Inspection Reports for Brookdale Carriage Club Providence II
5816 Old Providence Road Charlotte, NC 28226, Charlotte, NC, 28226
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 27
Capacity: 34
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey from 04/22/24 through 04/23/24 to assess compliance with regulations for the facility.
Findings
The facility failed to ensure that 3 of 3 sampled residents residing in the Special Care Unit had documented signed SCU disclosure statements as required by regulation.
Deficiencies (1)
Facility failed to ensure 3 of 3 sampled residents (#1, #2, and #3) residing in the Special Care Unit had documented signed SCU disclosure statements.
Report Facts
Licensed capacity: 34
Census: 27
Residents sampled: 3
Inspection Report
Annual Inspection
Capacity: 34
Deficiencies: 7
Date: Apr 1, 2022
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey and complaint investigation from 03/29/22 through 04/01/22, initiated by a complaint on 03/22/22.
Complaint Details
Complaint investigation initiated by Mecklenburg County Department of Social Services on 03/22/22 related to care and supervision deficiencies.
Findings
The facility failed to ensure competency validation for medication aides, proper personal care and supervision for residents with pressure ulcers, timely and accurate medication administration, and completion of Special Care Unit resident profiles and care plans. Deficiencies included failure to apply protective booties and offload pressure for residents with wounds, failure to notify physicians of changes or medication needs, and failure to complete required staff training.
Deficiencies (7)
Failure to ensure competency validation for medication aides prior to administering medications.
Failure to provide personal care assistance to residents with pressure ulcers including application of protective booties and offloading pressure.
Failure to ensure health care referral and follow-up for residents with wounds and medication needs.
Failure to implement physician orders for foam protective booties for residents with pressure ulcers.
Failure to administer medications as ordered including missing doses of pain medication and incorrect dosing of seizure medication.
Failure to complete Special Care Unit Resident Profile and Care Plan within required timeframes for residents with pressure ulcers.
Failure to provide required Special Care Unit staff orientation and training within the first week of employment.
Report Facts
Medication error rate: 7
Facility capacity: 34
Medication doses missed: 19
Medication dose error: 50
Staff training hours required: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete medication clinical skills competency validation and Special Care Unit orientation training. |
| Staff C | Medication Aide | Failed to complete medication clinical skills competency validation and Special Care Unit orientation training. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 1, 2019
Visit Reason
This is a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies related to building equipment and fire safety systems.
Findings
The survey found that some deficiencies were not corrected, specifically gaps around pipes and sprinkler escutcheon in the riser room that could allow fire and smoke to spread beyond the area of origin.
Deficiencies (1)
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.
Inspection Report
Capacity: 34
Deficiencies: 10
Date: Jun 19, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with building codes and adult care home regulations applicable to the facility.
Findings
Multiple deficiencies were cited related to building code compliance, physical plant maintenance, housekeeping, fire safety systems, plumbing, electrical equipment, and exhaust ventilation. Specific issues included inadequate emergency release switches, poor outdoor lighting, water damage, hazards such as loose grab bars, fire safety system gaps, doors not latching properly, open electrical junction boxes, and non-functioning exhaust fans.
Deficiencies (10)
Facility does not meet building code requirements for emergency release switches on locked doors.
Inadequate outdoor lighting; porch light out at West Stair Exit.
Ceilings not kept in good repair; water damage and mildew stains in mechanical closet.
Floors not kept clean; rust residue around toilet base in Room 134.
Facility not free of hazards; cracked and loose grab bar in second floor half bath.
Failure to maintain fire safety systems; holes and gaps in fire resistant ceilings and walls.
Fire doors do not latch properly in multiple locations, compromising smoke compartment safety.
Plumbing equipment not maintained; loose toilet tank in Room 134 Bath.
Electrical equipment not maintained; multiple open junction boxes in elevator and electrical rooms.
Exhaust ventilation not provided in required areas; non-functioning exhaust fans in janitor closet, Room 134 bathroom, and second floor biohazard room.
Report Facts
Total licensed capacity: 34
Number of cleanouts with uncovered openings: 3
Number of open electrical junction boxes: 6
Inspection Report
Capacity: 34
Deficiencies: 3
Date: May 26, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with applicable building codes and adult care home licensing standards.
Findings
The facility was found to have deficiencies including failure to meet code requirements for special locking on the outside courtyard exit gate, inadequate housekeeping with excessive particulate buildup on HVAC vents, and failure to maintain building and fire safety equipment with unsealed penetrations in fire-rated ceilings.
Deficiencies (3)
Special Locking (magnetic locks) on the Outside Courtyard exit gate does not have a release switch, risking occupants being trapped in an emergency.
Failure to maintain and clean HVAC air-distribution vents; bathroom return-air grilles have excessive particulate buildup.
Failure to maintain building and fire safety equipment; penetrations in fire-resistant rated ceilings were not fire-stopped.
Report Facts
Licensed capacity: 34
Inspection Report
Capacity: 34
Deficiencies: 7
Date: Apr 22, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 1996 North Carolina State Building Code, and the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds.
Findings
The facility failed to maintain ceilings in good repair, maintain the building in a clean manner, keep the facility free of odors, maintain the building free of hazards, ensure emergency evacuation systems were properly maintained, and maintain the HVAC system in a safe and operating condition.
Deficiencies (7)
Ceiling tiles throughout the facility are uplifted, cracked, chipped, or broken.
Facility failed to maintain the building in a clean manner; door frames coated with dust and lint.
Facility failed to maintain the facility free of odors; distinct odor of urine in rooms 128 and 129.
Molding pieces restricting windows from opening more than 6 inches removed in rooms 131 and 132, posing a fall hazard.
Dryer exhaust vent disconnected in 1st Floor Laundry, causing lint accumulation and fire hazard.
Emergency evacuation EXIT signs failed to illuminate on battery power in multiple locations.
HVAC return vents coated with dust in many areas of the facility.
Report Facts
Licensed capacity: 34
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