Inspection Reports for Brookstone Terrace of Thomasville
915 West Cooksey Drive Thomasville, NC 27360, Thomasville, NC, 27360
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 9, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies related to building construction and safety systems.
Findings
The survey found that deficiencies cited in the previous Biennial Construction Survey remain uncorrected and one new deficiency was added. Specifically, the facility made modifications to the building's safety systems without submitting required construction documents, and there were fire safety issues including gaps around sprinkler heads due to removed caps.
Deficiencies (2)
Facility conducted modifications to the building's safety systems without submitting construction documents and specifications to DHSR/Construction for review, including special locking added to exit doors without plan submission.
Failure to maintain the building's fire safety systems in a safe condition due to holes or gaps at penetrations through fire resistant rated ceilings or walls, including gaps around sprinkler heads where caps were removed.
Report Facts
Number of exit doors with special locking: 5
Days to submit 'as built' drawings: 90
Inspection Report
Capacity: 62
Deficiencies: 6
Date: Jun 6, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with applicable building codes and adult care home regulations.
Findings
The facility was found deficient in maintaining fire safety rehearsals, electrical safety near wet locations, and the safe operating condition of building equipment including fire safety systems, plumbing, emergency lighting, and fire extinguishers.
Deficiencies (6)
Facility did not have records of fire rehearsals conducted quarterly on each shift.
Electrical receptacles near water sources lacked ground fault protection as receptacles behind the washing machine did not trip on test.
Failure to maintain fire safety equipment in a safe operating condition, including removed door closer on kitchen door, gaps at fire sprinkler escutcheons, covered exit sign, and closed fire damper in supply duct.
Plumbing equipment not maintained safely; ice machine drain lacked a 2" air gap.
Emergency lights in multiple locations did not illuminate when tested.
Portable fire extinguishers lacked required monthly inspection documentation.
Report Facts
Total licensed beds: 62
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 13, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 12/13/23 and 12/14/23 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in tuberculosis screening for one resident, failure to ensure physician follow-up for abnormal heart rate in another resident, and failure to administer medications as ordered for a resident with diabetes.
Deficiencies (3)
Facility failed to ensure 1 of 5 sampled residents (#4) were tested for Tuberculosis disease in compliance with guidelines.
Facility failed to ensure physician follow-up was completed for 1 of 5 sampled residents (#5) who had heart rate values outside of the ordered parameter without notifying the primary care provider.
Facility failed to administer medications as ordered for 1 of 5 sampled residents (#1) who had a medication ordered to treat diabetes; specifically, Ozempic was documented as administered when the medication pen was unopened and available in the refrigerator.
Report Facts
Sampled residents: 5
Heart rate out-of-parameter days: 9
Ozempic doses: 4
Finger stick blood sugar range: 75
Finger stick blood sugar range: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director (RCD) | Responsible for ensuring TB screening and notified about Resident #5's abnormal heart rate | |
| Administrator | Provided expectations regarding TB screening and medication administration | |
| Medication Aide (MA) | Notified PCP and RCD about Resident #5's abnormal heart rate and administered medications | |
| Pharmacist | Provided information about medication orders and dispensing | |
| Primary Care Provider (PCP) | Ordered monitoring and medication for residents; not notified timely of abnormal vital signs |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 29, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 06/28/22 through 06/29/22 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure proper referral and follow-up for a resident with medication refusals, failed to administer medications as ordered for two residents, and failed to ensure medication aides observed residents taking their medications before documenting administration.
Deficiencies (4)
Failed to ensure referral and follow-up to meet health care needs for a resident who had multiple medication refusals without notifying the primary care provider.
Failed to administer lorazepam as ordered, resulting in administration more than once daily when ordered once daily as needed.
Failed to administer warfarin as ordered, with missed doses documented.
Failed to observe a resident taking medications before documenting administration; medications were left in the resident's room without supervision.
