Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Stewart Health Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of elopement was able to exit the facility unsupervised after a private sitter left and staff were not informed. The resident accessed an exit through a conference room where doors had been left open, and the wanderguard alarm system failed to activate due to a malfunction. The resident was found outside the facility with injuries after walking to a busy intersection, and staff were unaware of the resident's absence until notified by emergency services.
A resident with dementia and pneumonia was prescribed a probiotic to be given alongside an antibiotic, but the ordered probiotic was not administered despite MAR documentation indicating otherwise. The unopened medication was returned to the pharmacy, and the resident later developed a yeast infection requiring additional treatment. Interviews and records confirmed the probiotic was not provided as ordered.
The facility failed to maintain privacy during care and did not obtain written consent for the use of cameras in residents' rooms for two residents. Camera monitors were left unattended and visible to visitors, exposing residents' private areas during care. Staff and administration confirmed that written consent was not consistently obtained and that cameras were used as an extra level of supervision.
The facility failed to implement an effective infection prevention and control program, as the Infection Preventionist (IP) lacked proper training and oversight. The infection control policy manual was outdated, and essential components of the program, such as tracking infections and obtaining diagnostic results, were not completed. This oversight potentially affected all 60 residents.
The facility failed to develop an infection prevention and control program that included an antibiotic stewardship program with written protocols on antibiotic prescribing, documentation of the indication, dosage, and duration of use of antibiotics. The IP had incomplete or missing data for several months and was unable to provide necessary culture result information. The Administrator and DON were unaware of these deficiencies, attributing them to the transition to a new electronic system and the IP being new to the role.
The facility failed to develop and implement person-centered care plans for residents on anticoagulants, psychotropic medications, and those with wander/elopement alarms. Despite active orders and regular administration of these medications and devices, the care plans lacked necessary goals and interventions. Interviews with staff revealed a lack of awareness and oversight in including these critical elements in the care plans.
The facility failed to maintain proper food storage and cleanliness standards, with issues including an unclean ice cream cooler and multiple perishable food items in the walk-in cooler, reach-in refrigerator, and walk-in freezer found opened without labels or dates.
The facility failed to ensure that a resident's MOST form was signed by the resident or their representative. The form, indicating a DNR status, was signed by the NP but lacked the required resident or representative signature. Staff interviews confirmed the oversight.
The facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (ABN) prior to the discharge from Medicare Part A skilled services for a resident. The resident remained in the facility after Medicare Part A coverage ended, and the required ABN was not issued. The Social Worker was unaware of the requirement, and the Administrator confirmed the oversight.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in their assessments. One resident requiring a mechanical lift for transfers was not coded for lower extremity impairment, and another resident on anticoagulant medication was not coded for its use. Interviews revealed misunderstandings and errors by the MDS Coordinator.
A resident with severe cognitive impairment was transferred using a mechanical lift without locking the wheels on both the lift and the wheelchair. Despite being trained, two nurse aides did not follow the protocol, believing it was unnecessary with two aides present. The resident's care plan did not include interventions for using a mechanical lift.
The facility failed to provide stop dates for PRN psychotropic medications for two residents. One resident was prescribed Seroquel for behaviors without an end date, and another was prescribed Alprazolam for anxiety without a stop date. Interviews with staff confirmed the requirement for a 14-day stop date was not followed.
A medication cart on Dogwood Avenue was found unattended and unlocked, containing various medications and supplies. The nurse responsible admitted to normally locking the cart but failed to do so this time. The DON confirmed that the cart should always be secured when unattended.
The facility failed to complete and transmit a discharge and a death MDS assessment within the required timeframe for two residents. The MDS Coordinator could not locate the assessments in the electronic medical record systems, and the Administrator confirmed that the assessments should have been completed and transmitted within 14 days as per regulatory guidelines.
Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Wanderguard System
Penalty
Summary
A cognitively impaired resident with a history of elopement attempts, impaired safety awareness, hearing loss, and aphasia was admitted to the facility from an independent living apartment. Upon admission, the resident was identified as an elopement risk through multiple assessments, and interventions such as a wanderguard bracelet, every 2-hour checks, and a private sitter were implemented. Despite these measures, the resident continued to exhibit exit-seeking behaviors, including manipulating doors, cutting off the wanderguard bracelet, and attempting to leave the facility on several occasions. The care plan was updated to reflect these risks, and staff and family were aware of the resident's ongoing behaviors. On the day of the incident, the resident's private sitter left, and staff were not adequately informed of the change in supervision. The resident was last seen in his room, believed to be asleep, but was able to leave the room unsupervised. The conference room doors, which typically remained locked on weekends, were left open by the Dietary Manager, providing access to an exit door equipped with a wanderguard alarm system. However, the alarm system was malfunctioning and did not sound when the resident exited, allowing him to leave the building without staff knowledge. The resident walked down the main road, passed a security gate, and was found by a bystander near a busy intersection with injuries, including a facial contusion and skin tears. Interviews and record reviews confirmed that staff were unaware of the resident's absence until notified by security and emergency services. The malfunctioning wanderguard system was later confirmed through testing, and the lack of communication regarding the sitter's departure contributed to the lapse in supervision. The resident's room was located near the exit, and the path to the door was unobstructed. The incident resulted in the resident being found off campus with injuries and highlighted failures in supervision, monitoring, and the effectiveness of safety systems for residents at risk of elopement.
