Average — CMS composite of the measures below.
The next survey window likely opens around May 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 Huntersville Health & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with arthritis was found keeping OTC Tylenol and a decongestant nasal spray at the bedside without any documented assessment for self-administration. The resident said a family member brought in the meds and that she used them on her own, while the RN stated no residents on the unit were assessed to self-administer meds and the DON confirmed the resident should have been assessed if she wanted to keep and use medications in her room.
A resident with dementia, depression, anxiety, and later bipolar disorder did not have a Level II PASRR request submitted to NC MUST when the serious mental illness diagnosis was added. The record showed antidepressant and anxiolytic orders, an MDS noting bipolar disorder and no Level II PASRR evaluation, and staff stated the DPD missed the diagnosis and delayed submitting the FL-2 and PASRR request until much later.
A severely cognitively impaired resident with Alzheimer’s disease, who required assistance with ADLs and had known combative behaviors during care, became agitated and resistive while two NAs were providing incontinence care and dressing. One NA reported that the other NA responded to the resident’s attempts to bite and swing by striking the resident three times with an open hand—once on the lips, once on the cheek, and once on the back of the head—while telling the resident she would not be allowed to hit or bite staff. The reporting NA continued care after the first strike, did not immediately remove the other NA from the room, and only reported the incident after completing the transfer, resulting in a failure to protect the resident from staff-to-resident physical abuse.
A resident with Alzheimer’s disease and severe cognitive impairment, care planned for combative behaviors, became agitated and resistive during incontinence care. One NA removed the resident’s hands from the bed rail, placed them on the resident’s chest, and held them there to stop her from swinging her arms while another NA completed care. While the resident’s hands were being held down, she attempted to bite the NA, who then struck her on the lips with an open hand and told her she would not be allowed to fight or bite, continuing to restrain her. The resident became more agitated and began kicking. Staff later acknowledged they had been trained on abuse and restraints but did not recognize at the time that holding the resident’s hands down constituted a physical restraint and that care should have been stopped and attempted later.
A cognitively impaired resident with Alzheimer’s disease, known to be resistive to care, was being assisted with incontinence and dressing care by two NAs when the resident became agitated, grabbed the bed rail, and attempted to bite. One NA responded by striking the resident on the lips with an open hand and stating the resident would not fight or bite them, while the assisting NA, though shocked, continued providing care instead of stopping and intervening. As care and a subsequent transfer to a wheelchair continued, the resident swung at staff, and the same NA struck the resident two additional times—once on the face and once on the back of the head—while repeating similar statements. The assisting NA only removed the resident from the room and reported the incident after completing the transfer, later acknowledging she should have stopped care and removed the other NA after the first strike, demonstrating a failure to follow the facility’s abuse prevention and immediate reporting policy.
A resident with moderate cognitive impairment was discharged home with a midline IV catheter still in place, despite no ongoing need for IV access. The discharge summary did not indicate any devices, and staff interviews revealed the discharge was rushed and lacked proper education for the resident and responsible party. The oversight was acknowledged by nursing leadership and the medical director.
A resident with bipolar disorder was admitted with an expired PASRR level II, and facility staff failed to obtain a new level II assessment as required. Both the Assistant Discharge Planner and Discharge Planner were responsible for monitoring PASRRs but did not recognize the need for a new assessment, resulting in the deficiency.
A resident undergoing outpatient dialysis for stage 5 CKD was not provided with a bagged lunch on two treatment days, despite the facility's process for preparing such meals. The assigned nurse aide forgot to retrieve the prepared lunches, resulting in the resident returning hungry after dialysis. Both dietary and administrative staff confirmed that the lunches were available but not delivered as required.
A Treatment Nurse did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The nurse was observed removing and donning gloves multiple times without sanitizing hands in between, even after handling soiled dressings and before touching clean supplies and wounds. The nurse later stated she was aware of the requirement but forgot due to nervousness. Both the IP and DON confirmed that hand hygiene is expected after each glove removal and before new gloves are put on during wound care.
