Cycle 1
Health 2025-02-27 · Fire 2025-02-27
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cherryville, NC
Carolina Care Health and Rehabilitation
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
111 Harrelson Street, Cherryville, NC
(704) 435-4161
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1986-08-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
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
58%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.72% · Performance 21.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.95
Baseline 5.32% · Performance 7.55% · Measure score 0.95 · Achievement 0.95 · Improvement 0
Total nurse turnover
5.92
Baseline 37.36% · Performance 39.50% · Measure score 5.92 · Achievement 5.92 · Improvement 0
Adjusted total nurse staffing
2.55
Baseline 3.19 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 1.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 209 · Observed rate 11% · Lower 95% interval 7.83% |
| Discharge to community | 64.79% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 184 · Observed rate 61.41% · Lower 95% interval 56.92% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 113 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 73.26% |
53.69%
19.6 pts better
|
Numerator 63 · Denominator 86 |
| Discharge mobility score | 63.95% |
50.94%
13 pts better
|
Numerator 55 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 113 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.55% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 7.44% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 24.1% |
42%
17.9 pts worse
|
Numerator 40 · Denominator 166 |
| Discharge function score | 70.93% |
56.45%
14.5 pts better
|
Numerator 61 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.13% |
25.2%
2.9 pts better
|
Numerator 18 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.5 |
1.8
2.7 pts worse
|
1.8
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 4.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 3.9% · Q4 1.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 70.8% |
4.8%
66 pts worse
|
11.4%
59.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 69.2% · Q3 74.3% · Q4 73.1% · 4Q avg 70.8% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
7.2%
4.6 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.0% · Q4 4.6% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.7% |
21.6%
8.1 pts worse
|
19.6%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 28.4% · Q3 24.6% · Q4 30.4% · 4Q avg 29.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
15.0%
7.2 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.1% · Q3 8.9% · Q4 10.0% · 4Q avg 7.8% · 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 | 11.9% |
21.5%
9.6 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 36.4% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
16.8%
4.4 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.8% · Q3 29.0% · Q4 11.6% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.6%
2.3 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
21.2%
8.5 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.4% · Q3 19.8% · Q4 20.3% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.0%
1.2 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.4% · Q3 3.5% · Q4 2.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
79.9%
19.5 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.5% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
13.2%
3.5 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 15.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.9%
2.1 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.4% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-26
D · Potential for more than minimal harm
2024-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-26
D · Potential for more than minimal harm
2022-08-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-27
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 2025-03-22
D · Potential for more than minimal harm
2025-02-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-02-27
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-02-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-02-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-22
B · Minimal harm
2025-02-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-21
E · Potential for more than minimal harm
2024-01-05
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 2024-01-06
D · Potential for more than minimal harm
2024-01-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-06
D · Potential for more than minimal harm
2024-01-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-06
K · Immediate jeopardy
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-20
K · Immediate jeopardy
2022-08-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-20
K · Immediate jeopardy
2022-08-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-09-20
J · Immediate jeopardy
2022-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-11
E · Potential for more than minimal harm
2022-08-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-25
F761 · Pharmacy Service Deficiencies
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 2022-09-20
E · Potential for more than minimal harm
2022-08-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-25
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-09-20
D · Potential for more than minimal harm
2022-08-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-20
C · Minimal harm
2022-08-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-01
Penalties and ownership
What sits behind the stars
Ownership
Alfaro, Travis
W-2 Managing Employee · Individual
Ardent Health And Rehabilitation Co
5% Or Greater Direct Ownership Interest · Organization
Carolina Care Healthcare Properties LLC
5% Or Greater Mortgage Interest · Organization
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Peak Resources-Cherryville
Cherryville, NC
5-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
The Greens at Lincolnton
Lincolnton, NC
2-star overall rating with 2-star inspections with $46,908 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Cardinal Healthcare and Rehabilitation
Lincolnton, NC
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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