Inspection Reports for Brookdale Winston-Salem

NC, 27104

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Inspection Report Follow-Up Deficiencies: 2 Jun 13, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies related to building and fire safety code compliance.
Findings
The facility failed to meet fire-resistance-rated construction requirements and did not maintain self-closing fire-rated doors properly, specifically in the kitchen pantry area, which could affect occupant safety during evacuation.
Deficiencies (2)
Description
Pantry door was not a ¾ hour fire-resistant-rated door as required.
Self-closing fire-rated doors did not remain self-closing due to an unapproved mechanical kick down holder holding the kitchen pantry door open.
Inspection Report Annual Inspection Census: 38 Deficiencies: 10 Apr 11, 2024
Visit Reason
This was a Construction Section Biennial Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for Licensing of Adult Care Homes and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited including failure to meet fire sprinkler and fire-resistance-rated construction requirements, lack of current sanitation and fire safety reports, chronic unpleasant odors due to evaporated water seals in floor drains, inadequate fire safety rehearsals on each shift, unsafe and non-operating building equipment including smoke tight corridor doors and electrical receptacles, and failure to provide working exhaust ventilation in required spaces.
Deficiencies (10)
Description
Fire sprinkler system did not protect all required areas, including the Break Room Porch canopy.
Pantry door was not a ¾ hour fire-resistant-rated door as required.
Unresolved deficiencies from the last annual Fire Sprinkler System Inspection in November 2023.
Chronic unpleasant odors due to evaporated water seals in floor drains in D Hall Laundry allowing sewer gases to enter the building.
Fire safety rehearsals were not performed regularly on each shift quarterly as required.
Smoke tight corridor doors in A Wing Bedrooms A6 and A7 had gaps not allowed by code.
Fire-resistance-rated ceiling penetrations were not properly firestopped in multiple mechanical rooms and Program Coordinator area.
Fire-rated doors were held open by a rubber bungee cord in the Kitchen Pantry.
Ground-fault circuit-interrupter (GFCI) electrical receptacle near Meat Prep Sink did not trip when tested.
Exhaust fans in D Hall were not removing any air, failing to provide required ventilation.
Report Facts
Residents served: 38 Width of Break Room Porch canopy: 6 Pantry size: 100 Date of last Fire Sprinkler System Inspection: 202311
Inspection Report Annual Inspection Deficiencies: 5 Oct 26, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on October 25 and 26, 2023.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication administration and physician notification for a resident's blood pressure medication, failure to serve nutritionally adequate and therapeutic diets as ordered for residents, failure to provide adequate furnishings for residents to eat in their rooms, and failure to implement CDC recommended infection prevention and control practices related to PPE during a COVID-19 outbreak.
Deficiencies (5)
Description
Failed to ensure referral and follow-up to meet routine healthcare needs for 1 of 5 residents related to administration of blood pressure medication and notifying physician of low blood pressure reading.
Failed to ensure residents were served nutritionally adequate meals for 2 of 5 residents sampled.
Failed to serve therapeutic diets as ordered for 2 of 3 sampled residents who had an order for textured modified diet.
Failed to ensure residents were treated with respect and dignity by not providing adequate furnishings for residents to eat in their rooms.
Failed to ensure CDC recommended infection prevention and control practices were implemented related to PPE during a COVID-19 outbreak; staff did not consistently wear full PPE including face shields when entering rooms of residents positive for COVID-19.
Report Facts
Residents tested positive for COVID-19: 4 Residents sampled for medication administration deficiency: 5 Residents sampled for nutritional adequacy deficiency: 5 Residents sampled for therapeutic diet deficiency: 3
Employees Mentioned
NameTitleContext
Medication AideAdministered lisinopril to Resident #2 without holding medication for low blood pressure as ordered.
Resident Care Coordinator (RCC)Entered new orders into eMAR and interviewed regarding medication and diet deficiencies.
Health Wellness Director (HWD)Entered orders into eMAR and interviewed regarding medication and diet deficiencies and PPE compliance.
Executive Director (ED)Interviewed regarding expectations for medication administration, diet compliance, resident dignity, and PPE use.