A Wound Nurse failed to follow the facility's Enhanced Barrier Precautions (EBP) policy by not wearing a gown while providing care to a resident under transmission-based precautions. Despite signage instructing the use of gowns and gloves, the nurse only wore gloves during incontinence and wound care. The nurse admitted to forgetting the gown, and the DON confirmed staff were expected to adhere to posted precautions.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to assess whether a cognitively intact resident with arthritis could safely self-administer medications kept at the bedside. Resident #46 was admitted with a diagnosis of arthritis, and the admission MDS dated [DATE] indicated the resident was cognitively intact. Review of the medical record showed no documentation that Resident #46 had been assessed for the ability to self-administer medications, even though a physician order dated 03/17/26 allowed Tylenol 325 mg, 2 tablets by mouth every 6 hours as needed for pain. On 06/08/26, Resident #46 was observed with a bottle of OTC Tylenol 325 mg and a bottle of decongestant nasal spray on the bedside table. The resident stated she used the Tylenol before therapy for pain and used the nasal spray daily for congestion, and said the medications had been brought in by a family member and had been at the bedside for a couple of weeks. Subsequent observations on 06/09/26 and 06/10/26 again found both bottles on the bedside table. Nurse #1 stated she was not aware of any medication at the bedside and that no residents on the unit were assessed to self-administer medications. The DON stated no resident was allowed to keep home medications in the room and that Resident #46 should have been assessed if she wanted to keep and administer medications in her room. The Administrator stated nurses were expected to notice bedside medications and remove them immediately.
Missed Level II PASRR Request for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a Level II PASRR evaluation request to NC MUST for a resident with a serious mental illness. Resident #10 had been deemed Level I PASRR by the State and was admitted with diagnoses including dementia, depression, and anxiety. After a hospital stay, an updated FL-2 completed by the hospital physician added bipolar disorder to the resident’s diagnoses, and bipolar disorder was also added to the facility diagnosis list. The resident’s record showed orders for venlafaxine and buspirone for depression and anxiety, and the admission MDS coded the resident with bipolar disorder and antidepressant use, while also indicating the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness. There was no documentation that a Level II PASRR evaluation was completed when the bipolar disorder diagnosis was added. During interview, the Discharge Planning Director stated she was responsible for ensuring Level II PASRR evaluations were current and accurate, and said she missed the bipolar disorder diagnosis when it was added in 10/2025. She reported that she did not request the Level II PASRR evaluation or submit the FL-2 to NC MUST until 6/9/2026, after becoming aware of the need following a later hospital return, and uploaded clinical documents on 6/10/2026 to trigger the onsite Level II evaluation. The Administrator stated the Discharge Planning Director was responsible for submitting the requests and that the evaluation should have been done immediately when the diagnosis warranted screening.
Failure to Protect Cognitively Impaired Resident From Staff Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from staff-to-resident physical abuse during the provision of care. The resident had Alzheimer’s disease, was coded on the MDS with severe cognitive impairment, required moderate assistance with personal hygiene, toileting, dressing, and transfers, and was always incontinent of bowel and bladder. The resident had been care planned for combative behaviors with care, with interventions to assure safety, listen to the resident, and try to calm her. During an episode of incontinence care and dressing, the resident became agitated, was swinging her arms, and attempted to bite staff. According to the eyewitness account from NA #1, NA #2 responded to the resident’s resistive and combative behavior by striking the resident multiple times with an open hand. NA #1 reported that when the resident tried to bite NA #2 while holding onto the bed rail, NA #2 removed the resident’s hands from the rail and then “popped” the resident on the lips with an open hand, stating, “you’re not going to fight us or bite us,” with an audible popping sound. NA #1 continued providing incontinence care and did not immediately stop the interaction or remove NA #2 from the room. As care progressed, while the resident was seated at the edge of the bed and attempting to swing at NA #1, NA #2 again struck the resident on the left side of the face/cheek with an open hand, with a similar audible pop, and repeated the same statement. NA #1 further reported that during the transfer from bed to wheelchair, while the resident was mid-transfer and swinging her arms, NA #2 struck the resident a third time on the back of the head with an open hand, again telling the resident she was not going to hit staff. After each strike, the resident did not vocalize but appeared more agitated in facial expression. NA #1 acknowledged that she was in shock, continued care after the first strike, and did not immediately remove NA #2 from the room or stop the care. The DON later stated that both NAs should have stopped providing care when the resident became agitated and that NA #1 should have asked NA #2 to leave the room and reported the incident after the first strike. The Administrator’s account of NA #1’s report was consistent with NA #1’s description that NA #2 made open-hand contact with the resident’s mouth, face, and the back of the head during care.