Report Facts
Medication refusals: 8
Medication refusals: 7
Medication refusals: 12
Medication refusals: 7
Medication refusals: 18
Medication refusals: 35
Lorazepam administration: 5
Warfarin missed doses: 3
Warfarin INR goal range: 2.5
Warfarin INR goal range: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Documented medication refusals but failed to notify PCP as required. | |
| Resident Care Director (RCD) | Responsible for auditing eMARs and notifying PCP of medication refusals. | |
| Assistant Resident Care Director (ARCD) | Responsible for auditing eMARs and notification of PCP. | |
| Administrator | Expected staff to notify PCP and follow medication administration policies. | |
| Primary Care Provider (PCP) | Prescribed medications and expected notification of refusals and medication administration issues. | |
| Nurse Practitioner (NP) | Managed warfarin orders and expected proper administration. | |
| Memory Care Coordinator (MCC) | Administered warfarin and aware of medication delivery timing issues. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 8, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to health care and medication administration.
Findings
The facility failed to notify the primary care provider for one resident regarding blood pressure readings exceeding physician-ordered parameters and failed to assure medications were administered as ordered for two residents related to antihypertensive medication and a probiotic. Documentation and communication deficiencies were noted.
Deficiencies (3)
Facility failed to notify the primary care provider for Resident #2 regarding blood pressure readings exceeding ordered parameters.
Facility failed to assure medications were administered as ordered for Resident #3 related to antihypertensive medication (Clonidine).
Facility failed to assure medications were administered as ordered for Resident #5 related to probiotic Acidophilus.
Report Facts
Opportunities to notify PCP: 36
Opportunities to notify PCP: 33
Opportunities to notify PCP: 3
Episodes of elevated BP without Clonidine administration: 15
Tablets of Clonidine available: 21
Times Clonidine not administered by unaware MA: 10
Months Acidophilus not administered: 3
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 18, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey from April 16, 2019 to April 18, 2019 to assess compliance with regulations related to physical environment, medication administration, personal care and supervision, resident rights, and reporting requirements.
Findings
The facility failed to assure all exit doors were alarmed for a resident with dementia who eloped, failed to provide adequate supervision for residents with dementia and fall risks, failed to administer medications as ordered including a crushed enteric coated aspirin and missed doses of alprazolam resulting in hospitalization, failed to notify the county DSS of incidents requiring reporting, and failed to assure dignity and respect for a resident by placing her daily in a secured unit without access to her room or belongings.
Deficiencies (7)
Failed to assure 1 of 5 exit doors accessible for residents had an alarm activated for safety for a resident with dementia who eloped.
Failed to provide supervision for 2 of 5 residents with dementia exhibiting exit-seeking behaviors and repeated falls.
Failed to notify the primary care provider for 1 of 5 residents regarding consecutive missed doses of alprazolam resulting in hospitalization.
Failed to administer medications as ordered for 2 of 4 residents including crushing enteric coated aspirin and omission of allergy medication.
Failed to notify the county department of social services of incidents resulting in injury requiring emergency medical evaluation for 1 of 5 residents.
Failed to notify the county department of social services of incidents of neglect related to 1 of 5 residents who wandered from the facility.
Failed to assure dignity, respect and consideration for 1 resident by taking the resident to the secured unit daily for daycare without access to her bedroom, bathroom, or personal possessions.
Report Facts
Medication error rate: 7
Missed doses: 6
Missed doses: 8
Falls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Responsible for reviewing medication orders and sending incident reports to DSS |
| Administrator | Administrator | Responsible for facility oversight, aware of resident elopement and supervision issues |
| Mental health physician's assistant | Interviewed regarding Resident #1 elopement and supervision | |
| Primary care provider nurse practitioner | Interviewed regarding Resident #1 wandering and safety concerns | |
| Medication aide | Medication Aide | Interviewed regarding medication administration and supervision |
| Personal care aide | Personal Care Aide | Interviewed regarding supervision and resident care |
| Maintenance Director | Maintenance Director | Interviewed regarding door alarms and security |
| SCU Supervisor | Special Care Unit Supervisor | Interviewed regarding medication administration and falls |
| Pharmacy nurse | Interviewed regarding medication orders and administration | |
| Pharmacy representative | Interviewed regarding medication packaging and warnings |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jan 29, 2019
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to assess compliance with physical plant and safety regulations.
Findings
The survey found multiple deficiencies including unsafe outside premises due to soil erosion around a fence post, emergency equipment not maintained such as non-illuminating exit signs and uninspected fire doors, corridor doors with holes patched improperly, and fire sprinkler system components missing escutcheon plates exposing openings that could allow smoke and heat spread.
