Charlotte, NC
2-star overall rating with 2-star inspections with $53,176 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3211 Bishops Way Lane, Charlotte, NC
(704) 532-7000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
104
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.45
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.00
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.62
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
99%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0163
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.45
Baseline 17.80% · Performance 18.90% · Measure score 5.45 · Achievement 5.45 · Improvement 0
Healthcare-associated infections
9.07
Baseline 4.30% · Performance 5.12% · Measure score 9.07 · Achievement 9.07 · Improvement 0
Total nurse turnover
2.85
Baseline 63.91% · Performance 52.03% · Measure score 2.85 · Achievement 2.85 · Improvement 2.54
Adjusted total nurse staffing
7.11
Baseline 4.37 hours · Performance 5.10 hours · Measure score 7.11 · Achievement 7.11 · Improvement 4.69
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 636 · Observed rate 9.12% · Lower 95% interval 8.46% |
| Discharge to community | 59.63% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 658 · Observed rate 56.23% · Lower 95% interval 55.79% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.3% |
95.27%
1 pts better
|
Numerator 286 · Denominator 297 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 297 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 90 · Denominator 230 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 120 · Denominator 230 |
| Pressure ulcers or injuries, new or worsened | 1.68% |
2.29%
0.6 pts better
|
Numerator 5 · Denominator 297 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 5.12% |
7.12%
2 pts better
|
Better than the National Rate · Eligible stays 319 · Observed rate 3.76% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 207 · Denominator 207 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 41.74% |
56.45%
14.7 pts worse
|
Numerator 96 · Denominator 230 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 72 · Denominator 72 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 197 · Denominator 197 |
| Resident COVID-19 vaccinations up to date | 27.63% |
25.2%
2.4 pts better
|
Numerator 42 · Denominator 152 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
91.5%
6.1 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.8% · Q3 98.4% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 67.6% |
94.1%
26.5 pts worse
|
95.5%
27.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 67.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 4.9% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
4.8%
1.7 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 5.4% · Q4 3.6% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
7.2%
1.3 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 5.1% · Q3 7.0% · Q4 12.5% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
21.6%
7.5 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 11.9% · Q3 15.5% · Q4 12.3% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
15.0%
4.3 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 8.9% · Q3 9.5% · Q4 11.6% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.8%
7.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 5.9% · Q3 8.3% · Q4 12.8% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
0.9%
1.6 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 2.5% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
21.2%
1.3 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 23.9% · Q3 23.1% · Q4 20.3% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.0%
2.5 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.9% · Q3 11.0% · Q4 13.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
79.9%
9.5 pts better
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 88.9% · Q3 87.5% · Q4 91.6% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
13.2%
1.7 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.8% · Q3 0.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
78.1%
1.5 pts better
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
22.9%
4.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 24.7% · Expected 21.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-27
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-21
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-21
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-04-26
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-26
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-26
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-26
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-11
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-11
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-02
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-11-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-08
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-11-08
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-08
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-11-08
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-05
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-07-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-05
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-05
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-05
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-05
Penalties and ownership
Fine · fine $14,800
Fine
Fine · fine $38,376
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Nearby options
Charlotte, NC
2-star overall rating with 1-star inspections with $144,199 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Charlotte, NC
3-star overall rating with 3-star inspections with $14,069 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Charlotte, NC
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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