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
Staffing
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
1.46
Licensed practical nurse staffing
Aide hours / resident day
3.09
Nurse aide staffing
Weekend hours
4.62
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
99%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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