Improper Use of Physical Restraint During Care of Combative Resident
Penalty
Summary
The deficiency involves the failure to protect a resident’s right to be free from physical restraints when a nurse aide held the resident’s hands down against her chest during care. The resident had Alzheimer’s disease, was assessed with severe cognitive impairment on the admission MDS, and had been care planned for combative behaviors with interventions such as assuring safety, listening, and attempting to calm her. During an episode of care, the resident became agitated, was swinging her arms, and grabbed the bed rail, making it difficult for staff to move her. Nurse Aide #2 removed the resident’s hands from the bed rail, placed them on the resident’s upper chest, and held them there to prevent her from swinging her arms while Nurse Aide #1 completed incontinence care. Nurse Aide #1 reported that while Nurse Aide #2 was holding the resident’s hands down, the resident attempted to bite Nurse Aide #2, who then struck the resident on the lips with an open hand and told her she was not going to fight or bite them, continuing to restrain the resident’s hands. The resident became more agitated and began kicking her legs, making it more difficult to finish care. Nurse Aide #1 later stated she had received training on dealing with resident behaviors and abuse but did not realize at the time that holding the resident’s hands down on her chest constituted a restraint, and acknowledged that care should have been stopped and attempted later. The DON and Administrator confirmed that Nurse Aide #2 had held the resident’s hands against her chest to prevent injury and acknowledged that the resident’s hands were restrained when she was struck, and that staff had previously received training on all types of abuse, including physical restraints.
Failure to Protect Resident From Physical Abuse and Immediate Reporting of Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy requiring all employees to immediately report any suspected or witnessed abuse to the Administrator, DON, or immediate supervisor, and to protect residents from abuse. The policy, dated 10/17/23, states that all employees are responsible for immediate reporting and for prevention of abuse and neglect by advocating and enforcing resident rights. Resident #1, who had Alzheimer’s disease and a history of being resistive to care, was the subject of the incident. On the date of the event, NA #2 requested assistance from NA #1 to provide care to Resident #1, who was agitated and partially out of bed when NA #1 entered the room. During incontinence and dressing care, Resident #1 grabbed the bed rail and became difficult to move. NA #2 removed the resident’s hands from the rail, held them on the resident’s upper chest to prevent swinging, and when the resident attempted to bite, NA #2 struck the resident on the lips with an open hand and stated that the resident was not going to fight or bite them. NA #1 reported being shocked but continued providing incontinence care instead of stopping the interaction. As care continued, Resident #1 became more agitated and began kicking, and NA #1’s focus remained on quickly finishing care and getting the resident away from NA #2, rather than immediately stopping care and intervening after the first strike. After incontinence care, NA #1 sat Resident #1 on the edge of the bed to change her shirt while NA #2 stood near the end of the bed behind the resident. When the resident’s arm became stuck in the shirt and the resident swung at NA #1, NA #2 struck the resident a second time on the left side of the face with an open hand, again stating the resident was not going to fight or bite them. NA #1 told NA #2 to stop and indicated she could manage the care, but continued the transfer. During the transfer from bed to wheelchair, when the resident swung her arms again, NA #2 struck the resident a third time on the back of the head with an open hand, repeating that the resident was not going to hit them. NA #1 then completed the transfer, removed the resident from the room, and reported the incident to the Unit Manager. NA #1 later acknowledged that, in retrospect, she should have stopped care after the first strike, removed NA #2 from the room, and reported the incident immediately, indicating a failure to follow the facility’s abuse prevention and reporting policy in real time during the incident.
Resident Discharged Home with Midline Catheter Left In Place
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safe and orderly discharge of a resident who was sent home with a midline intravenous (IV) catheter still in place, despite no ongoing medical need for the device. The resident, who had moderate cognitive impairment and was admitted with diagnoses including dysphagia and hyponatremia, had previously received IV fluids via the midline catheter for hyponatremia. The discharge summary did not indicate any devices or orders requiring IV access upon discharge. However, the resident was discharged with the midline catheter still inserted in her arm. The responsible party discovered the catheter upon arrival home and contacted the facility. Interviews with staff revealed that the discharge was rushed, and there was a lack of recall regarding the education provided to the resident and her responsible party about the catheter. The unit manager and DON confirmed that the midline catheter should have been removed prior to discharge, and the medical director acknowledged this was an oversight by nursing staff. The interdisciplinary team had discussed discharge needs, but the removal of the midline catheter was not completed as required.