Lead CookInterviewed regarding failure to follow therapeutic diet menus.
Food Services Director (FSD)Interviewed regarding diet menu compliance and meal preparation.
Personal Care Assistant (PCA)Interviewed regarding meal service and PPE use during COVID outbreak.
Infectious Disease NurseInterviewed regarding COVID outbreak and PPE guidance.
Inspection Report Annual Inspection Deficiencies: 1 Oct 1, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 09/30/21 and 10/01/21 to evaluate compliance with licensed health professional support requirements.
Findings
The facility failed to ensure that Licensed Health Professional Support (LHPS) assessments were completed within 30 days of admission and quarterly thereafter for 3 of 5 sampled residents with LHPS tasks. The LHPS nurse position was vacant since August 2021, and corporate nurses were filling the role temporarily.
Deficiencies (1)
Description
Failure to ensure LHPS assessment was completed within 30 days of admission and quarterly thereafter for residents with LHPS tasks.
Report Facts
Sampled residents with LHPS tasks: 3 Sample size: 5 Date survey completed: Oct 1, 2021
Employees Mentioned
NameTitleContext
AdministratorInterviewed on 10/01/21 at 3:45pm regarding LHPS nurse vacancy and assessments.
Registered NurseCorporate RNInterviewed on 10/01/21 at 11:40am regarding LHPS assessments and nurse vacancy.
Inspection Report Census: 38 Deficiencies: 15 Nov 21, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with licensure, building codes, and physical plant requirements for an adult care home.
Findings
Multiple deficiencies were noted including failure of fire alarm exit doors to release, non-operational override switches, unclean ceilings and equipment, damaged floors and furnishings, unsafe and non-operating electrical and fire safety equipment, and plumbing equipment not maintained in safe condition.
Deficiencies (15)
Description
C Hall Exit door did not release upon fire alarm activation.
SCU Courtyard gate override switch is no longer operational.
Exhaust fans had heavy accumulations of dust and lint.
Sheetrock around attic access panel is loose and sagging.
HVAC grilles in kitchen have heavy coating of grease.
Kitchen floor behind entry door had excessive dirt and food particles.
B Hall Spa shower wing walls are water damaged and cove base not adhering.
Door hardware in Room C-8 is loose.
Emergency light in Sunroom did not illuminate on test.
Exit signs in Large Family Room did not appear illuminated.
Canned lights in corridors missing protective boxing in fire rated ceiling assemblies.
Items stored to ceiling along top shelves in Kitchen Pantry obstruct sprinkler heads.
Electrical outlets at B Hall Half Bath sink and Service Hall Housekeeping not secure to wall.
Hair washing sink in Beauty Salon not secure and lifts easily from counter.
Hinges loose on D Hall Spa door requiring excessive force to close and latch.
Report Facts
Number of residents served at initial licensing: 38
Inspection Report Follow-Up Deficiencies: 3 Mar 1, 2018
Visit Reason
This is a biennial follow-up construction survey conducted to assess compliance with physical plant requirements and to verify correction of previous deficiencies.
Findings
The facility's locking system did not meet licensure and code requirements at the time of construction or alteration. Specifically, there was no locking diagram posted at the fire alarm panel, and the emergency override switch for the special locking system near the front door was not labeled.
Deficiencies (3)
Description
Facility's locking system did not meet licensure and code requirements in effect at the time of construction or alteration.
No locking diagram posted at the fire alarm panel.
Emergency override switch for the special locking system near the front door is not labeled.
Inspection Report Follow-Up Deficiencies: 3 Jan 10, 2018
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies related to the facility's physical plant and construction compliance.
Findings
Deficiencies remain related to the facility's locking system, which lacks a master override switch for certain doors, and the absence of a locking diagram posted at the fire alarm panel. Additionally, ceilings were found not to be kept clean and in good repair, with water damage and mildew spots observed around an HVAC supply vent.
Deficiencies (3)
Description
Facility's locking system did not meet licensure and code requirements; no master override switch for front entry door and enclosed courtyard gate.
No locking diagram posted at the fire alarm panel.