Deficiencies (5)
Outside grounds not maintained in a clean and safe condition; fence post soil washed away.
Building emergency equipment not maintained; exit sign near Bedroom 303 did not illuminate on backup power.
Automatic roll-down fire door between Kitchen and Dining not inspected and tagged as required.
Corridor doors had holes patched with Bondo, which is not an acceptable repair for fire rated doors.
Fire sprinkler heads missing or with improperly fitted escutcheon plates exposing openings allowing spread of smoke and heat.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding battery backorder for exit sign, fire door inspection status, and escutcheon plate orders. |
Inspection Report
Capacity: 62
Deficiencies: 14
Date: Dec 5, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted on December 5, 2018, to assess compliance with physical plant, fire safety, and building maintenance regulations for the facility licensed for 62 beds including a 14-bed Special Care Unit.
Findings
Multiple deficiencies were cited including failure to maintain current fire safety inspection reports, exit door locks not operable by single hand motion, unsafe outside premises, hazards related to unsecured oxygen cylinders, missing towel bars, malfunctioning emergency and fire safety equipment, corridor doors not smoke resistant, fire sprinkler system issues, and unsafe electrical system conditions.
Deficiencies (14)
Facility failed to maintain current annual fire marshal inspection report.
Exit door locks not easily operable by single hand motion without keys.
Outside grounds not maintained in a clean and safe condition due to rotten fence post.
Oxygen cylinders not secured, creating hazard of dangerous projectile if fallen.
Broken toilet paper dispenser mounting brackets with sharp edges present injury hazard.
Facility failed to provide required individual towels and towel bars in resident bedrooms.
Emergency equipment including emergency lights and exit signs not maintained in safe operating condition; automatic roll-down fire doors not inspected or tagged as required.
Corridor doors had holes and gaps allowing passage of smoke, compromising fire safety.
Fire-resistance-rated ceiling penetrations not properly firestopped, allowing spread of smoke and heat.
Egress from some areas impeded by locking mechanisms requiring keys or special knowledge.
Fire sprinkler heads missing escutcheon plates or plates not covering holes, allowing smoke and heat spread.
Fire sprinkler heads obstructed by stored items within 18 inches below sprinkler heads.
Corridor doors held open with devices blocked from closing by furniture, and doors not coordinated to latch properly.
Electrical system unsafe due to use of multi-plug adaptors without overcurrent protection and extension cords powering decorations under doors.
Report Facts
Total licensed beds: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor | Conducted the Construction Section Biennial Survey. |
| Executive Director | Interviewed regarding lack of current fire marshal inspection report. | |
| Maintenance Director | Interviewed regarding lack of current fire marshal inspection report and fire door maintenance. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 10, 2017
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to assess the correction of previously cited deficiencies related to building equipment and fire safety.
Findings
The inspection found that the building fire safety and sprinkler system were not maintained in a safe and operating condition, with specific issues including unsealed penetrations in fire-resistance-rated ceiling assemblies and incomplete coverage of fire sprinkler cover plates, potentially exposing residents and staff to fire and smoke hazards.
Deficiencies (3)
Exterior Mechanical Room near Maintenance Office had a 2 inches x 3 inches hole with refrigerant piping not firestopped as it penetrates the fire-resistance-rated ceiling assembly.
Break Room's Mechanical Room had a gap approximately 3 inches wide in the ceiling between the back wall and the mechanical equipment that was not sealed.
Housekeeping near Bedroom 107 had a concealed fire sprinkler cover plate assembly that did not cover the complete hole through the fire-resistance-rated ceiling, allowing the spread of smoke and heat into the attic.
Inspection Report
Capacity: 62
Deficiencies: 11
Date: Mar 13, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with building, sanitation, fire safety, and physical plant regulations for the facility licensed for 62 beds including a 14-bed Special Care Unit.
Findings
Multiple deficiencies were cited including failure to maintain current sanitation and fire safety inspection reports, improper storage of portable medical oxygen cylinders, inadequate housekeeping, failure to maintain fire extinguishers and emergency equipment, fire safety code violations including fire door and sprinkler system issues, and failure to maintain hot water temperature within required limits.
