Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Carolina Care Health And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain consistent advanced directives for a resident, resulting in conflicting code status documentation between the electronic medical record and the code book. The resident's preference for CPR was not accurately reflected, as the code book indicated a DNR status. Staff interviews revealed that the Social Worker was responsible for updating these records, but discrepancies were found, leading to the deficiency.
A facility failed to complete a PASRR level II for a resident readmitted with mental health diagnoses, including schizoaffective disorder, anxiety disorder, and mood affective disorder. Despite an audit indicating a level II referral was addressed, the necessary documentation was missing, as confirmed by interviews with the Social Worker and Administrator.
A resident with impaired mobility and muscle weakness did not receive necessary toenail care, resulting in overgrown, cracked, and dirty toenails. Despite regular showers, staff failed to notice or address the issue, causing discomfort for the resident. The facility's administration acknowledged the need for timely nail care for dependent residents.
A facility failed to address drug irregularities for a resident prescribed PRN Lorazepam without a stop date or rationale for extended use. Despite a pharmacist's recommendation, the NP continued the order without proper documentation. Interviews revealed confusion over responsibility for addressing such recommendations, with the Psychiatric NP unaware of the issue. The facility's policy requiring a 14-day stop date or rationale was not followed.
A facility failed to ensure a PRN psychotropic medication order for a resident was time-limited and lacked rationales for extending therapy beyond 14 days. The resident, with severe cognitive impairment and anxiety disorder, had an order for Lorazepam without a stop date, which was discontinued after several months due to non-use. Interviews revealed staff awareness of the policy requiring a 14-day stop date, but there was a lack of adherence to this policy.
The facility failed to provide written notification to two residents and their responsible parties regarding hospital transfers, as required by regulations. Both residents were transferred for evaluation and treatment without receiving the necessary written notice. Interviews revealed that the facility lacked a process for such notifications, with the Social Worker unaware of the regulation and the Administrator acknowledging non-compliance.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to maintain accurate advanced directives for a resident, leading to discrepancies in the resident's code status documentation. The resident, who was cognitively intact, had conflicting Medical Orders for Scope of Treatment (MOST) forms in their electronic medical record and the code book at the nurse's station. The electronic medical record indicated a preference for Cardiopulmonary Resuscitation (CPR), while the code book showed a Do Not Resuscitate (DNR) status. This inconsistency was not aligned with the care conference notes, which indicated the resident's preference to remain a Full code. Interviews with staff revealed that the Social Worker was responsible for updating and maintaining the MOST forms in both the electronic medical record and the code book. However, the Social Worker acknowledged the discrepancy and was unsure why the MOST form from a specific date was not in the electronic medical record. The Director of Nursing and the Administrator both stated that they expected the resident's code status to be consistent across all records. The failure to ensure accurate and consistent documentation of the resident's advanced directives led to the identified deficiency.
Failure to Complete PASRR Level II for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed for a resident who was readmitted with mental health diagnoses. The resident, identified as Resident #40, was initially admitted with a PASRR level I completed. However, after being diagnosed with schizoaffective disorder, anxiety disorder, and mood affective disorder, and subsequently readmitted, no PASRR level II was conducted as required. Interviews with the Social Worker and the Administrator revealed that a PASRR level II should be completed upon admission for residents with mental health diagnoses or when there is a change in condition. Despite conducting a PASRR audit in December 2023 and January 2024, which included Resident #40, the facility could not locate the current PASRR letter to confirm if a level II had been completed. The Administrator acknowledged that Resident #40 was marked as addressed for a level II referral in the audit documentation, but the necessary documentation was missing.
Failure to Provide Toenail Care for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate toenail care for a resident who was dependent on staff for assistance with activities of daily living. The resident, who was admitted with diagnoses including muscle wasting and atrophy, required assistance due to impaired mobility and muscle weakness. The care plan indicated the need for monitoring and reporting declines in function, yet the resident's toenails were observed to be overgrown, cracked, and dirty, causing discomfort. Despite being scheduled for regular showers, the staff did not offer toenail care during these times. Observations revealed that the resident's toenails extended beyond the tips of his toes, with the right big toenail cracked and containing brownish substances. Interviews with nursing aides and a nurse confirmed that the resident was not diabetic and could have his toenails trimmed by staff. However, the staff failed to notice or address the condition of the resident's toenails during care. The Director of Nursing and the Administrator acknowledged the expectation for staff to be attentive to residents' skin conditions, including toenails, and to provide necessary care in a timely manner.
