Inspection Reports for Charter Senior Living of Charlotte

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey and complaint investigation from 12/17/24 through 12/18/24.

The facility failed to ensure therapeutic diets were served as ordered for 1 of 2 residents (Resident #6), who had a diet order for no straws but was observed being fed with a straw. The Type B Violation was abated but non-compliance continued.

The visit included a complaint investigation related to Resident #6 being fed with a straw despite a no straw diet order. The complaint was substantiated as non-compliance continued.

Biennial Construction Survey conducted to assess compliance with applicable physical plant, safety, and environmental regulations for the facility licensed for 104 beds.

Multiple deficiencies were identified including non-compliance with delayed egress door signage and operation, unsecured janitor closets, malfunctioning wanderer alarms, unsafe housekeeping and maintenance issues, fire safety system failures, inadequate heating system performance, prohibited use of portable unvented electric heaters, and lack of exhaust ventilation in specified areas.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual and follow up survey and a complaint investigation from 10/23/24 through 10/25/24.

The facility was found deficient in multiple areas including failure to serve physician-ordered therapeutic diets, failure to clarify medication orders, failure to maintain medication storage security, failure to notify local DSS of certain incidents, and failure to implement infection control policies consistent with CDC guidelines for glucometer use.

Complaint investigation was conducted as part of the visit. Specific complaint details are not separately stated but are integrated into findings such as failure to serve therapeutic diets and failure to notify DSS of incidents.

The Adult Care Licensure Section conducted a follow-up survey from 10/17/23 to 10/18/23 to verify correction of previous deficiencies related to medication administration.

The facility failed to ensure that sliding scale insulin was administered and documented as ordered for Resident #2. Multiple instances from 10/06/23 to 10/18/23 showed blood sugar levels recorded without documentation of insulin units administered. The facility acknowledged the documentation issue and took corrective actions to enable proper recording in the electronic Medication Administration Record (eMAR).

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted a follow up survey and a complaint investigation initiated by the County Department of Social Services on 07/17/23.

The facility failed to ensure referral and follow-up to meet the routine healthcare needs for Resident #1 related to medication refusals, personal care refusals, food and hydration refusals, and failure to notify the physician. Resident #1 was hospitalized with severe dehydration, hypoxia, septic shock, and other complications and subsequently died. Additionally, the facility failed to administer a medication as ordered for Resident #5 related to fluid retention and failed to have a signed care plan for Resident #1 within 15 days of completion.

Complaint investigation initiated by the County Department of Social Services on 07/17/23 related to Resident #1's care including medication refusals, personal care refusals, and failure to notify physician.

The Adult Care Licensure Section and the Mecklenburg County DSS conducted an annual and follow up survey from 03/14/23 through 03/17/23.

The facility had multiple deficiencies including failure to ensure medication aides passed required exams timely, incomplete resident care plans, failure to follow physician orders, medication administration errors, incomplete resident records, and missing special care unit disclosures and profiles.

The Adult Care Licensure Section conducted a follow-up survey and a complaint investigation from 09/28/21 to 09/30/21. The complaint investigation was initiated by the County Department of Social Services on 08/06/21.

The facility failed to ensure agency staff had required personnel registry checks upon hire, failed to administer medications as ordered for a resident, failed to accurately document sliding scale insulin administration for two residents, failed to complete quarterly resident profiles for special care unit residents, and failed to ensure medication aides completed required training hours.

The complaint investigation was initiated by the County Department of Social Services on 08/06/21 and included follow-up to previous deficiencies.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual and follow-up survey and a complaint investigation on 07/07/21 through 07/09/21, 07/12/21 with an exit date of 07/13/21.

The facility had multiple deficiencies including failure to maintain clean and safe environment, hot water temperatures exceeding regulatory limits, staff qualification and training deficiencies, incomplete resident records, failure to provide adequate personal care and supervision, medication administration errors, and failure to follow up on physician orders and pharmacy recommendations. These failures placed residents at risk for injury, neglect, and compromised health and safety.

Complaint investigation included issues with personal care, supervision, medication administration, resident rights, and health care. Specific complaints involved inadequate oral care, elopement incidents, medication errors, and failure to provide timely assistance to residents.

The Adult Care Licensure Section and Mecklenburg County DSS conducted a complaint investigation and a COVID-19 focused infection control survey with an onsite visit on July 20, 2020, a desk review from July 6 to July 20, 2020, and a telephone exit on July 20, 2020.

The facility failed to assure that 2 of 3 sampled staff had received the required 6 hours of special care unit orientation training within the first week of hire, and one staff had not completed the additional 20 hours of training required for working in the Special Care Unit. Documentation was missing for Staff A and Staff C regarding this training.

Complaint investigation conducted by Adult Care Licensure Section and Mecklenburg County DSS related to staff training deficiencies in the Special Care Unit.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey and complaint investigation on 06/17/19-06/19/19.

The facility was found deficient in multiple areas including housekeeping and furnishings with soiled and urine-smelling upholstered chairs, failure to ensure tuberculosis testing for staff, medication administration errors for three residents, incomplete special care unit staff training, and medication aide training and competency requirements not met.

Complaint investigation was conducted concurrently with the annual survey from 06/17/19 to 06/19/19.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey of Brookdale Cotswold from 11/29/17 to 12/01/17 with a telephone exit on 12/04/17.

The facility was found to have multiple deficiencies including chronic unpleasant odors in resident rooms, failure to maintain the building in a clean and orderly manner with hazards such as roaches and stained mattresses, failure to competency validate staff for licensed health professional support tasks, failure to ensure staff had current CPR certification, failure to ensure proper self-administration medication orders and labeling, failure to complete required pre-admission screening and disclosure for special care unit admissions, and failure to provide required special care unit staff orientation and training.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 6/28/16 to verify correction of previous deficiencies related to medication administration.

The facility failed to assure medications were administered as ordered by the licensed prescribing practitioner for 2 of 5 sampled residents (#1 and #2). Resident #1 did not receive the decreased dose of pantoprazole as ordered, and Resident #2 had multiple missed or undocumented doses of Spiriva and Zyrtec. Documentation and order processing errors were noted, and pharmacy coordination issues contributed to medication administration failures.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 03/02/16-03/04/16 to verify correction of previous deficiencies.

The facility failed to implement physician orders for blood pressure checks for one resident, failed to serve a therapeutic diet as ordered for another resident, failed to assure timely response to call light notifications for residents, and failed to administer medications as ordered for one resident. Additionally, one medication aide had not completed required annual infection control training.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an Annual Survey and Complaint Investigation on 11/4-11/6/15 and 11/19/15 with an exit conference on 11/10/15 via telephone.

The facility failed to ensure the Administrator was responsible for total operations including medication administration, resident rights, infection prevention, staffing, personal care, supervision, health care, nutrition, and medication aide training. Deficiencies included medication errors, lack of supervision on third shift, failure to assist residents with showers, delayed response to call bells, failure to follow up on health care needs, improper infection control practices, unlabeled insulin pens, and medication aides lacking required training and competency validation.

Complaint investigation included failure to administer medications as ordered, neglect related to pain medications, and delayed response to call bells for multiple residents.