Inspection Reports for The Brownstone
6400 Burlwood Rd, Charlotte, NC 28211, NC, 28211
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Inspection Report
Capacity: 6
Deficiencies: 5
Jan 9, 2025
Visit Reason
DHSR Construction Section conducted a Biennial Survey to ensure compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the applicable portions of the 2018 North Carolina State Building Code for Small Non-Ambulatory Care Facilities.
Findings
The survey identified multiple deficiencies including lack of mechanical ventilation in an interior bathroom, absence of handrails on certain exterior steps, a light fixture hanging below the required clearance height, water temperature exceeding the allowed maximum, and chipping paint and damage to exterior fascia and soffit.
Deficiencies (5)
| Description |
|---|
| Interior bathroom next to the sitting room did not have mechanical ventilation. |
| Steps from the screen porch and the door across from the screen porch did not have handrails. |
| Light fixture in the front foyer was hanging below 6 feet 8 inches clearance. |
| Water temperature was 122 degrees, exceeding the allowed range of 100-116 degrees. |
| Chipping paint on front and right side fascia boards and damage to the rear soffit. |
Report Facts
Total licensed capacity: 6
Water temperature: 122
Required light clearance: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Hickman | Report author conducting the survey |
Inspection Report
Follow-Up
Deficiencies: 2
Mar 15, 2022
Visit Reason
The Adult Care Licensure Section and Mecklenburg County DSS completed a follow-up survey on 03/15/22 to verify compliance with prior deficiencies.
Findings
The facility failed to ensure that one of three sampled staff (Staff A) had a current North Carolina Health Care Personnel Registry (HCPR) check and a criminal background check completed prior to being rehired on 02/02/22. Interviews and record reviews confirmed that these checks were not performed upon rehire as required.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure Staff A had no substantiated findings listed on the North Carolina Health Care Personnel Registry prior to rehire. |
| Facility failed to ensure Staff A had a criminal background check prior to rehire. |
Report Facts
Shifts worked by Staff A: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide/Personal Care Aide | Named in findings related to missing HCPR and criminal background checks upon rehire. |
| Business Office Manager | Responsible for ensuring staff employment records included HCPR and criminal background checks; failed to perform these checks for Staff A upon rehire. | |
| Facility Administrator | Interviewed regarding Staff A's employment and rehire status and awareness of missing checks. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Jan 12, 2022
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a complaint investigation initiated on January 6, 2022, regarding concerns at Senior Retreat at Stonehaven.
Findings
The facility failed to ensure staff qualifications were properly verified, including substantiated findings on the Health Care Personnel Registry and criminal background checks for one staff member. Resident #1 lacked a signed FL2 upon admission from hospital, had an inadequate care plan and supervision related to exit-seeking behavior, resulting in multiple elopements. Additionally, a former staff member allegedly took inappropriate photographs of Resident #1 while toileting, which was not properly reported or investigated. The facility also failed to notify the resident's responsible party of elopement incidents within required timeframes.
Complaint Details
Complaint investigation initiated on January 6, 2022, by Mecklenburg County Department of Social Services regarding staff qualifications, resident care and supervision, inappropriate photography by staff, and failure to notify responsible parties of incidents.
Severity Breakdown
Type B Violation: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry. | Type B Violation |
| Facility failed to ensure 1 of 4 sampled staff had a criminal background check performed upon hire. | Type B Violation |
| Facility failed to assure 1 of 3 sampled residents had a signed FL2 upon admission from hospital. | — |
| Facility failed to ensure 1 of 3 sampled residents had a care plan revised as needed based on assessments, specifically related to wandering and exit-seeking behaviors. | — |
| Facility failed to provide supervision for 1 of 3 sampled residents in accordance with assessed needs and symptoms related to exit-seeking behavior, resulting in multiple unsupervised elopements. | Type B Violation |
| Facility failed to ensure 1 of 3 sampled residents was treated with respect and dignity related to a former staff member taking inappropriate photographs while resident was using the restroom. | Type B Violation |
| Facility failed to report allegations of a former staff taking inappropriate photographs of a resident to the Health Care Personnel Registry within required timeframes. | — |
| Facility failed to notify the resident's responsible party of an elopement incident within 48 hours and document the notification. | — |
Report Facts
Shifts worked by Staff C: 13
Residents sampled: 3
Staff sampled: 4
Dates of resident elopements: 3
Distance from facility to road: 61
Vehicles observed: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide/Personal Care Aide | Failed to have substantiated findings cleared on Health Care Personnel Registry and lacked criminal background check. |
| Staff D | Medication Aide/Personal Care Aide | Alleged to have taken inappropriate photographs of Resident #1 while toileting; incident not properly reported or investigated. |
| Administrator | Responsible for overall facility management; did not report allegations to HCPR or notify family of elopements. | |
| Supervisor in Charge (SIC) | Responsible for facility management; failed to ensure incident reports were completed or proper notifications made. | |
| Resident #1's Care Manager | Hired by resident's POA to coordinate medical care; not informed of resident's elopement incidents. |
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