Inspection Report
Capacity: 83
Deficiencies: 3
Aug 26, 2025
Visit Reason
This is a Construction Section Biennial Survey conducted to ensure the facility meets the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2025 Rules for Adult Care Homes of Seven or More Beds, and the 1996 w/98 revision of the North Carolina State Building Code.
Findings
Deficiencies were cited related to unsafe electrical components near water sources and failure to maintain fire safety equipment, including unprotected outlets and gaps around sprinkler lines that could allow fire and smoke to spread.
Deficiencies (3)
| Description |
|---|
| The outlet behind the washer machine in the laundry room is not GFCI protected. |
| The outlet at the left side of the front porch is missing its in-use cover. |
| There is a large opening around a 2 inch sprinkler line coming through the wall in the laundry room that requires proper sealing. |
Inspection Report
Annual Inspection
Deficiencies: 1
Aug 14, 2024
Visit Reason
The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual and follow-up survey on August 13 and 14, 2024.
Findings
The facility failed to ensure medications were administered within the ordered parameters for one resident related to a medication used to treat high blood pressure and regulate heart rate. Specifically, metoprolol tartrate was administered multiple times when the resident's heart rate was below the ordered threshold, constituting medication errors.
Deficiencies (1)
| Description |
|---|
| Failed to ensure metoprolol tartrate was held when resident's systolic blood pressure was less than 110 or heart rate was less than 60, resulting in administration of medication on multiple occasions when heart rate was below 60. |
Report Facts
Medication administrations below heart rate threshold: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Interviewed regarding medication errors and facility procedures. |
| Administrator | Administrator | Interviewed regarding medication administration and order compliance. |
Inspection Report
Follow-Up
Deficiencies: 3
Feb 1, 2023
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey from 01/31/23 through 02/01/23 to verify correction of previous deficiencies.
Findings
The facility failed to ensure referral and follow-up for a dermatology visit for Resident #3, failed to administer medications as ordered for Resident #5, and failed to report allegations of physical abuse by staff to the Health Care Personnel Registry within 24 hours.
Deficiencies (3)
| Description |
|---|
| Failed to ensure referral and follow-up for 1 of 1 sampled resident (Resident #3) who had a referral for a dermatology visit related to a lesion on top of the head. |
| Failed to administer medications as ordered for 1 of 5 sampled residents (#5) related to a medication to treat allergies and a medication to treat pain. |
| Failed to report allegations of physical abuse by staff to the Health Care Personnel Registry within 24 hours of knowledge related to staff accused of causing bleeding to a resident's scalp during personal care (Resident #3). |
Report Facts
Medication cards supply: 28
Medication cards supply: 13
Medication cards supply: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Named in failure to follow-up on dermatology appointment and medication administration findings |
| Health and Wellness Director | Health and Wellness Director | Named in failure to follow-up on dermatology appointment and medication administration findings |
| Administrator | Administrator | Named in failure to follow-up on dermatology appointment, medication administration, and abuse reporting findings |
| Primary Care Provider | PCP | Named in failure to follow-up on dermatology appointment and medication administration findings |
| Medication Aide | Medication Aide (MA) | Named in medication administration and abuse reporting findings |
| Personal Care Aide | Personal Care Aide (PCA) | Named in abuse allegation and incident |
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 20, 2022
Visit Reason
The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual survey on October 19 and 20, 2022.