Failure to Administer Ordered Probiotic
Penalty
Summary
A deficiency occurred when a resident with dementia, Alzheimer's disease, anxiety, depression, and pneumonia was prescribed a probiotic (Saccharomyces boulardii) to be administered daily while receiving an antibiotic (Doxycycline Hyclate) for an upper respiratory infection. The physician's order specified the probiotic was to be given for a set period, and the medication administration record (MAR) was initialed by two nurses indicating the probiotic was administered. However, interviews and pharmacy records revealed that the prescribed probiotic capsules were never actually given to the resident, as the full supply was returned to the pharmacy unopened. Further investigation showed that the responsible party did not provide any probiotics to the facility, and the nurses involved either could not recall the order or were unavailable for comment. The resident subsequently developed a yeast infection, for which a medicated vaginal cream was ordered. The discrepancy between the MAR documentation and the unused medication was not explained by facility leadership, and there was no evidence that the probiotic was administered as ordered.
Failure to Maintain Privacy and Obtain Consent for Camera Usage
Penalty
Summary
The facility failed to maintain privacy during care and did not obtain written consent for the use of cameras in residents' rooms for two residents. Resident #13, who was moderately cognitively impaired, had a camera installed in her room without written consent. Observations revealed that the camera monitor was left unattended and visible to visitors, exposing Resident #13's private areas during care. Interviews with staff and the Director of Nursing (DON) confirmed that camera monitors were sometimes left unattended and that written consent was not consistently obtained for camera usage. Resident #38, who was severely cognitively impaired, also had a camera in his room without written consent. Similar to Resident #13, the camera monitor for Resident #38 was left unattended and visible to visitors, exposing his private areas during incontinence care. Staff interviews indicated that the camera was installed due to concerns about Resident #38 attempting to leave the facility, but no written consent was obtained. The DON and Administrator acknowledged that cameras were used as an extra level of supervision and were not turned off during care. Both residents experienced a lack of privacy during care due to the unattended and visible camera monitors. The facility's failure to obtain written consent for camera usage and to ensure that camera monitors were attended or out of view of visitors led to the exposure of residents' private areas, causing potential humiliation and dehumanization. Staff interviews and observations confirmed these deficiencies, highlighting the need for better privacy practices and consent procedures.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of an updated infection control policy and procedure manual. The manual provided by the administrator was last reviewed and approved in 2019, despite the policy stating it should be reviewed annually. The Infection Preventionist (IP), who assumed the role in September 2023, was unable to explain the surveillance process for tracking and trending infections or provide necessary policies and procedures, indicating a lack of proper training and oversight in infection control duties. Interviews with the IP revealed that she had completed the NC SPICE training in April 2023 but had not received adequate training on performing infection control duties, surveillance, line listing, or tracking/trending of infections. The IP was also unable to provide a list of reportable communicable diseases and stated that the facility's infection control policies were not readily accessible to staff. This lack of accessibility was confirmed by a nurse who could not locate the infection control manual at the nurse's station. Further interviews with the Medical Director, Administrator, and Director of Nursing (DON) highlighted a lack of awareness and oversight regarding the annual review of infection control policies. The Administrator attributed the failure to the facility's focus on transitioning to a new electronic computer system and the assumption that the new IP was adequately trained. This oversight resulted in the facility not completing essential components of the infection control program, such as line listing for tracking infections and obtaining diagnostic results, potentially affecting all 60 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop an infection prevention and control program that included an antibiotic stewardship program with written protocols on antibiotic prescribing, documentation of the indication, dosage, and duration of use of antibiotics. This deficiency was evident in the monthly surveillance data reviewed for December 2023, January 2024, February 2024, and March 2024. The Infection Preventionist (IP) had not completed an antibiotic line listing form prior to January 2024 and had incomplete or missing data for subsequent months. The IP was unable to provide culture result information for residents treated for urinary tract infections and did not have an active current list of residents receiving antibiotics. Additionally, the IP was unable to identify or describe the components of an antibiotic stewardship program or the infection surveillance process. During interviews, the Administrator and the Director of Nursing (DON) were unaware that the facility did not have an active antibiotic stewardship program and that the policy was not being followed. They attributed the failure to the facility's focus on transitioning to a new electronic computer system and the IP being new to the role. The Administrator explained that the IP had completed the North Carolina State Program for Infection Control and Epidemiology (NC SPICE) training, but the transition of duties from the prior DON to the new IP was not adequately managed, leading to lapses in infection control tasks related to antibiotic stewardship.