7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Charlotte, NC
0-star overall rating with 0-star inspections with Special Focus status with $228,845 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1930 West Sugar Creek Road, Charlotte, NC
(704) 598-4480
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
1998-11-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.32
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 50% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 7.5% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 17 · Denominator 20 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 1 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 106 |
| Staff flu vaccination coverage | 1.75% |
42%
40.2 pts worse
|
Numerator 2 · Denominator 114 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 45.2% |
91.5%
46.3 pts worse
|
93.4%
48.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.4% · Q2 44.4% · Q3 37.6% · Q4 43.3% · 4Q avg 45.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
94.1%
5.9 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 2.2% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
4.8%
3 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.5% · Q4 3.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 15.0% |
7.2%
7.8 pts worse
|
5.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.0% · Q3 14.1% · Q4 18.0% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
21.6%
9.2 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.0% · Q3 11.4% · Q4 12.2% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
15.0%
2.9 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 17.9% · Q3 18.6% · Q4 14.9% · 4Q avg 17.9% · 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 | 21.1% |
21.5%
0.4 pts better
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 19.8% · Q3 23.2% · Q4 33.5% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.5% |
16.8%
11.7 pts worse
|
14.9%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 29.7% · Q3 23.4% · Q4 30.9% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.9% · Q3 3.0% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
21.2%
8.7 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 24.3% · Q3 29.6% · Q4 24.6% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 2.4% · Q3 3.3% · Q4 6.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 6.6% |
79.9%
73.3 pts worse
|
81.7%
75.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 2.6% · Q3 5.3% · Q4 5.1% · 4Q avg 6.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.8% |
13.2%
13.6 pts worse
|
12.0%
14.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 32.6% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q3 3.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 11.6% |
78.1%
66.5 pts worse
|
79.7%
68.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 11.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.1% |
22.9%
15.2 pts worse
|
23.9%
14.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.1% · Observed 41.9% · Expected 26.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-05-19
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-07
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-07-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-07
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-23
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-23
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 2025-03-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-23
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-23
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-23
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 2024-08-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-02
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-02
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-02
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-12-13
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-13
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 2025-12-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-25
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 2025-07-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-20
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-12-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-20
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 2024-12-20
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-20
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 2024-12-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-18
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-07-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
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 2024-07-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-02
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-09
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-09
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-05-09
Penalties and ownership
Fine · fine $19,900
Fine
Fine · fine $113,051
Fine
Fine · fine $78,793
Fine
Payment Denial · denial start 2024-07-23 · 2 days
2 day denial
Fine · fine $6,899
Fine
Fine · fine $10,202
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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2-star overall rating with 2-star inspections with $276,401 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Charlotte, NC
2-star overall rating with 1-star inspections with $144,199 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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