Cycle 1
Health 2025-07-03 · Fire 2025-07-03
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Charlotte, NC
Pavilion Health Center at Brightmore
2-star overall rating with 2-star inspections with $112,580 in total fines with 7 recent health deficiencies
10011 Providence Road West, Charlotte, NC
(980) 245-8500
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
2014-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.44
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,648
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.40% · Performance 23.84% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.12
Baseline 5.42% · Performance 6.60% · Measure score 4.12 · Achievement 4.12 · Improvement 0
Total nurse turnover
2.47
Baseline 31.03% · Performance 53.57% · Measure score 2.47 · Achievement 2.47 · Improvement 0
Adjusted total nurse staffing
1.25
Baseline 3.18 hours · Performance 3.43 hours · Measure score 1.25 · Achievement 1.25 · Improvement 0.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 287 · Observed rate 11.15% · Lower 95% interval 8.67% |
| Discharge to community | 54.39% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 290 · Observed rate 48.97% · Lower 95% interval 49.58% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.23% |
95.27%
5 pts worse
|
Numerator 157 · Denominator 174 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 174 |
| Discharge self-care score | 38.24% |
53.69%
15.4 pts worse
|
Numerator 52 · Denominator 136 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 68 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0.57% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 174 · Adjusted rate 0.7% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 191 · Observed rate 5.76% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 27.97% |
8.2%
19.8 pts better
|
Numerator 33 · Denominator 118 |
| Staff flu vaccination coverage | 6.88% |
42%
35.1 pts worse
|
Numerator 13 · Denominator 189 |
| Discharge function score | 51.47% |
56.45%
5 pts worse
|
Numerator 70 · Denominator 136 |
| Transfer of health information to provider | 80.56% |
95.95%
15.4 pts worse
|
Numerator 29 · Denominator 36 |
| Transfer of health information to patient | 97.46% |
96.28%
1.2 pts better
|
Numerator 115 · Denominator 118 |
| Resident COVID-19 vaccinations up to date | 9.18% |
25.2%
16 pts worse
|
Numerator 9 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.5%
6.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 100.0% · Q3 100.0% · Q4 96.1% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.1%
3.3 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.6%
0.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.5% · Q3 2.9% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.8%
3.7 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
7.2%
3.3 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 12.1% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
21.6%
4.9 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 17.9% · Q3 14.8% · Q4 19.7% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
15.0%
6.9 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.5% · Q3 6.4% · Q4 10.9% · 4Q avg 8.1% · 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 | 27.6% |
21.5%
6.1 pts worse
|
16.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 37.7% · Q3 33.1% · Q4 15.9% · 4Q avg 27.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
16.8%
2.2 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 20.4% · Q3 11.5% · Q4 14.1% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.6%
1.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
21.2%
5.5 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 23.7% · Q3 29.6% · Q4 27.8% · 4Q avg 26.7% |
| 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 3.9% · Q2 9.4% · Q3 3.2% · Q4 2.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
79.9%
16.5 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 96.3% · Q3 97.5% · Q4 96.3% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
13.2%
4 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 16.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.5%
1.6 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.6% · Q3 3.2% · Q4 4.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.6% |
78.1%
11.5 pts better
|
79.7%
9.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.9%
5 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 22.9% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-26 · Fire 2024-03-26
19 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-03-26
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 2024-07-19
D · Potential for more than minimal harm
2024-03-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-03-26
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-07-19
D · Potential for more than minimal harm
2022-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-09
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-09
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.
Not marked corrected
D · Potential for more than minimal harm
2025-07-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-07-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-07-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-07-03
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 2025-07-11
D · Potential for more than minimal harm
2025-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-07-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-11
J · Immediate jeopardy
2024-03-26
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 2024-04-18
J · Immediate jeopardy
2024-03-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
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 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-06
D · Potential for more than minimal harm
2024-03-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
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 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-26
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 2024-04-18
D · Potential for more than minimal harm
2024-03-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-18
C · Minimal harm
2024-03-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-16
G · Actual harm
2022-09-29
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 2022-10-17
G · Actual harm
2022-09-29
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 2022-10-17
G · Actual harm
2022-09-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-17
B · Minimal harm
2022-09-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-17
Penalties and ownership
What sits behind the stars
$26,130
2025-12-09
Fine
Fine · fine $26,130
Fine
$86,450
2024-03-26
Fine
Fine · fine $86,450
Fine
Ownership
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Bork, Matthew
Operational/Managerial Control · Individual
Bork, Matthew
Corporate Director · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Krob, James
W-2 Managing Employee · Individual
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Purifoy, Penny
Operational/Managerial Control · Individual
Purifoy, Penny
Corporate Director · Individual
Wilson, Jeffrey
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Director · Individual
Nearby options
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#2
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#3
Brookdale Carriage Club Providence
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4-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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