Inspection Report
Follow-Up
Deficiencies: 1
Sep 24, 2025
Visit Reason
The Adult Care Licensure Section completed a follow-up visit and complaint investigation from September 23, 2025 to September 24, 2025.
Findings
The facility failed to ensure referral and follow-up to meet the acute health care needs for 1 of 5 sampled residents (#3) related to not notifying the pharmacy and the provider when medications for high cholesterol and vitamin deficiency were not delivered after being re-ordered.
Complaint Details
This visit was complaint-related and included a follow-up investigation. The complaint involved failure to notify pharmacy and provider about missing medications for Resident #3. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Failed to ensure referral and follow-up to meet acute health care needs for Resident #3 due to lack of notification to pharmacy and provider when atorvastatin calcium and cyanocobalamin medications were not delivered after re-order. |
Report Facts
Missed doses: 5
Missed doses: 3
Medication supply: 29
Medication supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Responsible for calling pharmacy to follow-up on missing medications and notifying primary care physician; interviewed multiple times. | |
| Medication Aide (MA) | Agency MA responsible for sending refill requests and notifying HWD; failed to notify about missing medications. | |
| Administrator | Interviewed regarding responsibilities for medication reorder and notification. | |
| Pharmacist | Contracted pharmacy pharmacist interviewed regarding medication orders and refills. |
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 17, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from 07/15/25 to 07/17/25 at Brookdale Carriage Club Providence I.
Findings
The facility failed to ensure 6 of 6 sampled residents had care plans signed by a physician or extender within 15 days of assessment, failed to revise a care plan after a significant change for 1 resident, failed to provide supervision for a resident with dementia who eloped, and failed to administer medications as ordered for 3 residents. Additionally, the facility failed to maintain accurate medication administration records for 2 residents.
Complaint Details
The visit included a complaint investigation related to care plan signatures and supervision of a resident with dementia who eloped.
Severity Breakdown
Type B Violation: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 6 of 6 sampled residents had care plans signed by a physician or extender within 15 days of assessment. | — |
| Failed to revise care plan for 1 of 6 sampled residents after significant change and dementia diagnosis. | — |
| Failed to provide supervision for 1 of 6 sampled residents with dementia who eloped from the facility. | Type B Violation |
| Failed to administer medications as ordered for 3 of 6 sampled residents related to Parkinson's disease, blood pressure, cholesterol, glaucoma, potassium levels, nerve pain, and mental health medications. | Type B Violation |
| Failed to ensure electronic Medication Administration Records (eMARs) were accurate for 2 residents related to documentation of medication administration and omissions. | — |
Report Facts
Residents with unsigned care plans: 6
Missed medication administration opportunities: 89
Medication administration opportunities: 93
Medication administration opportunities: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for completing care plan assessments and updating care plans; unaware of signature requirements; responsible for medication refill notifications. |
| Administrator | Administrator | Unaware of care plan signature requirements; responsible for oversight of care plans and medication administration processes. |
| Medication Aide | Medication Aide | Administered medications; responsible for documenting medication administration and notifying pharmacy and Health and Wellness Director of medication issues. |
| Resident Care Coordinator | Resident Care Coordinator | Expected to be notified of medication refill issues and missed doses; performed spot checks of eMARs. |
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 10, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey, follow-up survey, and complaint investigation from 02/08/2022 to 02/10/2022 with an exit conference via telephone on 02/10/2022.
Findings
The facility failed to ensure one resident had completed required tuberculosis testing upon admission and failed to administer medications as ordered for two residents related to missing or unavailable medications on the medication cart.
Complaint Details
Complaint investigation was part of the visit; specific substantiation status not stated.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 1 of 4 residents had completed tuberculosis testing upon admission in compliance with control measures. |
| Facility failed to administer medications as ordered for 2 of 5 sampled residents related to Hyoscyamine Sulfate and lorazepam not being available or administered as prescribed. |
Report Facts
Residents sampled for TB testing: 4
Residents sampled for medication administration: 5
Lorazepam administrations in December 2021: 10
Lorazepam administrations in January 2022: 2
Hyoscyamine Sulfate tablets sent by pharmacy: 15
Hyoscyamine Sulfate tablets sent by pharmacy: 90
Hyoscyamine Sulfate tablets sent by pharmacy: 90
Lorazepam tablets dispensed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for ensuring residents had required TB tests and medication management; interviewed regarding deficiencies. |
| Administrator | Administrator | Interviewed regarding oversight and responsibility for medication management and chart audits. |
| Medication Aide | Medication Aide | Interviewed regarding medication administration and availability on medication cart. |
| Pharmacy Technician | Pharmacy Technician | Interviewed regarding medication dispensing and pharmacy communications. |
| Hospice Team Leader | Hospice Team Leader | Interviewed regarding hospice medication management and awareness of medication availability. |
Inspection Report
Capacity: 108
Deficiencies: 13
Jan 10, 2019
Visit Reason
The report documents a Construction Section Biennial Inspection conducted to ensure the facility meets applicable regulations and building codes.