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for residents on anticoagulants, psychotropic medications, and those with wander/elopement alarms. Resident #209, who was moderately cognitively impaired and on apixaban, did not have goals and interventions for anticoagulant use in his care plan. Despite active orders and regular administration of the medication, the care plan lacked necessary monitoring for signs and symptoms of bleeding. Interviews with the nursing staff, DON, and MDS Coordinator revealed a lack of awareness and oversight in including these critical elements in the care plan. Resident #210, who was cognitively intact and on antipsychotic and antianxiety medications, also did not have goals and interventions for psychotropic medications in her care plan. Despite active orders and regular administration of quetiapine fumarate, the care plan did not address monitoring for behaviors associated with psychotropic medication use. The DON and MDS Coordinator acknowledged the oversight and confirmed that such goals and interventions should have been included. Resident #13, who was moderately cognitively impaired and had a wander/elopement alarm, did not have goals and interventions for the alarm in her care plan. Despite active orders to check the functionality and placement of the alarm every shift, the care plan was not updated to reflect this. Similar issues were found with Resident #20 and Resident #259, who were on anticoagulant and psychotropic medications but lacked corresponding care plans. Interviews with the MDS Nurse, DON, and Administrator confirmed these oversights, indicating a systemic issue in care plan development and implementation.
Failure to Maintain Proper Food Storage and Cleanliness
Penalty
Summary
The facility failed to maintain proper food storage and cleanliness standards, as observed during a survey. The ice cream cooler was found to have pink and brown-colored substances on all four walls, despite the Dietary Manager (DM) stating it was cleaned and sanitized daily. Additionally, several perishable food items in the walk-in cooler, including packages of crumbled blue cheese, shredded white cheddar cheese, and shredded white/yellow cheese, were found opened without labels or dates. The DM acknowledged that food should be labeled and dated after being opened but suggested that dietary aides might have opened the items without labeling them after her audit. Further observations revealed that a package of sliced American cheese in the reach-in refrigerator was also opened without a label or date. In the walk-in freezer, a package of hashbrowns and an unsealed bag of okra were found without labels or dates. The DM confirmed that opened food packages should be sealed, labeled, and dated but was unsure why these items were not. The Administrator was unaware of these issues and reiterated that all opened food packages should be labeled and dated.
Failure to Obtain Required Signatures on MOST Form
Penalty
Summary
The facility failed to ensure that the Medical Order for Scope of Treatment (MOST) form for a resident was signed by the resident or their representative. The resident, who was severely cognitively impaired, had a MOST form indicating a Do Not Resuscitate (DNR) status, which was signed by the Nurse Practitioner but lacked the required signature from the resident or their representative. This deficiency was identified during a review of the resident's medical records and confirmed through staff interviews. Staff interviews revealed that the facility's process involved the Social Worker obtaining advanced directives upon admission and the Medical Doctor or Nurse Practitioner discussing and completing the MOST form with the resident or their representative. However, in this case, the required signature was not obtained. The Director of Nursing, Nurse #1, and the Administrator all acknowledged that the form should have been signed by the resident or their representative, but it was not. The staff were unaware of the missing signature until it was pointed out during the survey.
Failure to Provide Required Beneficiary Notice
Penalty
Summary
The facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (ABN) prior to the discharge from Medicare Part A skilled services for one resident. Resident #29 was admitted to the facility and received a Notice of Medicare Non-Coverage (NOMNC) indicating that Medicare Part A coverage for skilled services would end on 01/18/2024. However, the resident remained in the facility after this date, and a CMS-10055 ABN was not issued to the resident or their responsible party. During an interview, the Social Worker confirmed the oversight and indicated a lack of awareness regarding the requirement to issue a CMS-10055 ABN in such circumstances. The Administrator acknowledged that both a NOMNC and an ABN should have been provided when the resident's Medicare Part A benefit ended and they remained in the facility.
