Inspection Report Summary
The most recent inspection on September 24, 2025, identified a deficiency related to failure to ensure referral and follow-up for a resident’s missing medications. Earlier inspections showed a pattern of deficiencies involving medication administration, care plan documentation, resident supervision, food safety, and environmental maintenance. Complaint investigations found one substantiated issue with staff treating a resident in a rushed manner, leading to termination of the nursing assistant, while abuse allegations were not substantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with medication management and care documentation, with no clear trend of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
81% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Oct 29, 2025 | 98.75 | 7.25 | 2 | Follow-Up Inspection | |
| Aug 28, 2025 | 93.5 | 3.5 | 10 | Annual Inspection | |
| Jan 5, 2024 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Dec 15, 2022 | 89 | 0 | 10 | Monitoring Visit | |
| Mar 14, 2022 | 99 | 3 | 4 | Annual Inspection | |
| Aug 14, 2019 | 99.5 | 5.5 | 6 | Annual Inspection | |
| Feb 6, 2017 | 101.5 | 5.5 | 4 | Annual Inspection | |
| Apr 10, 2014 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Oct 13, 2011 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Nov 23, 2010 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Aug 21, 2009 | 105.5 | 5.5 | 0 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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.
Complaint Details
The visit included a complaint investigation related to care plan signatures and supervision of a resident with dementia who eloped.
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.
Deficiencies (5)
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.
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.
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
Complaint Investigation
Deficiencies: 1
Date: Apr 7, 2025
Visit Reason
The inspection was conducted following a complaint alleging that Nursing Assistant #1 treated Resident #117 in a rude and hurried manner during care and mechanical lift transfers, raising concerns of potential abuse.
Complaint Details
The complaint involved an allegation of abuse by NA #1 toward Resident #117 during care and mechanical lift transfer. The allegation was investigated and found not substantiated. NA #1 was terminated due to poor customer service and care.
Findings
The investigation found that NA #1 was rushed and careless during Resident #117's mechanical lift transfer and care, causing the resident pain and distress. NA #1 was suspended and terminated for poor customer service and care. The abuse allegation was not substantiated by the facility's investigation.
Deficiencies (1)
Failed to treat 1 of 3 sampled residents with dignity by performing care in a manner that the resident felt was rude and hurried.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in findings for rude and hurried care causing resident distress; suspended and terminated. |
| NA #2 | Nursing Assistant | Witnessed NA #1 rushing transfer and reported incident to Administrator and Nurse #1. |
| Nurse #1 | Nurse | Received report from NA #2 about incident and reported to Administrator. |
| Administrator | Administrator | Received complaint from Resident #117 and staff, signed allegation and investigation reports. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 7, 2025
Visit Reason
The inspection was conducted following a complaint alleging that a nursing assistant treated Resident #117 in a rude and hurried manner during care and mechanical lift transfers, raising concerns about resident dignity and safety.
Complaint Details
The complaint alleged that NA #1 treated Resident #117 rudely and hurriedly during care and mechanical lift transfers, causing pain. The facility investigated, interviewed involved staff and the Administrator, and found the abuse allegation not substantiated. NA #1 was suspended and then terminated for poor customer service and care.
Findings
The facility failed to treat Resident #117 with dignity during care, as staff rushed the mechanical lift transfer causing pain to the resident. The investigation found the allegation of abuse was not substantiated, but the nursing assistant was terminated for poor customer service and care. Additional deficiencies were found related to inaccurate advance directive documentation for Resident #119 and improper hand hygiene practices in the kitchen, risking cross-contamination.
Deficiencies (3)
Failed to treat Resident #117 with dignity by performing care in a rude and hurried manner during mechanical lift transfers.
Failed to maintain accurate advance directive information throughout electronic and paper medical records for Resident #119.
Failed to perform hand hygiene between handling soiled and clean dishes, risking cross-contamination affecting 9 residents.
Report Facts
Residents affected: 3
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in complaint for rude and hurried care of Resident #117; terminated for poor customer service and care |
| NA #2 | Nursing Assistant | Witnessed NA #1 rushing mechanical lift transfer and reported incident |
| Nurse #1 | Nurse | Received report of incident from NA #2 and reported to Administrator |
| Administrator | Facility Administrator | Received complaint from Resident #117, signed investigation report, and confirmed abuse allegation not substantiated |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding Resident #119's advance directive status and confirmed DNR status |
| Director of Clinical Services | Director of Clinical Services | Created incorrect full code order for Resident #119 and responsible for care plan updates |
| Dietary Aide #1 | Dietary Aide | Observed failing to change gloves or wash hands between handling soiled and clean dishes |
| Corporate Kitchen Supervisor | Corporate Kitchen Supervisor | Observed Dietary Aide #1 glove violation and intervened |
| Dietitian | Dietitian | Interviewed about proper dishwashing procedures and glove use |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, staffing, food safety, and quality assurance at Brookdale Carriage Club Providence.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, providing appropriate wound care, accurate nurse staffing postings, honoring resident food preferences, food safety practices, proper garbage disposal, and sustaining quality assurance measures. Multiple observations and interviews revealed issues with environmental cleanliness, wound care documentation, staffing records, food choice communication, food storage and labeling, kitchen sanitation, and outdoor trash management.