Ceilings not kept clean and in good repair; water damage and black mildew spots around HVAC supply vent in B Hall exit corridor.
Inspection Report Census: 38 Deficiencies: 9 Nov 2, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and fire safety regulations for an adult care home.
Findings
Multiple deficiencies were identified including failure of the locking system to meet code requirements, poor housekeeping and maintenance issues such as damaged walls and ceilings, hazards due to obstructions, inadequate fire safety rehearsals, failure to maintain fire safety equipment and systems, unsafe electrical outlets, improper plumbing configurations, and insufficient exhaust ventilation in designated areas.
Deficiencies (9)
Description
Facilities locking system did not meet licensure and code requirements; no master override switch for maglocks; no locking diagram posted at fire alarm panel.
Walls and ceilings not kept clean and in good repair; damaged box for AC equipment; damaged shower base; mildew and water damage on ceilings.
Facility not maintained free from hazards; obstructions in front of electrical panels; nails with sharp edges on doors.
Facility not conducting quarterly fire drills on each shift as required; fire drill reports incomplete.
Failure to maintain building's fire safety components in safe operating condition; doors propped open with carts and wedges; doors not latching properly.
Fire safety systems compromised by holes or gaps at fire resistant ceiling penetrations; sprinkler head escutcheon plates dropped or unsecured.
GFCI electrical outlets damaged or non-functional in multiple locations.
Plumbing piping improperly installed without required air gap on icemaker drain line.
Facility did not provide exhaust ventilation at required rate in designated areas; bathroom exhaust fans not working (corrected during survey).
Report Facts
Residents served: 38 Fire drills conducted on first shift: 7 Fire drills not conducted on second shift: 1 Delayed egress door press time: 15 Required clearance in front of electrical panels: 36 Exhaust ventilation rate: 2 Air gap requirement: 2
Inspection Report Follow-Up Deficiencies: 3 Mar 24, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale Winston-Salem.
Findings
Some deficiencies were not corrected, including failure to meet NC State Building Code requirements for exit door locking arrangements and unsafe building maintenance related to fire-resistance and exit signage.
Deficiencies (3)
Description
The facility does not meet NC State Building Code requirements for exit door locking arrangements; emergency release switch is installed 11 feet away instead of within 3 feet of the door.
Building was not maintained in a safe manner by not maintaining the fire-resistance rating of building components, affecting smoke and fire containment.
Exit signage was not maintained in a safe manner; exit signs at front and rear exits to Day Room do not illuminate.
Report Facts
Distance of emergency release switch from exit door: 11 Required maximum distance for emergency release switch: 3
Inspection Report Census: 38 Deficiencies: 7 Jan 6, 2016
Visit Reason
This report is of a Biennial Construction Survey conducted to assess compliance with the 1996 and 2005 Rules for Licensing of Adult Care Homes and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were noted including noncompliance with building code requirements for exit door locking, lack of current sanitation and fire safety inspection reports, failure to conduct fire safety rehearsals on each shift quarterly, unsafe building maintenance such as unprotected penetrations and doors not closing properly, non-functioning exit signage, and inadequate exhaust ventilation in certain areas.
Deficiencies (7)
Description
Facility does not meet NC State Building Code requirements for exit door locking arrangements; front door lacks an on/off emergency release switch within 3 feet of the door.
Current sanitation and fire safety inspection reports were not available at the time of survey, including sanitation report, sprinkler annual inspection, and documentation of monthly kitchen range hood suppression system inspections.
Fire drills are not being performed on each shift each quarter; records indicate no 3rd shift fire drills in 2nd quarter of 2015.
Building not maintained safely; multiple unprotected penetrations in walls and ceilings, gaps around doors, loose fire collars, and open ceiling hatch compromising fire-resistance rating.
Facility components not maintained operable; several doors have issues such as broken casing, wedged open, or not closing and latching properly.
Exit signage not maintained; several exit signs do not illuminate, affecting visibility in emergencies.
Building exhaust ventilation not maintained; exhaust fan in bathroom of room D6 is not working.
Report Facts
Residents served: 38 Fire drills missing: 1

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