Deficiencies per Year
16
12
8
4
0
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Aug 14, 2024 | 96.5 | 2.5 | 6 | Annual Inspection | |
| Jan 18, 2023 | 91.5 | 5.5 | 14 | Annual Inspection | |
| May 26, 2020 | 102.5 | 4.5 | 2 | Annual Inspection | |
| Jul 10, 2018 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Oct 20, 2016 | 100.5 | 4.5 | 4 | Annual Inspection | |
| Jan 10, 2014 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Jul 26, 2012 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Jul 18, 2011 | 99.5 | 5.5 | 6 | Annual Inspection | |
| Jun 25, 2010 | 95 | 2.5 | 0 | Follow-Up Inspection | |
| Apr 1, 2010 | 92.5 | 2.5 | 3.5 | Follow-Up Inspection | |
| Jan 14, 2010 | 93.5 | 4.5 | 11 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 4
Aug 7, 2025
Visit Reason
The report documents a Biennial Follow Up Construction Survey conducted to assess the correction of previously cited deficiencies related to building and fire safety systems.
Findings
The survey found ongoing deficiencies including holes and gaps around sprinkler heads in fire-resistant ceilings that could allow fire and smoke to spread, and failure to maintain electrical emergency/safety lighting equipment in safe operating condition.
Deficiencies (4)
| Description |
|---|
| Sprinkler head dropped in Bedroom leaving a hole in the fire-resistant rated ceiling in Room 60. |
| Large opening around the sprinkler head in the closet of Room 60 without an escutcheon ring. |
| Missing escutcheon ring on sprinkler head in Dining Service Area leaving a hole in the fire-resistant rated ceiling. |
| Emergency light battery pack in Wellness Office not working and needing repair or replacement. |
Inspection Report
Annual Inspection
Deficiencies: 3
Jul 25, 2024
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual and follow-up survey on July 24, 2024 through July 25, 2024.
Findings
The facility was found deficient in ensuring timely physician authorization of resident care plans, serving therapeutic diets as ordered for residents with texture modified diets, and updating Special Care Unit resident profiles on a quarterly basis.
Deficiencies (3)
| Description |
|---|
| Failed to ensure Resident #5's care plan was signed and dated by the primary care physician within 15 calendar days of completion of the assessment. |
| Failed to ensure Residents #2 and #5 received therapeutic diets as ordered related to texture modified diets; both were served inappropriate foods (Caesar salad) instead of the prescribed diet. |
| Failed to ensure Resident #3 had Special Care Unit resident profiles updated on a quarterly basis as required. |
Report Facts
Number of sampled residents with care plan deficiency: 1
Number of sampled residents with therapeutic diet deficiency: 2
Number of sampled residents with SCU profile deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for reviewing and ensuring PCP signs care plans within 15 days and completing SCU resident profiles |
| Health and Wellness Coordinator | Health and Wellness Coordinator | Responsible for assessing and completing resident care plans |
| Administrator | Administrator | Provided information on facility policies and oversight of care plan completion and diet orders |
| Dietary Manager | Dietary Manager | Responsible for ensuring therapeutic diets were served as ordered and communicating diet orders to staff |
| Special Care Coordinator | Special Care Coordinator | Informed about resident diets and intervened if residents were served wrong diets |
| Resident #5's Primary Care Physician | Primary Care Physician | Ordered texture modified diet for Resident #5 and provided recommendations for diet modifications |
Inspection Report
Follow-Up
Deficiencies: 10
Dec 20, 2023
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to physical plant and construction compliance.
Findings
The facility was found to have multiple deficiencies including failure to comply with delayed egress door signage requirements, lack of plan submission for locking system changes, unsafe and unmaintained physical plant conditions such as damaged walls, flooring, fire safety system penetrations, electrical and plumbing issues, and non-functioning exhaust ventilation systems.