Findings
The facility failed to provide adequate supervision for a resident with a history of repeated falls, resulting in 20 unwitnessed falls, two emergency room visits, a fracture, and a head laceration. Additionally, medication administration errors were observed for three residents, including failure to mix topical medications, incorrect dosage measurement, and incorrect administration of nasal spray and oral medications.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide supervision according to the needs of a resident with repeated falls, resulting in multiple injuries including fractures and head laceration. | Type A2 Violation |
| Failure to administer medications as ordered for 3 residents, including errors with topical medications, dosage measurement, and administration of nasal spray and oral medications. | Type B Violation |
Report Facts
Number of falls for Resident #4: 20
Medication error rate: 23
Medication errors: 6
Dosage of Voltaren Gel: 2
Dosage of Miralax: 17
Dosage of Tums EX: 2
Inspection Report
Annual Inspection
Deficiencies: 4
Aug 29, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Weddington Park on 08/28/19-08/29/19 to assess compliance with regulations related to nutrition, medication labeling, medication administration, and infection control.
Findings
The facility failed to ensure therapeutic diets were served as ordered for one resident, failed to properly label insulin medication for one resident, failed to administer medications as prescribed for one resident, and failed to follow infection control procedures during medication administration by two medication aides.
Deficiencies (4)
| Description |
|---|
| Failed to assure therapeutic diets were served as ordered for 1 of 3 sampled residents with texture modified diet orders. |
| Failed to ensure Lantus insulin was properly labeled for 1 of 5 sampled residents; insulin pens lacked resident name, directions, and expiration dates. |
| Failed to assure medications were administered as ordered for 1 of 5 residents; Resident #8 missed doses of Prelief due to medication not being available. |
| Failed to ensure medications were administered in accordance with infection control measures; two medication aides did not use appropriate hand hygiene and handled medications improperly. |
Report Facts
Medication error rate: 9.3
Medication doses missed: 7
Medication supply: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Served incorrect diet items to Resident #1 and failed to follow therapeutic diet menu. | |
| Dining Services Coordinator | Managed kitchen and meal services; acknowledged errors in serving therapeutic diets. | |
| Medication Aide | Responsible for labeling insulin pens; failed to label Resident #3's insulin pens properly. | |
| Resident Care Coordinator | Responsible for medication cart audits and oversight of medication labeling. | |
| Health and Wellness Director | Responsible for medication cart audits and oversight of medication labeling. | |
| Administrator | Oversaw facility operations; unaware of medication and diet errors until survey. | |
| Primary Care Physician | Provided medication orders and confirmed expectations for medication administration. | |
| Medication Aide | Failed to follow infection control procedures during medication administration. | |
| Second Medication Aide | Failed to follow infection control procedures during medication administration. |
Inspection Report
Capacity: 83
Deficiencies: 9
Feb 28, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to ensure the facility meets applicable adult care home licensing rules and North Carolina State Building Code requirements.
Findings
Multiple deficiencies were cited related to physical plant conditions including corridor obstructions, housekeeping issues, fire extinguisher maintenance, fire safety rehearsals documentation, building equipment safety, fire door and smoke barrier maintenance, and unsafe conditions in the outside grounds.
Deficiencies (9)
| Description |
|---|
| Corridors are not free of obstructions, including blocked exits and mats interfering with door operation. |
| Building mechanical systems have excessive accumulation of dust/lint in ventilation systems. |
| Building not maintained free of hazards; unsecured large portable helium cylinder posing projectile risk. |
| Fire extinguishers not properly maintained; portable extinguisher in basement overdue for annual maintenance since September 2017. |
| Fire safety rehearsals not properly documented; missing staff response documentation. |
| Building emergency equipment not maintained in safe and operating condition; missing exit signs, non-illuminating emergency lights, and smoke barrier doors not latching properly. |
| Fire rated doors and smoke tight corridor doors not maintained; missing latch bolts, gaps, held open doors, and missing strike plates. |
| Outside grounds not maintained safely; exposed energized wires near basement stairs. |
| Corridor doors held open improperly preventing proper closing and latching. |
Report Facts
Licensed capacity: 83
Fire extinguisher maintenance overdue: 1
Open-ended sleeves not firestopped: 6
PVC pipes with dislodged fire collars: 2
Fire collars with insufficient tabs: 2
Gaps in corridor doors: 3
Inspection Report
Capacity: 83
Deficiencies: 5
Apr 19, 2017
Visit Reason
This is a Construction Section Biennial Survey to ensure the facility meets the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 w/98 revision of the North Carolina State Building Code; Section 409 Institutional Occupancy - Group I.
