Inspection Reports for The Charlotte Assisted Living & Memory Care

The visit was conducted as a monitoring follow-up to address a Type A2 violation related to inadequate supervision of residents, specifically concerning an elopement incident involving Resident #1.

The facility failed to provide adequate supervision for Resident #1, who eloped from the facility unnoticed despite wearing a roam alert device. Staff silenced the roam alert alarm instead of investigating, resulting in a substantial risk of physical harm. The facility submitted a plan of correction with a deadline of August 23, 2025.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual and follow-up survey from May 6, 2025 to May 7, 2025.

The facility failed to document the administration of oxygen for one resident on the electronic medication administration record and failed to ensure the resident had a physician's order to self-administer an albuterol inhaler used to treat shortness of breath.

This is a Construction Section Biennial Follow Up Construction Survey conducted to verify compliance with physical plant and safety code requirements.

Multiple deficiencies were cited including failure to meet code requirements for smoke-tight kitchen doors, corridors obstructed by equipment, inadequate outdoor lighting, poor housekeeping with water stains and ceiling damage, unsafe building equipment conditions including fire safety system gaps and electrical hazards, plumbing leaks, obstruction of sprinkler heads, and unsupervised operational ovens without locking features.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual and follow-up survey on April 25 - 26, 2023 to assess compliance with health care regulations and implementation of physician orders.

The facility failed to ensure proper referral and follow-up for physical and occupational therapy for one resident, failed to implement daily blood pressure checks as ordered for one resident, and failed to administer prescribed medication for blood sugar control for another resident. Deficiencies were related to lack of follow-up on referrals, missed orders, and incomplete medication administration documentation.

The Adult Care Licensure Section conducted a complaint investigation initiated by the Mecklenburg County Department of Social Services on 06/15/22 regarding concerns at The Charlotte Assisted Living.

The facility failed to restrict a window opening to six inches for a resident with a history of attempted suicide, resulting in the resident falling from a third floor window and death. Additionally, the facility failed to ensure adequate care and supervision for this resident with suicidal ideations, failed to complete criminal background checks for staff, and failed to maintain orderly resident records. The facility also failed to ensure proper physician orders for residents self-administering medications.

Complaint investigation initiated by Mecklenburg County Department of Social Services on 06/15/22 regarding concerns at The Charlotte Assisted Living.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey and a state involved complaint investigation survey with onsite visits from 10/19/21 to 10/22/21, a desk review on 10/25/21 and a telephone exit conference on 10/26/21. The complaint investigation was initiated by the Mecklenburg County Department of Social Services on 10/06/21.

The facility was found deficient in multiple areas including failure to properly issue discharge notices with receipt requests, failure to have and serve a therapeutic renal diet as ordered, and failure to administer medications as ordered for a sampled resident, including documentation inaccuracies and double dosing of medications.

Complaint investigation initiated by Mecklenburg County Department of Social Services on 10/06/21 related to discharge procedures and medication administration.

The Adult Care Licensure Section conducted a follow-up survey on 03/09/21 to 03/10/21 to verify correction of previous deficiencies related to implementation of physician orders.

The facility failed to ensure physician orders were implemented for 1 of 5 sampled residents (#3) regarding collection of a stool specimen for Clostridium difficile testing. Staff had difficulty collecting the stool specimen due to loose stool and lack of clear instructions, resulting in missed collections despite multiple attempts.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted a COVID-19 focused infection control survey and a state involved complaint investigation survey with onsite visits and desk reviews in November 2020.

The facility was found deficient in multiple areas including failure to provide adequate supervision leading to a resident fall and hospitalization, failure to ensure referral and follow-up for physical therapy and weight loss, failure to implement physician orders for medications and treatments, failure to follow COVID-19 testing and infection control guidance including retesting and admission restrictions during an outbreak, failure to accommodate compassionate care visits, and failure to administer medications as ordered.

Complaint investigation included review of a fall incident involving Resident #5, COVID-19 outbreak management, and medication administration concerns.

The Adult Care Licensure Section conducted an annual survey to assess compliance with state regulations including staff qualifications, health care, medication administration, and resident care.

The facility failed to ensure proper staff registry checks upon hire, timely referral and follow-up for physical and occupational therapy, and notification of physicians regarding resident behaviors and medication refusals. Medication administration errors were observed including failure to administer ordered medications and administering medications outside of prescribed parameters.

This is a biennial follow-up construction survey conducted to assess the facility's compliance with building and fire safety regulations.

The facility was found to have deficiencies related to unsafe storage of combustible materials in Bedroom 213 and failure to maintain required exhaust ventilation in multiple laundry and restroom areas.

The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure.

Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, electrical safety, and ventilation. These included missing audible signals on delayed egress doors, missing fire safety inspection reports, corridor obstructions, unclean mechanical systems, uncapped gas lines, improperly oriented evacuation plans, incomplete fire safety rehearsal records, lack of GFCI protection on electrical outlets, fire alarm system troubles, compromised fire rated walls and ceilings, doors not latching properly, excessive combustible storage, clogged sinks, and non-functioning exhaust ventilation in several areas.

Complaint follow-up construction survey conducted to verify correction of previously identified deficiencies related to physical plant and fire safety.