Deficiencies (10)
| Description |
|---|
| Delayed egress doors lacked required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.' |
| Facility made revisions to Memory Care Unit locking system without submitting plans for review and approval. |
| Outside premises not maintained in a clean and safe condition; aluminum trim on porch was off. |
| Walls, ceilings, and floors not kept clean and in good repair; multiple areas with damaged flooring, walls, and ceiling. |
| Fire safety systems not maintained; holes and gaps in fire resistant rated ceilings and walls allowing potential fire and smoke spread. |
| Electrical emergency/safety lighting equipment not maintained in safe operating condition; emergency light battery pack damaged. |
| Electrical equipment not maintained safely; GFCI outlets unsecured or without power; electrical boxes unsecured. |
| Plumbing not maintained safely; loose toilet seats creating slip hazards. |
| Fire safety equipment not maintained; resident room doors had gaps preventing proper smoke and fire resistance. |
| Exhaust ventilation not maintained in specified spaces; multiple exhaust fans not working causing humidity and odor issues. |
Report Facts
Date of inspection: Dec 20, 2023
Delayed egress door alarm time: 15
Date of locking system change: Nov 14, 2022
Size of ceiling stain: 6
Hole diameter in door: 3
Gap size in door: 0.5
Hole size in door: 0.25
Inspection Report
Capacity: 112
Deficiencies: 16
Jul 26, 2023
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with applicable physical plant, building, and safety codes and regulations for the facility licensed for 112 beds including 25 Special Care beds.
Findings
Multiple deficiencies were cited related to physical plant and safety code compliance including missing signage on delayed egress doors, lack of emergency release switches for electromagnetic locks, failure to submit required construction plans, unsafe and unclean premises, damaged furnishings, fire safety equipment and electrical system deficiencies, blocked emergency egress paths, plumbing issues, and inadequate exhaust ventilation.
Deficiencies (16)
| Description |
|---|
| Delayed egress doors lack required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS'. |
| Electromagnetic locks lack on/off emergency release switches at required locations. |
| Facility made revisions to locking system without submitting plans for approval. |
| Outside premises not maintained in a clean and safe condition with peeling paint, damaged trim, and pest entry points. |
| Walls, ceilings, floors, and furnishings not kept clean and in good repair; multiple locations with damage, mildew, dust accumulation, and broken furnishings. |
| Facility not maintained free from hazards; obstructions near electrical panels. |
| Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel shows trouble. |
| Holes and gaps in fire resistant rated ceilings and walls due to missing sprinkler escutcheon rings, open junction boxes, and unsealed penetrations. |
| Electrical emergency/safety lighting equipment not maintained; damaged or non-functioning emergency lights and exit signs. |
| Electrical equipment not maintained safely; loose, missing, or non-functioning GFCI outlets and unsecured electrical boxes. |
| Emergency egress pathways obstructed by carts, heavy cans, and plants, impeding safe evacuation. |
| Loose toilet seats creating potential slip or fall hazards. |
| Resident room doors have gaps due to loose hinges causing failure to resist passage of smoke. |
| Mechanical equipment not maintained in operating condition; disconnected condensate line and blocked access to mechanical rooms. |
| Fire safety doors do not completely close and latch, compromising smoke compartment integrity. |
| Exhaust ventilation not maintained in specified spaces; multiple exhaust fans not working causing humidity and odor issues. |
Report Facts
Licensed beds: 112
Special Care Unit beds: 25
Inspection Report
Annual Inspection
Deficiencies: 7
Dec 1, 2022
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual and follow-up survey from November 29, 2022 through December 1, 2022.
Findings
The facility was found deficient in multiple areas including failure to complete annual medical examinations (FL2) for residents, incomplete resident assessments and care plans, lack of timely physician certification of care plans, failure to complete quarterly licensed health professional support assessments, inadequate response to quarterly medication reviews, failure to disclose special care unit information, and failure to maintain updated special care unit resident profiles on a quarterly basis.