Findings
Deficiencies were cited related to housekeeping and furnishings, building maintenance, and fire safety. Issues included failure to provide ventilation where odors are generated, moisture damage to interior walls, lack of fire protection in penetrations of fire-rated floor/ceiling assemblies, and interior doors that do not latch properly, compromising fire containment.
Deficiencies (5)
| Description |
|---|
| Mechanical exhaust fans are not exhausting interior air in hall 'A', kitchen mop sink closet, and rooms 40 to 44, causing odors. |
| Sheet-rock wall damaged due to moisture migration underneath the 3-compartment sink in the kitchen. |
| Piping and electric cable penetrations above the water heater in the basement penetrate fire-rated floor/ceiling assembly without fire protection. |
| Interior doors at multiple locations are damaged, out of adjustment, and do not latch, preventing containment of fire and/or smoke. |
| Doors at kitchen/dining hall and dining room entry have kick down door stops obstructing closing and latching unless mechanically released by staff. |
Report Facts
Licensed capacity: 83
Inspection Report
Follow-Up
Deficiencies: 2
Mar 4, 2015
Visit Reason
Follow-up survey conducted to verify correction of deficiencies cited in the previous survey dated 11/20/2014.
Findings
Most deficiencies from the prior survey were corrected; however, remaining deficiencies related to fire safety and building maintenance were observed, including breaches in fire-resistance-rated construction and fire doors not closing properly, which could affect containment of smoke and fire.
Deficiencies (2)
| Description |
|---|
| Breaches through fire-resistance-rated construction in basement and attic compromising fire safety. |
| Fire rated doors in firewall/smoke barrier did not close completely, failing to contain smoke/fire. |
Report Facts
Pipe penetration size: 4
Hole size: 1.5
Gap size: 0.5
Gap size: 0.5
Hole size: 4
Pipe size: 2
Inspection Report
Capacity: 83
Deficiencies: 13
Nov 20, 2014
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 w/98 revision of the North Carolina State Building Code.
Findings
Multiple physical plant deficiencies were identified including improper delayed egress signage, unsafe building maintenance with blocked or malfunctioning fire doors, breaches in fire-resistance-rated construction, unsafe electrical and fire alarm systems, unsecured portable oxygen cylinders, non-operational emergency lighting and exit signs, lack of documented inspections for the commercial kitchen hood fire suppression system, and missing safety devices on plumbing equipment.
Deficiencies (13)
| Description |
|---|
| Delayed egress doors lacked required signage at multiple hall exits. |
| Exit doors had doubled cylinder dead bolts in addition to panic bar hardware, restricting safe egress. |
| Pantry door locked with a hasp device and padlock from kitchen side. |
| Fire sprinkler escutcheon plates missing, dislodged, or not covering openings in fire-resistance-rated ceilings at multiple locations. |
| Ceilings and smoke barrier walls had holes and gaps compromising fire/smoke containment. |
| Fire rated doors in firewall/smoke barrier did not close or latch properly, including broken view window and loose hardware. |
| Corridor doors were blocked open or missing latch bolts, preventing proper smoke/fire containment. |
| Electrical panels obstructed and exterior electrical disconnects unsecured, exposing live parts. |
| Fire alarm system duct-mounted smoke detector sampling tubes dirty and possibly nonfunctional. |
| Portable medical oxygen cylinders stored unsecured, risking projectile hazard. |
| Emergency lighting and exit signs failed to operate on backup power in multiple locations. |
| Commercial kitchen hood fire suppression system monthly inspections not documented since last annual recertification. |
| Water heater and boiler missing pressure relief valve pipe extensions. |
Report Facts
Total licensed capacity: 83
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