Cycle 1
Health 2025-05-07 · Fire 2025-05-07
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Huntersville, NC
Huntersville Health & Rehabilitation Center
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
13835 Boren Street, Huntersville, NC
(704) 912-2222
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
2016-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing
LPN hours / resident day
1.20
Licensed practical nurse staffing
Aide hours / resident day
1.97
Nurse aide staffing
Weekend hours
3.40
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.5%
4.2 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
94.1%
0.3 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.6%
1.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
4.8%
1.1 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 16.3% |
7.2%
9.1 pts worse
|
5.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
21.6%
6.4 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
15.0%
8.5 pts better
|
16.7%
10.2 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 ability to walk independently worsened | 31.4% |
21.5%
9.9 pts worse
|
16.3%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
16.8%
4.8 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.6%
1.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.8% |
21.2%
13.6 pts worse
|
19.8%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.0%
0.2 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
79.9%
8 pts better
|
81.7%
6.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
13.2%
2.6 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
78.1%
4.2 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.9%
4.4 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-07
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-06-11
D · Potential for more than minimal harm
2024-01-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-01-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-22
F · Potential for more than minimal harm
2022-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-06-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-06-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-07
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-07
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 2025-05-30
D · Potential for more than minimal harm
2025-05-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-01-25
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 2024-02-22
E · Potential for more than minimal harm
2024-01-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-25
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 2024-02-22
B · Minimal harm
2024-01-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-22
G · Actual harm
2023-04-10
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 2023-03-24
B · Minimal harm
2023-04-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-24
E · Potential for more than minimal harm
2022-06-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-05
E · Potential for more than minimal harm
2022-06-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-07-05
E · Potential for more than minimal harm
2022-06-09
F726 · Nursing and Physician Services Deficiencies
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 2022-07-05
E · Potential for more than minimal harm
2022-06-09
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 2022-07-05
E · Potential for more than minimal harm
2022-06-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-07-05
D · Potential for more than minimal harm
2022-06-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-05
B · Minimal harm
2022-06-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-07-05
B · Minimal harm
2022-06-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-07-05
Penalties and ownership
What sits behind the stars
Ownership
Huntersville Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ck 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Drm South LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Gardin, William
W-2 Managing Employee · Individual
Lauren 2020 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Lauren 2020 LLC
5% Or Greater Indirect Ownership Interest · Organization
Leps 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Norman 5571 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Norman 5571 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Norman 5571 LLC
5% Or Greater Indirect Ownership Interest · Organization
Rl 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Robin 2008 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Robin 2008 LLC
5% Or Greater Indirect Ownership Interest · Organization
Rsbrm South Manager LLC
Operational/Managerial Control · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Springrock South LLC
5% Or Greater Indirect Ownership Interest · Organization
Summer South LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lakeside Health & Rehab Center
Huntersville, NC
3-star overall rating with 3-star inspections with $11,629 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Huntersville Oaks
Huntersville, NC
3-star overall rating with 3-star inspections with $9,937 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Autumn Care of Cornelius
Cornelius, NC
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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