Deficiencies (7)
| Description |
|---|
| Failed to ensure annual FL2 medical examinations were completed for 2 of 5 sampled residents (#3 and #1). |
| Failed to ensure 1 of 3 sampled residents (#1) had an updated resident assessment annually. |
| Failed to ensure physician certification of care plans within 15 days for 3 of 3 sampled residents (#1, #4, #5). |
| Failed to ensure quarterly licensed health professional support assessments were completed for 3 of 5 sampled residents (#1, #4, #5). |
| Failed to take action in response to quarterly medication review recommendations for 2 of 5 sampled residents (#3 and #5). |
| Failed to disclose the form of care and treatment provided for residents in the special care unit for 2 of 2 sampled residents (#2 and #3). |
| Failed to ensure initial special care unit resident profiles were updated quarterly for 2 of 2 sampled residents (#2 and #3). |
Report Facts
Sampled residents with incomplete annual FL2: 2
Sampled residents with incomplete annual assessment: 1
Sampled residents with care plans not certified within 15 days: 3
Sampled residents with incomplete quarterly LHPS assessments: 3
Sampled residents with unacted quarterly medication review recommendations: 2
Sampled residents without SCU disclosure statement: 2
Sampled residents without quarterly updated SCU resident profiles: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director | Interviewed regarding deficiencies and facility policies on multiple occasions. | |
| Administrator | Interviewed regarding deficiencies and facility policies on multiple occasions. | |
| Health and Wellness Director | Responsible for completion and auditing of FL2s, care plans, LHPS reviews, medication review follow-up, and resident profile tracking. | |
| Health and Wellness Coordinator | Responsible for completing resident care plans. | |
| Regional Nurse | Interviewed regarding LHPS reviews and monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 4
Feb 27, 2020
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual survey and complaint investigation on February 26-27, 2020.
Findings
The facility failed to administer medications as ordered for 1 of 5 sampled residents (Resident #1), including failure to provide ursodiol for liver disease, ipatropium albuterol nebulization for wheezing, flonase nasal spray for allergies, and a silicone foot pad for pain relief. Medication orders were not properly filled or administered, and the prescribing physician was not notified of medication shortages or backorders.
Complaint Details
The inspection included a complaint investigation related to medication administration failures for Resident #1.
Deficiencies (4)
| Description |
|---|
| Failure to administer ursodiol 500mg twice daily as ordered due to medication backorder and lack of physician notification. |
| Failure to administer ipatropium albuterol 0.5-3mg nebulization as needed for wheezing; medication not available and not ordered. |
| Failure to administer flonase 50mcg nasal spray daily for allergies; medication not available and not ordered. |
| Failure to provide silicone foot pad as ordered for right forefoot pain relief; incorrect heel pads sent and no silicone pads available or applied. |
Report Facts
Days ursodiol not available: 20
Times silicone foot pad applied: 18
Times silicone foot pad removed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for weekly cart audits and medication availability oversight; interviewed regarding medication administration failures. |
| Health and Wellness Coordinator | Health and Wellness Coordinator (HWC) | Reviewed cart audit sheets and new orders; unaware of medication shortages and backorders. |
| Administrator | Facility Administrator | Interviewed regarding responsibilities for medication ordering and oversight; unaware of medication shortages and failures. |
| Primary Care Physician | Resident #1's Primary Care Physician | Provided medical orders and expectations for medication administration; unaware of medication shortages. |
| Prescribing Physician | Prescribing Physician for silicone foot pad | Ordered silicone foot pad for Resident #1; interviewed about foot condition and treatment. |
Inspection Report
Follow-Up
Deficiencies: 7
Jan 14, 2020
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building safety and maintenance.
Findings
Multiple deficiencies were found including lack of current fire marshal inspection reports, unresolved sprinkler system issues, malfunctioning GFCI electrical outlets, non-working emergency lights and exit signs, compromised fire-rated walls and ceilings, and unsafe plumbing drain line conditions.
Deficiencies (7)
| Description |
|---|
| No recent Fire Marshal building safety inspection report located; annual inspections required. |
| Sprinkler system inspection report from 2018 listed corrections with no evidence of correction. |
| GFCI type receptacles not working properly; two electrical outlets near sink/tub unprotected from ground faults. |
| Battery powered emergency lights would not work when tested, risking resident and staff safety. |
| Exit signs malfunctioning or hanging by wires, potentially delaying evacuation. |
| One-hour fire rated walls and ceilings compromised by unsealed holes and penetrations in multiple locations. |
| Ice machine drain line extended into floor drain, risking contamination. |
Report Facts
Date of sprinkler system inspection: Jan 18, 2018
Emergency light operation time requirement: 90
Inspection Report
Routine
Capacity: 112
Deficiencies: 14
Oct 31, 2019
Visit Reason
The report documents a biennial construction section survey of Brookdale Concord Parkway to assess compliance with state building codes and adult care home regulations.
Findings
The facility was found to have multiple deficiencies including failure to meet NC State Building Code requirements for special locking exit doors, lack of current fire safety inspection reports, maintenance issues with bathrooms and corridors, malfunctioning exit door locks, absence of wanderer alarms on exit doors, unsafe outside premises, poor housekeeping and maintenance of building systems, inadequate fire safety rehearsals, electrical outlet malfunctions, and compromised fire safety features such as exit signs and fire-rated walls.