Findings
The inspection identified multiple deficiencies including improper storage in bathrooms, unsafe handling of portable medical oxygen cylinders, blocked exit paths, fire safety issues such as decorations hanging from sprinkler heads, malfunctioning exit signs, corridor doors not latching properly, improper storage near sprinkler heads, compromised fire-rated walls and ceilings, presence of prohibited portable electric heaters, non-working exhaust ventilation, and unsecured medication storage.
Deficiencies (13)
| Description |
|---|
| Shower room on the upper floor was so completely full of storage that entry was not possible. |
| Improper handling and storage of portable medical oxygen cylinders in multiple rooms. |
| Exterior exit path blocked by 15 chairs stored directly in the pathway. |
| Required exit marked 'Stop, Staff Exit Only' not maintained free of hazard and obstruction. |
| Decorations hanging from all fire sprinkler heads in the Activity room. |
| Records of fire safety rehearsals lacked sufficient description of what the rehearsals involved. |
| Exit signs throughout the building not working on battery when tested. |
| Multiple corridor and smoke barrier doors did not latch properly or were wedged open, compromising fire and smoke resistance. |
| Improper storage too close to fire sprinkler head, stacked within 4 inches of ceiling in Linen Services room (corrected during survey). |
| Holes and penetrations in required one-hour fire rated walls and ceilings in upper public men's bathroom and Brookdale Therapy room. |
| Portable electric heater found in the DHR office, violating prohibition of such heaters. |
| Exhaust ventilation not working in the bathroom off room 308. |
| Medication room door wedged open with no staff present; medications not kept under locked security. |
Report Facts
Total licensed capacity: 108
Number of portable medical oxygen cylinders improperly stored: 8
Number of chairs blocking exterior exit path: 15
Inspection Report
Capacity: 108
Deficiencies: 6
Jan 26, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey to ensure the facility meets the 1996 Regulations for Homes for the Aged and Disabled and applicable portions of the 2005 Regulations for Adult Care Homes and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were cited related to physical plant conditions including failure to maintain fire-rated exit passageways, damaged wall construction due to water migration, failure to maintain doors to resist smoke and fire passage, unsafe plumbing piping, and inadequate exhaust ventilation in specified areas.
Deficiencies (6)
| Description |
|---|
| Failed to maintain the construction of fire-rated exit passage ways, affecting fire and smoke containment. |
| Damaged interior wall construction in Lower Level East Stair Tower due to water migration. |
| Failed to maintain physical condition of interior/exterior doors to resist passage of smoke and/or fire, including a 1/2" gap in Lower Level Dining Room entry doors. |
| Failed to maintain safe operation of fire-rated doors in stair towers; exterior exit door and frame rusted and door does not close securely due to water migration. |
| Plumbing piping not maintained in a safe manner; Warming Kitchen ice machine drain line only 3/4 inch above floor drain instead of required minimum 2 inch clearance. |
| Failed to provide required exhaust ventilation in Lower Level Mop Sink Closet and Lower Level Shower Room, causing potential exposure to housekeeping odors. |
Report Facts
Total licensed capacity: 108
Gap size: 0.5
Drain line clearance: 0.75
Required drain line clearance: 2
Inspection Report
Annual Inspection
Deficiencies: 2
Jan 13, 2017
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on January 12-13, 2017 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to ensure physician notification and follow-up for two residents regarding daily blood pressure monitoring and lab collections, and failed to administer medications as ordered for one resident. Specifically, blood pressure checks were not documented or completed as ordered for Resident #4, a lab draw was not performed as ordered for Resident #1, and Vitamin C medication was not administered as ordered for Resident #2.
Deficiencies (2)
| Description |
|---|
| Failed to ensure physician notification for 2 of 5 sampled residents who had physician's orders for daily blood pressure monitoring and lab collection every 6 months. |
| Failed to administer medications as ordered by the physician for 1 of 5 sampled residents with an order for Vitamin C 500 mg twice daily for 60 days. |
Report Facts
Sampled residents: 5
Residents with blood pressure monitoring orders not followed: 2
Vitamin C medication order duration: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Facility nurse responsible for managing MARs and eMARs, interviewed regarding blood pressure monitoring documentation | |
| Health Wellness Director | Licensed Practical Nurse responsible for medication administration oversight and order entry, interviewed about order entry errors and Vitamin C medication order | |
| Administrator | Interviewed regarding staff responsibilities and order clarifications | |
| Nurse Practitioner (NP) | Ordered Vitamin C medication and provided clinical input on medication administration and wound healing | |
| Medication Aide (MA) | Interviewed regarding awareness of Vitamin C medication order and documentation |
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