Failure to Address PRN Psychotropic Medication Irregularities
Penalty
Summary
The facility failed to adequately respond to identified drug irregularities concerning the use of a PRN psychotropic medication for a resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, cognitive communication deficit, unspecified dementia, and anxiety disorder, had a physician's order for Lorazepam to be administered as needed for anxiety/agitation. The order lacked a stop date, and there was no documented rationale for extending the therapy beyond 14 days, as required by guidelines. Despite the Consulting Pharmacist's recommendation to address this issue, the Nurse Practitioner simply wrote 'continue' without providing a rationale or ensuring compliance with the facility's policy. Interviews revealed a lack of clarity and communication among the staff regarding who was responsible for addressing pharmacy recommendations for psychotropic medications. The Nurse Practitioner acknowledged signing off on the recommendation but could not explain why the Psychiatric NP, who usually handled such matters, did not address it. The Psychiatric NP stated that if she had been aware of the recommendation, she would have discontinued the order, as the resident had not received any doses of Lorazepam initially. The Director of Nursing and the Administrator both confirmed that the facility's policy required PRN psychotropic medications to have a 14-day stop date or a documented rationale for longer use, which was not adhered to in this case.
Failure to Ensure Time-Limited PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a physician's order for a PRN psychotropic medication was time-limited and provided rationales for therapy exceeding 14 days for a resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, cognitive communication deficit, unspecified dementia, and anxiety disorder, had a physician's order for Lorazepam 1mg three times a day PRN for anxiety/agitation. This order, dated 10/25/2024, did not contain a stop date and was discontinued on 02/14/2025 due to non-use. The medical records lacked rationales for extending the therapy beyond 14 days, and the resident received seven doses of PRN Ativan between December 2024 and January 2025. Interviews with facility staff revealed a lack of adherence to the facility's policy requiring PRN psychotropic medication orders to have a 14-day stop date. Nurse #3, a recent addition to the staff, was aware of the policy but could not recall specifics, while Nurse #4 and the Director of Nursing confirmed the policy's requirements. The Psychiatric Nurse Practitioner stated that if she had been aware of the pharmacy recommendation and the resident's non-use of Lorazepam, she would have discontinued the order. The facility's administrator also expected compliance with the policy, indicating a systemic oversight in ensuring adherence to established protocols for psychotropic medication management.
Failure to Notify Residents and RPs of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for two residents, Resident #6 and Resident #55, who were transferred to the hospital for evaluation and treatment. Resident #6, who was her own responsible party, was transferred on December 19, 2024, without receiving any written notification. Similarly, Resident #55, who had a designated responsible party, was transferred on February 11, 2025, without any written notification being provided to either the resident or the responsible party. Both residents returned to the facility after their hospital stays. Interviews with the facility's Social Worker and Administrator revealed that the facility did not have a process in place for providing written notifications of hospital transfers. The Social Worker was unaware of the regulation requiring such notifications, while the Administrator acknowledged awareness of the regulation but admitted that the facility was not in compliance. The lack of written notification was confirmed through record reviews and interviews with the involved parties.
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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.
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Nursing homes near Cherryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peak Resources-cherryville | 2.5 mi | ★★★★★ | 0 | 0 |
| The Greens At Lincolnton | 9.6 mi | ★★★★★ | 8 | 0 |
| Cardinal Healthcare And Rehabilitation | 9.7 mi | ★★★★★ | 1 | 0 |
| Cleveland Pines | 9.7 mi | ★★★★★ | 7 | 0 |
| Lincolnton Rehabilitation Center | 10.4 mi | ★★★★★ | 0 | 0 |
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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.