Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briar Creek Health Center during CMS and state inspections, most recent first.
The facility did not submit required Payroll Based Journal (PBJ) staffing data to CMS for three consecutive quarters, as confirmed by CASPER database review and staff interviews. The corporate payroll department, responsible for submissions, ceased reporting due to low census numbers, resulting in noncompliance with federal staffing data requirements.
A resident admitted with multiple fractures and physician orders for pain management did not have pain or opioid pain medication addressed in the 48-hour baseline care plan. Although pain medications were administered and assessments documented, the care plan only included activities of daily living and fall risk. Staff interviews revealed reliance on the physician order summary as the care plan, and pain management was omitted due to workload and process gaps.
A facility failed to follow infection control policies during wound care for a resident with a full-thickness wound and a suprapubic catheter. A nurse did not wear a gown or perform hand hygiene between steps, contrary to the Enhanced Barrier Precautions and hand hygiene policies. The DON acknowledged the resident should have been on EBP due to the presence of an indwelling medical device and a wound.
Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not submit the required Payroll Based Journal (PBJ) staffing data for three consecutive quarters: the third and fourth quarters of federal fiscal year 2024 and the first quarter of federal fiscal year 2025. This deficiency was identified through a review of PBJ staffing data reports from the Certification and Survey Provider Enhanced Reports (CASPER) database, which confirmed the absence of submissions for the specified periods. Interviews with facility staff revealed that the responsibility for submitting PBJ data rested with the corporate payroll department. The Administrator stated that payroll information from the facility was sent to the corporate office, which was responsible for the actual submission. The Administrator further confirmed that the corporate office had stopped submitting PBJ data due to the facility's low census numbers, believing that the facility would not receive a staffing star rating. The corporate Director of Workforce Management, who became responsible for PBJ submissions in early 2025, also confirmed that the data for the three quarters in question had not been submitted and that it was too late to submit the missing data after contacting CMS.
Failure to Address Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed pain and opioid pain medication for a resident who was admitted with multiple fractures following a fall. Physician orders included scheduled acetaminophen and as-needed oxycodone for pain, along with instructions to assess pain every shift using a numeric scale and document findings and interventions. Medication administration records confirmed that pain medications were given and pain assessments were documented. However, the baseline care plan created within 48 hours of admission only addressed activities of daily living and fall risk, omitting any mention of pain or pain management. Interviews with facility staff revealed that the MDS Coordinator and DON relied on the physician order summary as the initial care plan, which they believed included pain management. The MDS Coordinator acknowledged that pain and pain medication were not included in the baseline care plan due to a busy schedule. The DON stated that the order summary was used as the baseline care plan and was reviewed with the resident or representative, but pain was not specifically addressed in the care plan in progress. The facility Administrator confirmed that pain should have been addressed in the 48-hour care plan and was uncertain who would complete it if the MDS Coordinator was unavailable.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures during the care of a resident with a full-thickness wound and a suprapubic catheter. Nurse #1 did not wear a gown while performing wound care, which is required under the facility's Enhanced Barrier Precautions (EBP) policy. This policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or wounds, regardless of multi-drug-resistant organism (MDRO) colonization. Additionally, Nurse #1 did not perform hand hygiene after removing a soiled dressing, cleaning the wound, and before applying a new dressing, which is contrary to the facility's hand hygiene and clean dressing change policies. The Director of Nursing (DON), who also serves as the Infection Control Nurse, acknowledged that the resident should have been on EBP due to the presence of an indwelling medical device and a wound. The DON confirmed that staff are educated on infection control during orientation and annually, and that proper procedure involves washing hands and changing gloves between each step of wound care. However, Nurse #1 was unsure about the necessity of EBP for wounds and did not follow the required hand hygiene protocol, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 219 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Sharon At Southpark | 0.7 mi | ★★★★★ | 0 | 0 |
| The Stewart Health Center | 1.2 mi | ★★★★★ | 1 | 1 |
| Sardis Oaks | 2.8 mi | ★★★★★ | 4 | 0 |
| Pelican Health Randolph Llc | 2.8 mi | ★★★★★ | 15 | 0 |
| Brookdale Carriage Club Providence | 3.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.