The Stewart Health Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
09/10/25 at 3:01 PM an interview was conducted with Family Member #1 and Family Member #2. During
the interview they stated the facility had contacted them regarding the incident on 09/06/25. The interview revealed that the facility had discussed issues with Resident #1 attempting to elope from the facility with them since admission on [DATE REDACTED] and they hired a private sitter to sit with him originally on 07/22/25 during
the night and day. Family Member #1 stated on 09/01/25 the family gradually started to reduce the time frame to 4 hours a day. Family Member #1 stated the facility wanted to move Resident #1 to the locked memory care unit on 07/22/25 and she strongly protested it because she wanted him near his spouse who was also located on the unit. Resident #1 was very strong-willed and was confused as to why he could not leave the facility as he typically did prior to admission to the facility. The Family Members explained they did not have contact information for the private sitter and stated they would attempt to gain the information and let the surveyor know. The interview revealed Resident #1 had previously lived on campus in an independent living setting, however the resident was becoming more forgetful such as leaving his coffee pot
on during the day. Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment. On 09/10/25 at 11:41 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated on 09/06/25 Nurse #1 notified her Resident #1 had gone out of the conference room door and they were notified by the Police Department that he was on the main road outside of the facility campus. She stated Resident #1 was alert, he had an abrasion to his right cheek and hand and was sent to the hospital for an evaluation. The DON accompanied him to the hospital while she went to the facility to assist staff members. The ADON explained typically on weekends the double doors leading to the conference room were locked, however the Dietary Manager had come in that morning and unlocked the doors. The Dietary Manager was in the kitchen at the time of the incident and did not see the resident walk by and go out of the door. The interview revealed Resident #1 had several attempts to exit the facility prior to 09/06/25 and he was placed on every 2-hour monitoring, and the facility had discussed the incident at length with the Family members.On 09/10/25 at 9:45 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #1 was previously in the independent living housing on the campus however due to a decline in cognition, he was moved into the skilled nursing home for increased supervision. The DON shared for exam
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The Stewart Health Center in Charlotte, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Charlotte, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Stewart Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.