Inaccurate MDS Coding for Functional Limitations and Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. Resident #38, who was admitted with muscle weakness and severe cognitive impairment, was observed requiring a sit-to-stand mechanical lift for transfers. Despite this, the MDS indicated no impairment of the lower extremities and only partial to moderate assistance needed for transfers. Interviews with the Nurse Aides, MDS Coordinator, Director of Nursing (DON), and Administrator revealed a misunderstanding of the criteria for coding lower extremity impairment, resulting in inaccurate MDS documentation for Resident #38. Resident #209, admitted with atrial fibrillation, had an active order for the anticoagulant medication apixaban. The resident's Medication Administration Record confirmed daily administration of apixaban, yet the admission MDS did not reflect the use of anticoagulants. Interviews with the DON and MDS Coordinator indicated that the MDS Coordinator mistakenly categorized apixaban as an antiplatelet medication, leading to the omission. Both the DON and Administrator acknowledged the responsibility of the MDS Coordinator in ensuring accurate MDS assessments, which was not met in this case.
Failure to Secure Mechanical Lift and Wheelchair During Transfer
Penalty
Summary
The facility failed to secure a mechanical lift and wheelchair during a transfer for a resident diagnosed with lack of coordination, muscle weakness, and essential tremors. The resident required partial to minimal assistance for sit-to-stand and toileting transfer and was severely cognitively impaired. During an observation, two nurse aides transferred the resident using a mechanical lift without locking the wheels on both the lift and the wheelchair. Both aides were aware of the requirement to lock the wheels but did not do so because they believed it was unnecessary with two aides present. The resident's care plan did not include goals or interventions for using a mechanical lift. Interviews with the nurse aides, the Director of Nursing (DON), and the Staff Development Coordinator (SDC) confirmed that staff had received education and competency checks on the use of mechanical lifts, including the importance of locking the wheels during transfers. Despite this training, the aides did not follow the protocol, leading to the deficiency. The Administrator also confirmed that staff received education on mechanical lifts and transfers upon hire and as needed.
Failure to Provide Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a stop date for psychotropic medications prescribed as needed for two residents. Resident #210 was admitted with a diagnosis of delirium and was prescribed Seroquel 12.5 milligrams every 12 hours as needed for behaviors, starting on 2/15/2024, without an end date. Despite a recommendation from the pharmacist on 2/21/2024 to discontinue the medication by 2/29/2024, the order remained active until 3/5/2024. Interviews with the nurse, pharmacist, DON, and administrator revealed a lack of awareness and adherence to the 14-day stop date requirement for PRN antipsychotic medications. Resident #259, admitted with diagnoses including depression, anxiety, and unspecified dementia without behavioral disturbances, was prescribed Alprazolam 0.25 mg every 24 hours as needed for anxiety on 2/12/2024, also without a stop date. The resident received doses on 2/18/2024, 2/27/2024, and 2/28/2024. Interviews with the nurse, DON, medical director, and administrator confirmed that PRN psychotropic medications should have a 14-day stop date, which was not implemented in this case.
Unsecured Medication Cart on Dogwood Avenue
Penalty
Summary
The facility failed to secure resident medications left in an unattended medication cart on Dogwood Avenue. During a continuous observation, the medication cart was found with the lock not engaged, as indicated by the visible red dot on the lock. The cart was unattended, and several staff members, residents, and visitors were observed walking past it. Upon returning to the cart, a nurse was asked to open the drawer without turning the key, and it was found to contain various prescribed and over-the-counter medications and supplies. The nurse admitted that her normal practice was to lock the cart when not in its presence but was uncertain why she did not engage the lock this time. An interview with the Director of Nursing (DON) confirmed that the medication cart should have been secured and locked unless the nurse was present. The DON stated that any staff member noticing the unlocked cart should have immediately pressed the lock and notified the assigned nurse. The responsibility for ensuring the cart was secured lay with the nurse assigned to it.
Failure to Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit a discharge and a death Minimum Data Set (MDS) assessment within the required timeframe for two residents. Resident #52 was discharged to assisted living, but the discharge MDS assessment was not completed or transmitted. The MDS Coordinator was unable to locate the discharge MDS in either the former or current electronic medical record systems and was unsure why it was not completed. The Administrator confirmed that the discharge MDS should have been completed and transmitted within 14 days as per regulatory guidelines. Resident #18 expired in the facility, but the death MDS assessment was not completed or transmitted. The MDS Coordinator could not find the death MDS in either the former or current electronic medical record systems and suggested that the assessment was likely missed due to ongoing training on the new electronic medical record system. The Administrator acknowledged that the death MDS assessment should have been completed and transmitted within 14 days according to regulatory guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Sharon At Southpark | 1 mi | ★★★★★ | 0 | 0 |
| Briar Creek Health Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Sardis Oaks | 3.7 mi | ★★★★★ | 4 | 0 |
| Brookdale Carriage Club Providence | 3.7 mi | ★★★★★ | 1 | 0 |
| Pelican Health Randolph Llc | 3.9 mi | ★★★★★ | 15 | 0 |
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