Several deficiencies were found including missing required signage on exit doors, improperly maintained evacuation maps, and fire-resistance doors that did not close or latch properly. Some corridor doors were propped or wedged open, compromising fire and smoke containment. One deficiency was corrected during the survey.

This was a complaint follow-up construction survey. Some deficiencies from prior inspections were not corrected, requiring further action.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey and a complaint investigation on November 6th - 9th, 2018.

The facility failed to assure 3 storage rooms containing hazardous chemicals were locked and not accessible to residents; failed to maintain the facility free of chronic urine odors; failed to keep resident hallway chairs clean and in good repair; failed to provide personal care assistance including catheter care, incontinent care, showers, and bed linen changes; failed to provide adequate supervision for residents including one who exited the special care unit unsupervised; failed to serve therapeutic diets as ordered due to lack of menus; failed to administer medications as ordered including unavailable medications and incorrect administration; failed to implement infection control measures during medication administration; failed to store resident medications securely; and failed to ensure call bell system was monitored and responded to appropriately.

Complaint investigations were initiated by the county on 09/20/18, 09/27/18, 10/05/18, 10/18/19, 10/25/18 and on 10/29/18.

The inspection was conducted as a Construction Section Complaint Survey and a Complaint Follow Up Construction Survey triggered by allegations that the ceiling was caving in and leaking into several residents' rooms, the HVAC system was leaking, the hurricane damaged the roof, and the building had bed bugs.

The complaint was substantiated. Multiple deficiencies were cited including failure of delayed egress doors to release under required force, missing required signage, lack of emergency release switches for special locking doors, presence of bed bugs, building mechanical systems not kept clean or in good repair, walls and ceilings damaged or unclean, unsafe storage of portable oxygen cylinders, failure to maintain evacuation plans and maps, fire safety doors not closing or latching properly, combustible storage blocking exits, emergency equipment not maintained, sprinkler system deficiencies, corridor doors propped open preventing fire containment, and inadequate general lighting in corridors and rooms.

The complaint was substantiated. Allegations included ceiling caving in and leaking into residents' rooms, leaking HVAC system, hurricane damage to roof, and presence of bed bugs.

The inspection was conducted as a complaint investigation based on allegations that the sanitation score was below 85 and there was a roof or HVAC leak in the corridor near room 319.

The complaint was substantiated with multiple deficiencies found including delayed egress doors not functioning properly, obstructions in corridors and exit paths, sanitation issues including a recent sanitation score below 85, unsafe handling of portable oxygen cylinders, missing monthly inspections for fire suppression systems, dry waste traps, damaged window screens, wet and damaged carpets, trip hazards, combustible materials stored in stairwells, inadequate fire safety rehearsals, compromised fire rated walls and ceilings, corridor doors propped open or not latching, plumbing equipment not maintained, and inadequate general lighting in corridors.

The complaint alleging sanitation score below 85 and a roof or HVAC leak near room 319 was substantiated.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey, a follow-up survey, and a complaint investigation from July 30, 2018 to August 2, 2018.

The facility was found deficient in multiple areas including unlocked hazardous chemical storage accessible to residents, poor housekeeping and maintenance with stained carpets and damaged walls, unclean and damaged furniture, inadequate sanitation scores, unsafe fire and electrical equipment, incomplete food service orientation for staff, incomplete tuberculosis testing, inadequate supervision leading to resident elopement and falls, failure to notify physicians and family of incidents, medication administration errors, lack of self-administration medication oversight, absence of policies for managing aggressive behaviors and infection control, failure to report incidents to authorities, incomplete special care unit staff training, and sharing of glucometers among diabetic residents.

The Adult Care Licensure Section and Mecklenburg County Department of Social Services conducted an annual survey and complaint investigations on April 19-21, 2017, initiated by complaints from March and April 2017.

The facility was found deficient in multiple areas including failure to ensure tuberculosis testing for staff, failure to provide personal care according to residents' care plans, medication administration errors, failure to observe residents taking medications, and failure to properly assess and document residents' ability to self-administer medications.

Complaints were initiated by the Mecklenburg County Department of Social Services on March 03, 2017, March 09, 2017, April 12, 2017, and April 17, 2017.

The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure during a Construction Section Biennial Survey.

Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, electrical safety, and maintenance issues including obstructed exit enclosures, loose handrails, chronic unpleasant odors, improper storage of oxygen cylinders, inadequate fire plan documentation, non-functional electrical outlets, delayed egress door malfunctions, fire barrier penetrations, unsafe electrical panel access, malfunctioning doors, fire alarm and sprinkler system issues, and use of prohibited portable electric heaters.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 03/01/16 and 03/02/16 to verify correction of previous deficiencies.

The facility failed to ensure 5 of 7 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry. Additionally, the facility failed to serve therapeutic diets, including mechanical soft diets and nectar thickened liquids, as ordered by physicians for 4 of 6 sampled residents.

The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey from 09/30/2015 through 10/02/2015 to assess compliance with regulations.

The facility failed to ensure that all staff had substantiated findings checked on the North Carolina Health Care Personnel Registry. Additionally, the facility did not serve 8 ounces of pasteurized milk at least twice a day to Memory Care Unit residents and failed to serve therapeutic diets as ordered for 4 of 8 sampled residents, including pureed and mechanical soft diets.