Deficiencies (14)
| Description |
|---|
| Failed to meet NC State Building Code requirements for special locking (magnetic locks) on exit doors; staff did not carry emergency release switch keys and were unaware of emergency release switch location. |
| No recent Fire Marshal building safety inspection report located; outstanding corrections from previous sprinkler system inspection not documented as corrected. |
| Tub accessible on two sides was not maintained serviceable; faucet missing control knob in AL spa. |
| Corridors were obstructed reducing clear width below required 6 feet; deficiencies corrected during survey. |
| Exit door locks not easily operable by single hand motion; delayed egress door mechanically locked and exit doors locked improperly preventing proper operation. |
| Exit doors accessible to residents during day lacked required wanderer alarms. |
| Outside grounds not maintained safe; broken yardlight exposing wiring and missing weather-tight cover on receptacle outlet. |
| Building mechanical systems not kept clean and in good repair; excessive dust/lint accumulation and ceiling damage observed. |
| Housekeeping hazards including hasp and padlock on pantry door, loosely mounted toilet, combustible storage near gas furnace, no key to soiled linen room, and blocked electrical panels (corrected during survey). |
| Fire drill rehearsals not conducted regularly on all shifts each quarter as required. |
| GFCI electrical outlets in wet locations not working properly or without power. |
| Building equipment not maintained safe; delayed egress locking system deactivated, emergency lights not working, exit signs malfunctioning, fire rated walls and ceilings compromised with holes and unsealed penetrations, corridor doors not closing or latching properly, improper storage near sprinkler heads, missing documentation for fire suppression system inspections, and plumbing drain lines not maintained safely. |
| Exhaust ventilation not working in employee bathroom in AL building. |
| Resident call system activated in room 38 but no staff responded. |
Report Facts
Total licensed beds: 112
Special Care beds: 25
Fire sprinkler inspection date: Jan 18, 2018
Clear corridor width required: 6
Clear corridor width observed: 4.5
Clear corridor width observed: 4.75
Fire drill rehearsals missing: 3
Fire drill rehearsals missing: 4
Storage clearance below sprinkler head: 6
Storage clearance below sprinkler head: 7
Inspection Report
Annual Inspection
Census: 5
Deficiencies: 1
May 1, 2018
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual and follow-up survey on 05/01/18-05/02/18.
Findings
The facility failed to assure therapeutic diets, specifically regular chopped meats, were served as ordered for 1 of 5 residents (Resident #2). The issue was due to failure to update the therapeutic diet seating chart and nutritional diet tracking tool, resulting in Resident #2 initially receiving the wrong diet.
Deficiencies (1)
| Description |
|---|
| Failed to assure therapeutic diets (regular chopped meats) were served as ordered for Resident #2. |
Report Facts
Residents affected: 1
Residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Medication Aide | Interviewed regarding knowledge of resident diets and use of nutritional diet tracking tool. |
| Cook | Cook | Responsible for serving therapeutic diets; initially served wrong diet to Resident #2. |
| SCU Program Coordinator | Program Coordinator | Responsible for updating therapeutic diet seating chart and nutritional diet tracking tool; failed to update for Resident #2. |
| Executive Director | Executive Director | Interviewed about process for receiving and communicating therapeutic diet orders. |
| Resident #2 Primary Care Physician | Primary Care Physician | Interviewed regarding knowledge of Resident #2's diet order. |
Inspection Report
Capacity: 112
Deficiencies: 9
Nov 1, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements, building codes, and safety standards for the facility licensed for 112 beds including 25 Special Care beds.
Findings
Multiple deficiencies were cited including failure to meet code requirements for special locking door systems, housekeeping and cleanliness issues, unsafe and non-operating building equipment such as emergency exit signs and fire alarm systems, fire safety concerns, electrical system issues, interior door malfunctions, and failure of exhaust ventilation systems in several areas.
