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

Compare this facility

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

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

Hours and turnover

RN hours / resident day

0.73

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

1.20

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.90

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.93

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.40

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.34

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

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.46

CMS adjusted total nurse staffing hours

Case-mix index

1.54

Higher values indicate more complex resident acuity

RN turnover

27%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,315

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

44.92

Composite VBP score used to determine payment impact.

Payment multiplier

0.9981

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.35

Baseline 20.91% · Performance 18.03% · Measure score 7.35 · Achievement 7.35 · Improvement 6.93

Healthcare-associated infections

7.56

Baseline 6.62% · Performance 5.58% · Measure score 7.56 · Achievement 7.56 · Improvement 5.92

Total nurse turnover

1.63

Performance 57.00% · Measure score 1.63 · Achievement 1.63 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.42

Baseline 4.35 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.86%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 714 · Observed rate 9.8% · Lower 95% interval 8.94%
Discharge to community	65.54%	50.57% 15 pts better	Better than the National Rate · Eligible stays 776 · Observed rate 61.34% · Lower 95% interval 62.3%
Medicare spending per beneficiary	1.09	1.02 0.1 pts worse
Drug regimen review with follow-up	95.53%	95.27% 0.3 pts better	Numerator 449 · Denominator 470
Falls with major injury	0.85%	0.77% 0.1 pts worse	Numerator 4 · Denominator 470
Discharge self-care score	60.06%	53.69% 6.4 pts better	Numerator 200 · Denominator 333
Discharge mobility score	69.37%	50.94% 18.4 pts better	Numerator 231 · Denominator 333
Pressure ulcers or injuries, new or worsened	2.77%	2.29% 0.5 pts worse	Numerator 13 · Denominator 470 · Adjusted rate 2.99%
Healthcare-associated infections requiring hospitalization	5.57%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 515 · Observed rate 4.66% · Lower 95% interval 4%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 151
Staff flu vaccination coverage	13.38%	42% 28.6 pts worse	Numerator 21 · Denominator 157
Discharge function score	61.86%	56.45% 5.4 pts better	Numerator 206 · Denominator 333
Transfer of health information to provider	83.04%	95.95% 12.9 pts worse	Numerator 328 · Denominator 395
Transfer of health information to patient	89.47%	96.28% 6.8 pts worse	Numerator 34 · Denominator 38
Resident COVID-19 vaccinations up to date	16.96%	25.2% 8.2 pts worse	Numerator 39 · Denominator 230

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 · Adjusted 1.1 · Observed 1.7 · Expected 2.9 · Used in QM five-star
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 · Adjusted 1.4 · Observed 1.7 · Expected 2.0 · Used in QM five-star
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 · Q1 89.7% · Q2 92.9% · Q3 100.0% · Q4 100.0% · 4Q avg 95.7%
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 · 4Q avg 93.8%
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 · Q1 6.9% · Q2 7.1% · Q3 3.0% · Q4 4.0% · 4Q avg 5.2% · Used in QM five-star
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 · Q1 3.6% · Q2 7.4% · Q3 3.3% · Q4 0.0% · 4Q avg 3.7%
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 · Q1 28.0% · Q2 12.5% · Q3 14.8% · Q4 9.1% · 4Q avg 16.3%
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 · Q1 11.1% · Q2 20.0% · Q3 17.9% · Q4 12.0% · 4Q avg 15.2%
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 · Q1 3.8% · Q2 8.7% · Q3 4.3% · Q4 10.0% · 4Q avg 6.5% · 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	31.4%	21.5% 9.9 pts worse	16.3% 15.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 31.4% · Used in QM five-star
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 · Q1 15.4% · Q2 30.4% · Q3 24.0% · Q4 17.4% · 4Q avg 21.6% · 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% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 0.9% · Used in QM five-star
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 · Q1 42.4% · Q2 20.5% · Q3 37.6% · 4Q avg 34.8%
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 · Q1 6.3% · Q2 9.9% · Q3 4.2% · Q4 2.8% · 4Q avg 5.8% · Used in QM five-star
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 · Q1 84.9% · Q2 82.0% · Q3 91.2% · Q4 93.6% · 4Q avg 87.9%
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 · Adjusted 10.6% · Observed 9.6% · Expected 10.1% · Used in QM five-star
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 · Q1 1.4% · Q2 1.1% · Q3 0.7% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star
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 · 4Q avg 82.3%
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 · Adjusted 18.5% · Observed 15.6% · Expected 20.1% · Used in QM five-star

Survey summary

Recent inspection cycles

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)

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

100% 1 facilities 2021-05-28

Charles 1994 Family Grantor Trust