7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Gastonia, NC
2-star overall rating with 2-star inspections with $202,719 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2065 Lyon Street, Gastonia, NC
(704) 867-7300
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1994-05-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
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
0.55
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
2.93
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
3,896
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
9.01
Baseline 19.54% · Performance 17.26% · Measure score 9.01 · Achievement 9.01 · Improvement 8.6
Healthcare-associated infections
4.87
Baseline 8.29% · Performance 6.52% · Measure score 4.87 · Achievement 4.40 · Improvement 4.87
Total nurse turnover
3.01
Performance 51.39% · Measure score 3.01 · Achievement 3.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.38 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.05% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 320 · Observed rate 14.69% · Lower 95% interval 10.19% |
| Discharge to community | 60.27% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 324 · Observed rate 51.85% · Lower 95% interval 53.96% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.61% |
95.27%
4.3 pts better
|
Numerator 256 · Denominator 257 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 257 |
| Discharge self-care score | 46.41% |
53.69%
7.3 pts worse
|
Numerator 84 · Denominator 181 |
| Discharge mobility score | 51.93% |
50.94%
1 pts better
|
Numerator 94 · Denominator 181 |
| Pressure ulcers or injuries, new or worsened | 1.17% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 257 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 5.95% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 7.92% |
42%
34.1 pts worse
|
Numerator 8 · Denominator 101 |
| Discharge function score | 49.72% |
56.45%
6.7 pts worse
|
Numerator 90 · Denominator 181 |
| Transfer of health information to provider | 99.42% |
95.95%
3.5 pts better
|
Numerator 171 · Denominator 172 |
| Transfer of health information to patient | 84.13% |
96.28%
12.2 pts worse
|
Numerator 53 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 12.03% |
25.2%
13.2 pts worse
|
Numerator 16 · Denominator 133 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
91.5%
5.5 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 95.0% · Q3 100.0% · Q4 95.8% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.5% · Q3 0.0% · Q4 2.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.4% |
4.8%
4.6 pts worse
|
11.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 12.8% · Q3 15.0% · Q4 4.4% · 4Q avg 9.4% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
7.2%
6.5 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
21.6%
7.2 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 23.5% · Q3 15.6% · Q4 11.9% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.6% |
15.0%
13.4 pts better
|
16.7%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · 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 ability to walk independently worsened | 70.2% |
21.5%
48.7 pts worse
|
16.3%
53.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 70.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.7% |
16.8%
20.9 pts worse
|
14.9%
22.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 54.5% · Q3 31.0% · Q4 26.3% · 4Q avg 37.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 4.9% · Q4 4.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
21.2%
0.4 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 17.5% · Q3 29.3% · Q4 16.7% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
6.0%
0.4 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.4% · Q3 5.1% · Q4 5.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
79.9%
10.5 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.2% · Q2 52.6% · Q3 70.0% · Q4 93.0% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
13.2%
2.8 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 11.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 1.0% · Q4 1.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
78.1%
1.4 pts worse
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
22.9%
3.3 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 20.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
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 2024-08-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-05
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
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 2023-03-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-31
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2023-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-13
Inspection history
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-27
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-08-27
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-27
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-27
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-07
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-24
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-06
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-06
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-06
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-06
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-02-06
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 2023-02-06
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-02-06
Penalties and ownership
Fine · fine $84,529
Fine
Fine · fine $118,190
Fine
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Gastonia, NC
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Gastonia, NC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Gastonia, NC
2-star overall rating with 2-star inspections with $71,559 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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