Deficiencies (9)
| Description |
|---|
| Facility failed to meet code requirements for doors equipped with Special Locking Arrangements, including emergency release switches requiring metal keys and lack of central on/off emergency release switches. |
| Building mechanical systems not kept clean and in good repair, including excessive dust/lint on ventilation grilles and radiation dampers. |
| Facility failed to keep walls, ceilings, floors, floor coverings, and furniture clean and in good repair; ceiling stained with mold growth in public restroom. |
| Building emergency equipment not maintained in safe and operating condition; exit signs failed to illuminate on backup power and had incorrect directional indicators. |
| Fire Alarm system not maintained in safe and operating condition; HVAC duct smoke detector sample tubes dirty. |
| Building fire safety compromised by gaps around cable bundles and dropped escutcheon plates allowing smoke and heat spread. |
| Electrical system not maintained safely; power tap plugged into extension cord and unsecured GFCI receptacle. |
| Interior doors not maintained safely; corridor door did not latch and was held open by kick down device. |
| Exhaust ventilation systems failed to operate in housekeeping, spa, and public restroom areas, causing odor issues. |
Report Facts
Licensed beds: 112
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 22, 2016
Visit Reason
The Adult Care Licensure Section and the Cabarrus County Department of Social Services conducted an annual survey on 9/21/16 and 9/22/16 at Brookdale Concord Parkway.
Findings
The facility was found to have unclean and damaged walls and baseboards with mold growth in multiple resident rooms, and failed to serve therapeutic diets as ordered by the physician for one resident in the Special Care Unit.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure walls/baseboards were clean and in good repair throughout the facility, with mold observed in multiple resident rooms. |
| Facility failed to ensure therapeutic diets (regular pureed) were served as ordered by the physician for 1 of 2 sampled residents in the Special Care Unit. |
Report Facts
Length of mold areas: 7
Length of mold areas: 23
Length of mold areas: 21
Length of mold areas: 17
Number of residents on pureed diets: 2
Meal components for Resident #1: 1
Meal components for Resident #1: 8
Meal components for Resident #1: 2
Meal components for Resident #1: 0.5
Meal components for Resident #1: 0.5
Meal components for Resident #1: 1
Meal components for Resident #1: 5
Meal components for Resident #1: 8
Meal components for Resident #1: 8
Meal consumption: 0.75
Meal consumption: 0.5
Inspection Report
Follow-Up
Deficiencies: 3
Feb 17, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale Concord Parkway.
Findings
Some deficiencies were not corrected, including issues with the central emergency release switch for magnetic locking, lack of wiring diagram at the fire alarm panel, and corridor doors not closing or latching properly, which could compromise fire safety.
Deficiencies (3)
| Description |
|---|
| The central emergency release switch for the magnetic locking on the exits and courtyard gate did not release the doors and gate as required. |
| No wiring diagram or system components location map was located at the fire alarm panel as required by Code. |
| Many corridor doors are not closing well and/or latching to resist the passage of fire and smoke; specifically, the pair of doors to the dining room will not latch when closed. |
Report Facts
Citations: 10
Inspection Report
Capacity: 112
Deficiencies: 6
Nov 6, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
The facility was found deficient in multiple areas including magnetic locking emergency release switches, monthly inspection of the kitchen range hood fire suppression system, incomplete fire drill rehearsals, fire safety issues with corridor doors and fire rated walls, emergency lighting failures, electrical hazards, exhaust ventilation failures, and improper exit signage and locked exits.
Deficiencies (6)
| Description |
|---|
| Emergency release switches at magnetically locked exits were locking type and staff did not carry keys; central emergency release switch did not release doors and courtyard gate; no wiring diagram at fire alarm panel. |
| Range hood fire suppression system in kitchen not inspected monthly as required. |
| Fire drill rehearsal records lacked descriptions; missed rehearsals on various shifts and quarters for Assisted Living and Memory Care buildings. |
| Many corridor doors not closing or latching properly; mechanical 'kick-downs' holding doors open; holes and penetrations in one-hour fire rated walls and ceilings; dirty ceiling radiation dampers; broken emergency lighting; dirty smoke detector sampling tube; broken fire extinguisher cabinet handles; non-functioning GFCI receptacle; ice machine drain line in contact with floor drain; multi electrical outlet expander in use. |
| Doors in smoke barrier wall not closing or latching; exit sign pointing in wrong direction; locked exit preventing egress; evacuation plans oriented incorrectly; storage in front of main electrical panel. |
| Exhaust fans not working in bathroom off room 31, laundry, soiled linen closet, and resident bathrooms. |
Report Facts
Total licensed beds: 112
Special Care Unit beds: 25
Fire safety citations: 18
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