Cycle 1
Health 2025-12-18 · Fire 2024-09-27
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Charlotte, NC
Sardis Oaks
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5151 Sardis Road, Charlotte, NC
(704) 365-4202
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Atrium Health
Operator or chain grouping
Approved since
1990-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 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
0.90
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,224
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0139
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.99
Baseline 16.46% · Performance 17.27% · Measure score 8.99 · Achievement 8.99 · Improvement 0
Healthcare-associated infections
6.28
Baseline 5.76% · Performance 5.96% · Measure score 6.28 · Achievement 6.28 · Improvement 0
Total nurse turnover
5.97
Performance 39.29% · Measure score 5.97 · Achievement 5.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.24
Baseline 3.96 hours · Performance 3.72 hours · Measure score 2.24 · Achievement 2.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 7.35% |
| Discharge to community | 71.74% |
50.57%
21.2 pts better
|
Better than the National Rate · Eligible stays 57 · Observed rate 68.42% · Lower 95% interval 59.13% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.59% |
95.27%
3.3 pts better
|
Numerator 70 · Denominator 71 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 71 |
| Discharge self-care score | 38.18% |
53.69%
15.5 pts worse
|
Numerator 21 · Denominator 55 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 33 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 5.63% |
2.29%
3.3 pts worse
|
Numerator 4 · Denominator 71 · Adjusted rate 5.33% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 3.23% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 3 · Denominator 96 |
| Staff flu vaccination coverage | 95.1% |
42%
53.1 pts better
|
Numerator 97 · Denominator 102 |
| Discharge function score | 50.91% |
56.45%
5.5 pts worse
|
Numerator 28 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 70.45% |
96.28%
25.8 pts worse
|
Numerator 31 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 31.43% |
25.2%
6.2 pts better
|
Numerator 11 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.3 |
1.8
2.5 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 3.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
91.5%
4.8 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 98.6% · Q3 93.5% · Q4 97.3% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.6%
0.9 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.7% · Q3 1.3% · Q4 1.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.8%
4.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
7.2%
2.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 5.5% · Q4 3.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
21.6%
11.4 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.5% · Q3 13.7% · Q4 8.7% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
15.0%
5.5 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.8% · Q3 9.6% · Q4 10.6% · 4Q avg 9.5% · 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 | 24.4% |
21.5%
2.9 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q3 23.5% · Q4 20.1% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
16.8%
2.9 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 7.5% · Q3 7.6% · Q4 20.6% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.4% |
2.6%
2.8 pts worse
|
1.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.7% · Q3 5.2% · Q4 8.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
21.2%
7.3 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 21.5% · Q3 30.8% · Q4 34.2% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
6.0%
2.2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.8% · Q3 7.5% · Q4 10.4% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
79.9%
3.7 pts better
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 71.8% · Q2 78.8% · Q3 92.2% · Q4 91.5% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
13.2%
2.2 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
78.1%
15.2 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
22.9%
4.7 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 18.2% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2023-04-14
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-14 · Fire 2021-07-09
6 health deficiencies
Top issue: Quality of Life and Care (3 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
2024-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-09-27
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 2024-11-26
D · Potential for more than minimal harm
2024-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-04-14
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 2023-06-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
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 2026-01-22
D · Potential for more than minimal harm
2025-12-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-01-15
E · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-27
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 2024-10-25
D · Potential for more than minimal harm
2024-09-27
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 2024-10-25
D · Potential for more than minimal harm
2024-09-27
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 2024-10-25
D · Potential for more than minimal harm
2024-09-27
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 2024-10-25
D · Potential for more than minimal harm
2024-09-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-04-14
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 2023-05-12
F · Potential for more than minimal harm
2023-04-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
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 2023-05-12
D · Potential for more than minimal harm
2023-04-14
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 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-12
Penalties and ownership
What sits behind the stars
Ownership
Advocate Health Inc
Operational/Managerial Control · Organization
Atrium Health Inc
Operational/Managerial Control · Organization
Ball, Rodney
Corporate Officer · Individual
Broad River Rehabilitation
Operational/Managerial Control · Organization
Clode, Colin
Operational/Managerial Control · Individual
Haynes, Kenneth
Corporate Officer · Individual
Patel, Dupal
Operational/Managerial Control · Individual
Pro Diversity Partners, LLC
Operational/Managerial Control · Organization
The Charlotte-Mecklenburg Hospital Authority
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Pelican Health Randolph LLC
Charlotte, NC
2-star overall rating with 2-star inspections with $19,663 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brookdale Carriage Club Providence
Charlotte, NC
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
White Oak Manor - Charlotte
Charlotte, NC
3-star overall rating with 2-star inspections with $40,250 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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