Cycle 1
Health 2025-04-07 · Fire 2025-04-07
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Charlotte, NC
Brookdale Carriage Club Providence
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
5804 Old Providence Road, Charlotte, NC
(704) 365-8551
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
14
Certified beds
Average residents
6
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
1997-04-03
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,847
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0009
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.22
Baseline 19.36% · Performance 18.09% · Measure score 7.22 · Achievement 7.22 · Improvement 4.96
Healthcare-associated infections
2.26
Baseline 6.82% · Performance 7.16% · Measure score 2.26 · Achievement 2.26 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 4.69% · Lower 95% interval 6.99% |
| Discharge to community | 67.02% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 61 · Observed rate 62.3% · Lower 95% interval 56.26% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 37 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 87.88% |
53.69%
34.2 pts better
|
Numerator 29 · Denominator 33 |
| Discharge mobility score | 72.73% |
50.94%
21.8 pts better
|
Numerator 24 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 3.3% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 27 |
| Staff flu vaccination coverage | 36.73% |
42%
5.3 pts worse
|
Numerator 18 · Denominator 49 |
| Discharge function score | 78.79% |
56.45%
22.3 pts better
|
Numerator 26 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
79.9%
11.4 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 91.5% · Q3 93.5% · Q4 94.9% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
13.2%
9.9 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 2.8% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.0% |
78.1%
4.9 pts better
|
79.7%
3.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.5% |
22.9%
16.4 pts better
|
23.9%
17.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 5.6% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-21 · Fire 2024-02-21
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
D · Potential for more than minimal harm
2024-02-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-14
F · Potential for more than minimal harm
2022-09-14
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-10-12
F · Potential for more than minimal harm
2022-09-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-09-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-09
C · Minimal harm
2022-09-14
K321 · Smoke Deficiencies
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 2023-01-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-02-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-21
F584 · Resident Rights Deficiencies
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 2024-03-15
D · Potential for more than minimal harm
2024-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-15
C · Minimal harm
2024-02-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-15
E · Potential for more than minimal harm
2022-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-12
Penalties and ownership
What sits behind the stars
Ownership
Bkd Fm Holding Company LLC
5% Or Greater Direct Ownership Interest · Organization
Arc Managment LLC
Operational/Managerial Control · Organization
Clontz, Stephanie
Operational/Managerial Control · Individual
Hall, George
Operational/Managerial Control · Individual
Jones Lang Lasalle Multifamily LLC
5% Or Greater Security Interest · Organization
Kaestner, Henry
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Lewis, Laura
Operational/Managerial Control · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Rutter, Doug
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sardis Oaks
Charlotte, NC
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Pelican Health Randolph LLC
Charlotte, NC
2-star overall rating with 2-star inspections with $19,663 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Sharon Towers
Charlotte, NC
4-star overall rating with 4-star inspections
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