Failure to Complete Required PASRR Level II Assessment for Resident with Expired Authorization
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) level II for a resident who had a history of bipolar disorder. The resident was admitted with a PASRR level II that had expired prior to admission, and no new level II PASRR was obtained after admission. Record review confirmed that the expired PASRR was not updated, and the necessary assessment was not completed as required. Interviews with facility staff revealed that both the Assistant Discharge Planner and the Discharge Planner were responsible for monitoring and completing level II PASRRs. The Assistant Discharge Planner was unaware that the resident's PASRR was a level II that had expired, mistakenly believing it was a level I, and therefore did not obtain a new assessment. The Discharge Planner acknowledged that a new level II PASRR should have been obtained but was overlooked. The Administrator confirmed that the responsibility for ensuring current level II PASRRs rested with the Discharge Planner and Assistant Discharge Planner.
Failure to Provide Bagged Lunch for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with stage 5 chronic kidney disease, who was admitted for short-term rehabilitation and required outpatient dialysis three times a week, was not provided with a bagged lunch on the days of her dialysis treatments. The resident reported that she left the facility for dialysis after having breakfast in the morning and returned in the late afternoon, expressing that she was very hungry upon return as no lunch was provided. The facility had a process in place where the dietary department prepared bagged lunches for dialysis days, and nursing staff were responsible for retrieving and sending the lunch with the resident. Despite this process, the assigned nurse aide admitted to forgetting to collect and send the bagged lunch with the resident on two separate occasions. The dietary manager confirmed that the lunches were prepared and available in the kitchen on those days, but was unaware that they were not delivered to the resident. The medical director and administrator both acknowledged that a bagged lunch should have been provided to the resident on dialysis days.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a Treatment Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. The nurse was observed performing wound care procedures, including cleaning and dressing two wounds, but did not sanitize her hands each time after removing gloves and before donning new gloves, as required by policy. The nurse washed her hands at the start and end of the procedure but neglected to perform hand hygiene between glove changes, even after handling soiled dressings and before touching clean supplies and the resident's wounds. The nurse acknowledged during an interview that she was aware of the hand hygiene requirements but attributed her lapses to nervousness during the observation. The Infection Preventionist and Director of Nursing both confirmed that the expectation is for staff to sanitize hands after each glove removal and before putting on new gloves during wound care. The incident was observed during a wound care session for a resident with wounds on the left thigh, and the nurse's failure to perform proper hand hygiene was directly witnessed by surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its policy for Enhanced Barrier Precautions (EBP) when a Wound Nurse did not don a gown before entering a resident's room to provide care. The resident was under transmission-based precautions due to a wound located on the sacrum. The facility's policy, dated March 26, 2024, required the use of gowns and gloves during high-contact resident care activities, including wound care. Despite the EBP signage on the resident's door instructing staff to wear a gown and gloves, the Wound Nurse entered the room, performed hand hygiene, applied gloves, and provided incontinence and wound care without wearing a gown. During an interview, the Wound Nurse acknowledged that the resident was under Enhanced Barrier Precautions and admitted to forgetting to put on a gown, although she typically wore one while providing wound care. The Director of Nursing confirmed that all staff were expected to follow the precautions posted on residents' doors and use the assigned personal protective equipment (PPE). The observation and interviews revealed that the Wound Nurse should have worn a gown while providing care to the resident, as per the facility's infection control policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 216 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 Huntersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Health & Rehab Center | 1.2 mi | ★★★★★ | 15 | 0 |
| Huntersville Oaks | 1.5 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Cornelius | 5 mi | ★★★★★ | 2 | 0 |
| Rockwell Park Rehabilitation And Healthcare Center | 8.7 mi | — | 11 | 1 |
| University Place Nursing And Rehabilitation Center | 8.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Huntersville Health & Rehabilitation Center.
100% money-back within 48 hours.
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.