
Type B Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assure administration of Carbidopa-Levodopa medication as ordered for Resident #3, leading to inconsistent dosing and increased risk of falls. | Type B Violation |
Report Facts
Medication tablets dispensed: 240
Medication tablets remaining expected: 97.5
Medication tablets remaining observed: 85
Medication tablets remaining observed: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for medication cart audits and medication management |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for medication cart audits and medication management |
Inspection Report
Annual Inspection
Deficiencies: 5
Jan 30, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey on January 29-30, 2019 to assess compliance with state regulations for the facility.
Findings
The facility failed to provide adequate supervision for 2 sampled residents with a history of falls, failed to assure physician notification for residents with abnormal blood sugar readings and missed medication administration, failed to maintain cleanliness and food safety in the kitchen and food storage areas, and failed to administer medications as ordered by licensed practitioners.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide supervision for 2 of 2 sampled residents with a history of falls, resulting in multiple falls and injuries. | Type B Violation |
| Failed to assure physician notification for 2 of 5 sampled residents with abnormal blood sugar readings and missed medication administration. | — |
| Failed to maintain cleanliness and prevent contamination in kitchen, dining, and food storage areas including dirty floors, walls, and improperly labeled food items. | — |
| Failed to administer medications as ordered for 2 of 5 sampled residents related to Humalog and amlodipine. | — |
| Failed to assure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to personal care and supervision. | — |
Report Facts
Falls: 5
Falls: 6
Missed medication doses: 12
Medication administration opportunities: 31
Medication administration opportunities: 29
Medication administration opportunities: 31
Medication administration opportunities: 29
Kitchen sanitation score: 98.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Named in findings related to supervision failures for Resident #2 and Resident #6 |
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in findings related to supervision failures and medication administration |
| Administrator | Facility Administrator | Named in interviews regarding supervision failures, medication administration, and kitchen cleanliness |
| Dietary Manager | Dietary Manager (DM) | Named in findings related to kitchen cleanliness and food safety |
| Medication Aide | Medication Aide (MA) | Named in findings related to medication administration failures for Residents #3 and #4 |
| Personal Care Aide | Personal Care Aide (PCA) | Named in findings related to supervision failures for Residents #2 and #6 |
Inspection Report
Follow-Up
Deficiencies: 2
Feb 21, 2018
Visit Reason
This was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies.
Findings
Deficiencies were cited related to chronic unpleasant odors in the facility and failure to maintain fire safety equipment in a safe operating condition, specifically a kitchen door that did not close properly during fire alarm testing.
Deficiencies (2)
| Description |
|---|
| Facility was not free of chronic unpleasant odors, including a strong odor near the spa by Room 10. |
| Failure to maintain fire safety equipment in a safe operating condition; kitchen door separating kitchen from dining area did not have a closer and did not close during fire alarm test. |
Inspection Report
Follow-Up
Deficiencies: 9
Jan 11, 2018
Visit Reason
This is a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies related to building maintenance and safety systems.
Findings
The facility was found to have unresolved deficiencies including chronic unpleasant odors, mechanical equipment not maintained clean, fire safety systems with gaps and obstructions, plumbing piping not safely installed, and lack of monthly fire safety equipment inspections.
Deficiencies (9)
| Description |
|---|
| Facility was not free of chronic unpleasant odors in Spa by Room 10 and bathroom in Hall, Room 14. |
| Mechanical vents and exhaust fans had heavy accumulation of dust on grilles and hardware. |
| Failure to maintain fire safety systems in a safe condition due to holes or gaps at penetrations through fire resistant ceilings. |
| Attic access hatch by Room 15 did not close tightly. |
| Escutcheon plates on sprinkler heads in multiple rooms had slipped down leaving gaps in ceilings and partial obstructions. |
| Door separating kitchen from dining area did not have a closer and did not close during fire alarm test. |
| Kitchen icemaker condensate drain line was not a minimum 2 inches above the drain. |
| Monthly in-house service checks for kitchen range hood suppression system were not conducted or logged. |
| Hole approximately 8 inches by 36 inches in wall of mechanical room to repair frozen pipe. |
Report Facts
Hole size: 288
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 8, 2017
Visit Reason
The Adult Care Licensure Section and the Gaston County Department of Social Services conducted an annual survey and complaint investigation on November 07 and November 08, 2017. The complaint investigation was initiated by the Gaston County Department of Social Services on September 19, 2017.
Findings
The facility failed to assure therapeutic diets were served as ordered for 2 of 6 sampled residents with texture modified diet orders. Additionally, the facility failed to administer medications as ordered for 2 of 5 sampled residents, including missed doses of digoxin and failure to administer prescribed eye medications.
Complaint Details
The complaint investigation was initiated by the Gaston County Department of Social Services on September 19, 2017.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to assure therapeutic diets were served as ordered for 2 of 6 sampled residents with texture modified diet orders, including serving pecan pie with nuts and not providing gravy or proper texture modifications. | — |
| Facility failed to administer medications as ordered for 2 of 5 sampled residents, including missed doses of digoxin and failure to administer prescribed artificial tears and bacitracin ophthalmic ointment. | Type B Violation |
Report Facts
Residents sampled for diet: 6
Residents sampled for medication: 5
Digoxin tablets available: 28
Digoxin tablets filled: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Responsible for supervising medication aides and ensuring medication orders are processed and followed |
| Dining Services Manager | Dining Services Manager | Responsible for training dietary cooks and ensuring residents receive foods appropriate to their diets |
| Executive Director | Executive Director | Responsible for oversight of Dietary Services Manager and facility management |
| Medication Aide | Medication Aide | Responsible for administering medications and notifying pharmacy for refills |
Inspection Report
Census: 78
Capacity: 78
Deficiencies: 16
Oct 18, 2017
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with building codes and licensing rules applicable to the facility.