Deficiencies (11)
Facility failed to maintain current annual sanitation and fire safety inspection reports.
Portable medical oxygen cylinders were not properly secured, creating hazards.
Facility failed to maintain building in a clean manner; excessive dust/lint and grease accumulation in kitchen HVAC.
Fire extinguishers and associated equipment were not properly maintained; missing monthly inspections and outdated annual maintenance.
Emergency lighting did not illuminate on backup power in multiple corridors.
Fire safety issues including blocked radiation dampers, unsealed penetrations in fire-resistance-rated assemblies, open attic access door, detaching gypsum construction, and missing firestopping.
Automatic roll-down fire door between kitchen and dining had not been inspected as required.
Interior doors not maintained in safe and operating condition; smoke seals missing or falling out, doors wedged or held open preventing proper closure.
Building sprinkler system not maintained; fire sprinkler cover plates missing or dropped, exposing openings allowing smoke and heat spread.
Commercial kitchen hood fire suppression system lacked required inspections, maintenance, and documentation.
Hot water temperature at plumbing fixtures used by residents was below the required minimum of 100 degrees Fahrenheit.
Report Facts
Total licensed beds: 62
Date of inspection: Mar 13, 2017
Hot water temperature range: 88
Hot water temperature range: 90
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 14, 2016
Visit Reason
The Adult Care Licensure Section and the Davidson County Department of Social Services conducted an annual survey on April 13-14, 2016 with an exit conference on April 15, 2016.
Findings
The facility failed to ensure staff tuberculosis testing compliance and failed to implement proper infection control procedures related to glucometer use and disinfection, resulting in multiple deficiencies including improper labeling, inconsistent glucometer cleaning, and inaccurate documentation of fingerstick blood sugar (FSBS) readings for residents.
Deficiencies (2)
Failed to assure that 1 of 6 sampled staff was tested upon employment for Tuberculosis disease in compliance with control measures.
Failed to implement infection control procedures consistent with CDC guidelines regarding sharing and proper disinfection of glucometers for 4 of 4 sampled residents.
Report Facts
Staff sampled for TB testing: 6
Residents sampled for glucometer infection control: 4
FSBS values expected: 19
FSBS values recorded: 10
FSBS values expected: 45
FSBS values recorded: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in tuberculosis testing deficiency for failure to have current TB test upon re-hire | |
| Resident Care Coordinator | Responsible for ensuring staff TB testing and glucometer infection control compliance; interviewed multiple times regarding deficiencies | |
| Medication Aide | Multiple Medication Aides interviewed regarding glucometer cleaning and FSBS testing procedures |
Inspection Report
Annual Inspection
Capacity: 62
Deficiencies: 10
Date: Dec 5, 2014
Visit Reason
This is a biennial survey conducted to assess compliance with the 1991 Homes for the Aged Minimum and Desired Standards and Regulations, applicable portions of the 2005 Licensing of Adult Care Homes of Seven or More Beds, and the 1991 North Carolina State Building Code.
Findings
The facility was found deficient in several areas including failure to label delayed egress signage on the courtyard gate, improper storage of oxygen bottles, non-illuminating exit signs and emergency lights, malfunctioning GFCI receptacle, lack of access to HVAC duct detection tubes, broken roll-down fire door, and compromised fire resistance due to propped open doors and blocked corridors.
Deficiencies (10)
Courtyard gate equipped with a 15-second delayed egress system but missing required delayed egress signage.
Oxygen bottles stored in an unapproved container that does not provide adequate support in Room 101.
Exit signs at Breezeway Entrance and Room 401 did not illuminate on battery power.
Emergency lights on the 100 Hall did not illuminate on battery power.
GFCI receptacle in Men's Room at Main entrance did not reset after testing.
HVAC ducts in The Cottage lack access to duct detection sampling tubes.
Roll-down fire door in kitchen area of The Cottage is broken and does not operate.
Corridor door to Sun Porch is propped open with a door stop, compromising fire resistance.
One corridor double door blocked by a large stack of chairs.
Kick-down device present on Beauty Shop corridor door.
Report Facts
Total licensed beds: 62
Delayed egress time: 15
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