Cycle 1
Health 2025-07-02 · Fire 2024-04-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lincolnton, NC
Lincolnton Rehabilitation Center
3-star overall rating with 2-star inspections with $71,117 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1410 East Gaston Street, Lincolnton, NC
(704) 732-1138
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1976-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 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
0.64
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,504
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.74% · Performance 22.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.23% · Performance 10.85% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.86
Baseline 62.50% · Performance 60.17% · Measure score 0.86 · Achievement 0.86 · Improvement 0.12
Adjusted total nurse staffing
0.90
Baseline 3.23 hours · Performance 3.33 hours · Measure score 0.90 · Achievement 0.90 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 8.73% · Lower 95% interval 7.15% |
| Discharge to community | 48.19% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 42.11% · Lower 95% interval 39.21% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 98 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 36.36% |
53.69%
17.3 pts worse
|
Numerator 20 · Denominator 55 |
| Discharge mobility score | 41.82% |
50.94%
9.1 pts worse
|
Numerator 23 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 100 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 10.85% |
7.12%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 17.5% · Lower 95% interval 6.46% |
| Staff COVID-19 vaccination coverage | 4.07% |
8.2%
4.1 pts worse
|
Numerator 5 · Denominator 123 |
| Staff flu vaccination coverage | 46.15% |
42%
4.1 pts better
|
Numerator 114 · Denominator 247 |
| Discharge function score | 36.36% |
56.45%
20.1 pts worse
|
Numerator 20 · Denominator 55 |
| Transfer of health information to provider | 87.3% |
95.95%
8.7 pts worse
|
Numerator 55 · Denominator 63 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 11 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.5%
5.4 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 89.3% · Q4 98.9% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.1%
4.8 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.6%
1.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.4% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.9% |
4.8%
9.1 pts worse
|
11.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 17.9% · Q3 10.7% · Q4 13.6% · 4Q avg 13.9% |
| Percentage of long-stay residents who lose too much weight | 11.5% |
7.2%
4.3 pts worse
|
5.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.7% · Q3 13.6% · Q4 14.8% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
21.6%
9.8 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.5% · Q2 31.7% · Q3 24.7% · Q4 26.1% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
15.0%
3.6 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.5% · Q3 9.5% · Q4 10.3% · 4Q avg 11.4% · 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 | 9.0% |
21.5%
12.5 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 4.5% · Q3 13.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
16.8%
4.1 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 14.5% · Q3 11.1% · Q4 7.7% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · 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 1.2% · Q3 1.2% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
21.2%
5.3 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 30.1% · Q3 25.9% · Q4 16.2% · 4Q avg 26.5% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
6.0%
3.7 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.0% · Q3 3.3% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
79.9%
3.5 pts better
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 91.1% · Q3 72.7% · Q4 74.8% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.8% |
13.2%
9.4 pts better
|
12.0%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.8% · Observed 4.2% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
78.1%
7.9 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
22.9%
7.2 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 17.9% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-13 · Fire 2022-11-10
7 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-11-10 · Fire 2021-03-11
14 health deficiencies
Top issue: Resident Rights (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-31
D · Potential for more than minimal harm
2022-11-10
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 2023-01-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-02
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 2025-07-25
D · Potential for more than minimal harm
2025-05-01
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 2024-06-22
G · Actual harm
2024-04-13
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 2024-05-14
G · Actual harm
2024-04-13
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-05-14
G · Actual harm
2024-04-13
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-05-14
G · Actual harm
2024-04-13
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 2024-05-14
D · Potential for more than minimal harm
2024-04-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-13
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 2024-05-14
D · Potential for more than minimal harm
2024-04-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-14
G · Actual harm
2024-02-15
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 2024-05-14
G · Actual harm
2024-02-15
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-02-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-02-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-02-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
D · Potential for more than minimal harm
2024-02-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-13
D · Potential for more than minimal harm
2022-11-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-09
Penalties and ownership
What sits behind the stars
$71,117
2024-02-15
Fine
Fine · fine $71,117
Fine
Ownership
Clark, Kevin
Operational/Managerial Control · Individual
Cronquist, Royce
Corporate Officer · Individual
Howe, Sarah
Operational/Managerial Control · Individual
Kelly, Michelle
Corporate Officer · Individual
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Corporate Officer · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
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
#2
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
#3
Peak Resources-Cherryville
Cherryville, NC
5-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
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