Deficiencies (7)
Failed to maintain lighting, cabinets, and walls in good repair in resident rooms and activity room nutrition area.
Failed to provide treatment as ordered by physician for a non-pressure wound for 1 resident.
Failed to post accurate nurse staffing information and resident census on daily staffing sheets for multiple dates.
Failed to honor food choices for 3 sampled residents, with potential to affect 9 residents receiving food from the kitchen.
Failed to label and date leftover food items, discard dented canned goods, maintain clean utility cart, keep food storage clean and orderly, prevent cross-contamination, dry prep pans before stacking, clean metal plate warmers, and maintain hand washing sink in good repair.
Failed to remove loose garbage, food, and debris from outdoor trash receptacle area behind the kitchen.
Failed to maintain implemented procedures and monitor interventions in the Quality Assessment and Assurance Committee, showing inability to sustain an effective Quality Assurance Program.
Report Facts
Dates with no resident census data listed: 13
Dates with inaccurate daily posted staffing sheets: 3
Days reviewed for daily posted staffing: 83
Residents affected by food choice deficiency: 9
Dented canned goods observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in wound care deficiency for Resident #214; documented wound care without verification. | |
| Maintenance Director #1 | Interviewed regarding maintenance request system and unaware of reported facility concerns. | |
| Director of Nursing | DON | Interviewed about wound care audits, staffing oversight, and food choice processes. |
| Administrator | Interviewed about awareness of facility concerns including maintenance, staffing, and food safety. | |
| Dietary Manager | DM | Interviewed regarding kitchen management, food safety deficiencies, and outdoor trash area responsibility. |
| Dietary Aide #1 | Interviewed about meal choice processes and resident menu options. | |
| Activity Director | Interviewed about menu distribution and resident food choice assistance. | |
| Nurse Aide #1 | Interviewed about menu distribution and alternate food options for residents. | |
| Maintenance Director #2 | Interviewed about repair of leaking wash station sink. |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 12, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and storage regulations, including temperature control, labeling, and cleanliness of kitchen equipment and food items.
Findings
The facility failed to maintain proper food storage temperatures, discard expired or potentially hazardous foods, label and date food items correctly, repair malfunctioning refrigeration units, and maintain cleanliness in refrigerators and freezers, which had the potential to affect food served to residents.
Deficiencies (7)
Failed to store milk products at or below 41°F, with reach-in refrigerator temperatures at 48°F.
Expired and unlabeled food items found, including coffee grounds dated 7/27/22 with scoops left inside.
Expired chicken quarter legs, cooked ham, cucumber dip, sweet potatoes, and lemon slices found in main kitchen walk-in refrigerator.
Debris on floor of walk-in refrigerator including empty water bottles, vegetables, raw pasta, tomatoes, and plastic pieces.
Soft and defrosted shrimp improperly returned to freezer after thawing.
Open and unlabeled bag of Brussels sprouts and box of corn kernels with ice crystals in walk-in freezer; icicles and water dripping on stacked boxes.
Malfunctioning freezer unit causing ice crystal formation and fan issues; frequent repairs needed.
Report Facts
Containers of thickened milk: 2
Containers of milk: 2
Chicken quarter legs: 24
Cooked ham: 1
Shrimp bags: 2
Boxes under freezer pipes: 26
Icicle length: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding refrigerator temperatures, food labeling, and corrective actions |
| Associate Director of Dining Services | Associate Director of Dining Services (ADDS) | Observed relabeling food items and interviewed about food safety practices |
| Director of Dining Services | Director of Dining Services (DSM) | Conducted tours of kitchen areas and interviewed about food storage and freezer issues |
| Chef | Chef | Interviewed about food expiration and kitchen cleanliness |
| Administrator | Administrator | Interviewed regarding overall kitchen compliance with regulations |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: 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.
Complaint Details
Complaint investigation was part of the visit; specific substantiation status not stated.
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.
Deficiencies (2)
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
Date: 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)
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
Date: 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)
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
Date: 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)
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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