Findings
Multiple deficiencies were identified related to physical plant conditions including fire safety system maintenance, housekeeping, mechanical and electrical equipment, lighting, ventilation, and safety hazards such as unsecured hand grips and protruding nails. Several fire safety components were missing or not functioning properly, and ventilation systems were inadequate.
Deficiencies (16)
| Description |
|---|
| Smoke barrier wall doors by Rooms 10 and 42 lacked required vision panels of labeled wire glass or fire rated glass. |
| Delayed egress doors (main entry and Magnolia Room exit) lacked required signage. |
| Outside grounds not maintained in a clean and safe condition; paint flaking on handrails and peeling sheetrock tape on porch ceiling. |
| Facility not free of chronic unpleasant odors in Spa by Room 10, A Hall Room 14 bathroom, and B Hall. |
| Walls, ceilings, plumbing fixtures, and mechanical equipment not kept in good repair; including water damage, damaged walls, unsecured toilet, and dust accumulation on vents and fans. |
| Facility not maintained free of hazards; unsecured hand grips, protruding nails, and sliding locksets on bathroom doors creating entrapment hazards. |
| Fire safety systems not maintained safe; missing escutcheon plates on sprinkler heads, gaps in rated ceilings, and unsealed conduit penetrations. |
| Delayed egress systems at exits by Room 34 and Magnolia Room not working (one corrected on site). |
| Mechanical equipment not maintained; missing grille in Business Office supply vent. |
| Electrical equipment unsafe; exterior GFCI outlets did not trip or lacked power and protective covers. |
| Fire safety doors (kitchen to dining) lacked closers and did not close properly during fire alarm test; door hardware loose. |
| Plumbing piping not installed/maintained safely; icemaker condensate drain line too low and floor drain blocked. |
| Fire safety equipment not inspected or maintained; kitchen range hood suppression system not serviced or logged monthly. |
| Dryer exhaust booster not working; heat and lint exhausted into laundry room creating fire hazard. |
| Corridor lighting inadequate; missing bulbs and covers resulting in dim lighting. |
| Exhaust ventilation inadequate; bathroom fans not working or weak, and exhaust system not operating in B Hall. |
Report Facts
Licensed capacity: 78
Addition bed count: 30
Inspection Report
Annual Inspection
Deficiencies: 4
Nov 6, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from November 3, 2015 to November 5, 2015 with an exit conference on November 6, 2015.
Findings
The facility was found deficient in tuberculosis testing for 2 of 5 sampled residents, inadequate supervision for 1 of 3 residents with falls, failure to notify the Primary Care Provider of medication refusal for 1 resident, and failure to implement blood pressure monitoring as ordered for 3 residents. Multiple violations were cited related to these issues.
Severity Breakdown
Type B Violation: 3
Type A2 Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to assure 2 of 5 sampled residents were tested for tuberculosis disease on admission in compliance with control measures. | Type B Violation |
| Failed to assure adequate supervision for 1 of 3 sampled residents with falls. | Type A2 Violation |
| Failed to notify the Primary Care Provider of refusal of Lasix for 1 of 5 sampled residents. | Type B Violation |
| Failed to implement blood pressure monitoring as ordered by prescribing practitioner for 3 of 5 sampled residents. | Type B Violation |
Report Facts
Refusals of Lasix: 46
Refusals of Lasix: 58
Refusals of Lasix: 16
Refusals of Lasix: 5
Blood pressure readings required: 13
Blood pressure readings documented: 7
Blood pressure readings required: 13
Blood pressure readings documented: 8
Blood pressure readings documented: 2
Blood pressure readings missing: 15
Blood pressure readings missing: 20
Blood pressure readings missing: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Interviewed regarding tuberculosis testing, medication refusals, and blood pressure monitoring. |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding resident care plans, blood pressure monitoring, and physician orders. |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration and documentation practices. |
| Executive Director | Executive Director | Interviewed regarding fall prevention interventions. |
Inspection Report
Capacity: 78
Deficiencies: 11
Oct 14, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with building codes and physical plant requirements for the facility licensed for 78 residents.
Findings
The facility failed to meet several physical plant and safety requirements including delayed egress door signage and function, clear exit paths, full sprinkler coverage, maintenance of walls, ceilings, floors, and furnishings, building safety including fire resistance and electrical/plumbing systems, and mechanical exhaust ventilation.
Deficiencies (11)
| Description |
|---|
| EXIT doors equipped with delayed egress system lacked required signage and one door did not release after 15 seconds. |
| Main entrance/exit path was congested with wheelchairs and walkers, narrowing accessible path to less than 6 feet. |
| Storage closet outside office was not equipped with a sprinkler head. |
| Walls, ceilings, and floors were scarred, stained, patched without finish coat, or water damaged; furniture and fixtures were chipped or rusted; strong odors present. |
| Grab bar beside commode in Resident Room 40 was loose and may not support full weight. |
| Unsealed penetrations in walls allowing possible spread of smoke beyond compartment of origin. |
| Missing blank in Electrical Panel B and an EXIT sign near Room 54 did not illuminate on battery. |
| Loose commode in Men's Room with water present at floor connection. |
| Duct smoke detector sampling tubes were dirty throughout the facility. |
| Corridor door to Employee Lounge did not close completely and latch. |
| Exhaust fans were not working in Resident Rooms 35 and 40. |
Report Facts
Licensed capacity: 78
Delayed egress time: 15
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