Inspection Reports for Aldersgate
3800 Shamrock Dr, Charlotte, NC 28215, United States, NC, 28215
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe transfers using a mechanical lift, which resulted in a resident sustaining a left distal femur fracture.
Complaint Details
The investigation was complaint-related, focusing on an injury of unknown source to Resident #79. The resident sustained a left distal femur fracture after being transferred with a mechanical lift. Staff interviews and investigation did not conclusively determine the cause of the injury, though unsafe transfer practices were noted. The complaint was substantiated with findings of actual harm.
Findings
The facility failed to ensure safe transfers for Resident #79, who required a mechanical lift and two-person assistance. Nursing Assistant #1 transferred the resident alone on 8/30/25, after which the resident complained of left leg pain and was later diagnosed with a left distal femur fracture requiring surgery. Staff interviews revealed inconsistent statements about assistance during transfers, and the cause of the fracture remained inconclusive but suspected to be related to a fall or trauma.
Deficiencies (1)
Failure to provide safe transfers using a mechanical lift, resulting in a resident sustaining a left distal femur fracture.
Report Facts
Residents reviewed for accidents: 3
Date of fracture surgery: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Nursing Assistant | Transferred Resident #79 alone using mechanical lift on 8/30/25. |
| Nursing Assistant #2 | Nursing Assistant | Reported not assisting with transfers of Resident #79 on 8/30/25. |
| Nursing Assistant #3 | Nursing Assistant | Notified Nurse #3 of Resident #79's leg pain on 8/30/25. |
| Nurse #3 | Nurse | Assessed Resident #79's leg pain and coordinated x-ray and care. |
| Medical Director | Medical Director | Provided medical opinion on fracture cause and resident cognition. |
| Director of Nursing | Director of Nursing | Conducted investigation and reviewed staff statements. |
| Administrator | Administrator | Notified of injury and commented on investigation and safety concerns. |
| Private Caregiver | Licensed Occupational Therapy Assistant | Provided care and reported resident's pain and condition on 8/30/25. |
| Activities Director | Activities Director | Observed resident at Bingo and reported no incidents during activity. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 30, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident care, including dignified dining assistance, abuse reporting and investigation, safe transfers, medication storage, and food safety practices.
Complaint Details
The complaint investigation included allegations of undignified feeding practices, failure to report and investigate an injury of unknown source, unsafe mechanical lift transfers causing injury, improper medication storage, and food safety violations. The injury of unknown source was reported to the state survey agency but not to Adult Protective Services. The investigation was incomplete and inconsistent statements from staff were not fully explored.
Findings
The facility was found deficient in multiple areas: failure to provide dignified dining assistance by staff standing while feeding residents; failure to properly report and investigate an injury of unknown source to Adult Protective Services; unsafe mechanical lift transfers resulting in a resident's femur fracture; improper storage of prescription topical medications outside locked cabinets; and food safety violations including improper scoop storage, outdated food items, and failure to use facial hair coverings in the kitchen.
Deficiencies (5)
Failed to promote a dignified dining experience by assisting residents with eating while standing.
Failed to implement abuse policy and procedures including reporting injury of unknown source to Adult Protective Services and thoroughly investigating the injury.
Failed to provide safe transfers using a mechanical lift, resulting in a resident's acute comminuted left femur fracture.
Failed to store prescription topical medicated cream and powder in secure locked storage areas, leaving them accessible at bedside and bathroom counters.
Failed to ensure scoops were stored properly to prevent cross-contamination, discarded outdated prepared food items, and required facial hair coverings in food preparation areas.
Report Facts
Residents reviewed for accidents: 3
Use by dates of outdated food items: 2
Dates of medication orders: 2
Dates of fracture surgery and hospital discharge: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #5 | Nurse Aide | Named in undignified dining assistance finding for standing while feeding residents. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding feeding assistance training and medication storage. |
| Administrator | Administrator | Interviewed regarding expectations for dignified dining, abuse reporting, medication storage, and food safety. |
| Director of Nursing | Director of Nursing | Completed investigation report on injury of unknown source; unavailable for interview. |
| Nurse Aide #1 | Nurse Aide | Involved in mechanical lift transfers of Resident #79 without assistance. |
| Nurse Aide #2 | Nurse Aide | Interviewed regarding assistance with Resident #79 transfers. |
| Nurse #3 | Nurse | Assessed Resident #79's leg pain and coordinated x-ray and care. |
| Private Caregiver | Licensed Occupational Therapy Assistant | Provided care and reported Resident #79's leg pain and swelling. |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety violations including scoop storage and facial hair covering. |
| Nurse #5 | Nurse | Interviewed regarding medication storage practices for Resident #21. |
| Nurse Aide #6 | Nurse Aide | Interviewed regarding Resident #21's self-application of medications. |
| Physician Assistant #1 | Physician Assistant | Interviewed regarding medication storage policies. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 16, 2024
Visit Reason
The inspection was conducted based on complaints and concerns related to resident participation in care planning, Medicare non-coverage notices, timely completion of assessments, nursing staff competency, medication storage, food safety, and infection control practices.
Complaint Details
The complaint investigation was substantiated with findings of failure to invite a resident to care plan meetings, failure to obtain required Medicare Non-Coverage signatures, delayed assessments, nurse incompetency in infection control leading to immediate jeopardy, expired medications in storage, and improper food labeling and storage.
Findings
The facility was found deficient in multiple areas including failure to invite a cognitively intact resident to participate in care plan meetings, failure to obtain signed Medicare Non-Coverage notices, delayed completion of Minimum Data Set assessments, inadequate nurse competency in disinfecting shared glucometers leading to immediate jeopardy, failure to remove expired medications from storage, improper labeling and dating of food items, and failure to follow infection prevention protocols for glucometer disinfection.
Deficiencies (7)
Failed to invite a cognitively intact resident to participate in care plan meetings.
Failed to have a signed Notice of Medicare Non-Coverage letter prior to discharge for a resident.
Failed to complete a comprehensive Minimum Data Set assessment within 14 days of the Assessment Reference Date.
Failed to ensure nurse competency in disinfecting shared blood glucose meters, resulting in immediate jeopardy to resident health or safety.
Failed to remove expired medications from medication storage room refrigerator.
Failed to label and date leftover food items stored in dry goods storage, walk-in cooler, and resident nourishment room refrigerators.
Failed to follow manufacturer's instructions for cleaning and disinfection of shared blood glucose meters between resident usage.
Report Facts
Residents reviewed for participation in care plan meetings: 4
Residents reviewed for Medicare Non-Coverage notice: 3
Residents reviewed for Minimum Data Set assessment timeliness: 4
Nursing staff reviewed for competency: 3
Expired medication quantity: 81
Glucometers disinfected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Failed to demonstrate competency in disinfecting shared blood glucose meters; observed not disinfecting glucometer per manufacturer's instructions. |
| Social Worker #1 | Social Worker | Responsible for NOMNC forms and care plan meeting scheduling; acknowledged failure to obtain Resident #307's NOMNC signature. |
| MDS Coordinator #1 | MDS Coordinator | Reported care plan meeting scheduling process and acknowledged missed timely completion of Resident #8's MDS assessment. |
| Director of Nursing | Director of Nursing (DON) | Provided expectations on care plan meetings, MDS assessments, and glucometer disinfection; acknowledged Nurse #1's failure. |
| Administrator | Administrator | Stated expectations for resident invitations to care plan meetings, NOMNC signatures, medication expiration checks, food labeling, and glucometer disinfection. |
| Nurse #2 | Nurse | Responsible for medication room refrigerator where expired medications were found. |
| Infection Preventionist | Infection Preventionist | Provided training on glucometer disinfection; confirmed Nurse #1 missed recent training; described infection control risks. |
| Dietary Manager | Dietary Manager | Reported on food labeling and storage practices in resident common area refrigerators. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements for Asbury Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide communication in a resident's language, unresolved resident council grievances about food service, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans especially regarding communication and anticoagulant medication, failure to honor resident dietary preferences, failure to discard expired food items, and ineffective Quality Assessment and Assurance (QAA) program to sustain corrective actions.
Deficiencies (7)
Failed to provide communication to a resident in a language she could understand (Resident #4).
Failed to resolve group grievances brought to resident council meetings regarding missing food items over four consecutive months.
Failed to accurately code the admission Minimum Data Set (MDS) assessment for Resident #4.
Failed to develop comprehensive care plans addressing communication and anticoagulant medication needs for residents.
Failed to obtain and honor a resident's dietary preferences (Resident #4).
Failed to discard expired food items in freezers, refrigerators, and dry storage rooms in satellite kitchens.
Failed to maintain effective Quality Assessment and Assurance (QAA) program to monitor and sustain corrective actions related to food procurement and safety.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #2 | Responsible for completing BIMS assessment and care planning for Resident #4; failed to document language barrier and use language line. | |
| Nurse Aide #1 | Assigned to Resident #4; unable to communicate effectively due to language barrier and lack of communication tools. | |
| Life Enrichment Director | Activities Director | Handled resident activities; unaware of need to use communication board or language line for Resident #4. |
| Administrator | Expected interpreter services to be documented; unaware of unresolved grievances and expired food issues; sent reminders about language line use. | |
| Culinary Director | Implemented computer tablets for meal orders; acknowledged dietary staff turnover and communication breakdowns. | |
| Director of Nursing | DON | Expected accurate MDS coding and care plans; acknowledged anticoagulant medication as high-risk requiring care plan inclusion. |
| Kitchen Ambassador | Completed pureed menus for Resident #4 without family input due to language barrier. | |
| Dietician | Usually contacts family for dietary preferences; did not contact Resident #4's family. | |
| Culinary Chef | Responsible for labeling and discarding expired foods; noted vague guidance on shelf life. | |
| Assistant Culinary Chef | Participated in food storage observations. |
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