Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mecklenburg Heath And Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
A resident with severe cognitive impairment and dependent on staff for all ADLs sustained acute bilateral tibia and fibula fractures of unknown source. Despite facility policy requiring immediate reporting and investigation of such injuries, no report was submitted to the state agency and no formal investigation was completed. The DON and Medical Director determined the fractures were pathological without reviewing all relevant records, and the required procedures for injuries of unknown source were not followed.
A resident with severe cognitive impairment and total dependence for transfers was moved using a mechanical lift by only one nurse aide, despite facility policy requiring two staff for such transfers. The aide performed the transfer alone after the resident complained of leg pain, and did not request assistance, resulting in a deficiency for not providing adequate supervision and a safe environment.
A resident with colorectal cancer and heart failure received chemotherapy, including a continuous infusion pump, as documented in clinical and physician notes. However, the MDS was not coded to reflect chemotherapy administration during the assessment period due to missed information by the MDS team.
A nurse failed to follow insulin pen administration protocol by not waiting the required 6-10 seconds after injection before removing the needle from a resident's skin, as observed during medication administration for a diabetic resident. This resulted in clear fluid draining from the injection site and was not in accordance with facility policy or professional standards.
Expired medications, specifically a box of hemorrhoidal suppositories, were found in the Central Supply storage room. Staff interviews revealed that while nurses and coordinators were expected to check and dispose of expired medications before removal from storage, this process was not consistently followed, resulting in expired drugs remaining accessible.
A Unit Coordinator failed to perform hand hygiene before donning clean gloves while conducting blood glucose testing and insulin injections for two residents. Despite prior training, the staff member did not follow the facility's hand hygiene policy during diabetes care procedures, as confirmed by direct observation and staff interviews.
Failure to Preserve Resident Dignity During Shower Transfer
Penalty
Summary
The facility failed to maintain Resident #67’s dignity during a shower transfer when two nurse aides moved her in a mechanical lift from her room into the common area hallway to a reclining shower bed on the other side of the hall. Resident #67 had diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia. Her quarterly MDS indicated she was severely cognitively impaired, required a wheelchair for mobility, was dependent on staff for transfers, dressing, and bathing, and had a care plan that included assistance with positioning, transfers, toileting, personal hygiene, and bathing as needed. During continuous observation, NA #1 and NA #2 transferred Resident #67 with a bath sheet covering the front of her nude body, but her bare hips and the bare sides of her buttocks were exposed while she was moved through the hallway. Other staff members and residents were present in the hallway during the transfer. Resident #67 later stated that the nurse aides would cover the front part of her body with a sheet and leave her sides exposed, and that she really did not like that. Her care plan also addressed behavioral symptoms, including undressing with the door open, refusing care, crying, and cursing, and included providing an appropriate level of privacy. The nurse aides stated they usually placed the reclining shower bed right outside Resident #67’s room because there was not enough room to place both the mechanical lift and the bed inside the room. NA #1 said the bed had been moved across the hall on the observed occasion and that they typically would not push the lift across the hall. NA #2 stated her normal process was to undress Resident #67 in bed and cover her with a shower sheet before transfer, and she did not realize Resident #67 was exposed. The DON later observed that the mechanical lift fit between the beds in the room, but the reclining shower bed barely fit at the foot of the bed and could not safely be used inside the room due to space constraints. The DON and Administrator stated they expected staff to preserve Resident #67’s dignity and ask about her shower preference.
Failure to Report and Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the reporting and investigation of an injury of unknown source for a dependent resident. The resident, who was severely cognitively impaired, non-ambulatory, and required a mechanical lift for all transfers, sustained acute fractures to both the left and right tibia and fibula. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the state agency and a thorough investigation, no initial allegation report or 5-day investigation report was completed or submitted. The policy also required that all injuries of unknown source, especially those involving serious bodily injury, be reported within two hours of discovery. Upon discovery of the fractures, the DON and ADON interviewed staff and found no reports of falls or trauma, and the Medical Director, after reviewing the resident's medical record, determined the fractures were pathological due to the resident's history of osteoporosis and previous fractures. However, the Medical Director did not review the emergency department or hospital records and was unaware of the bilateral nature of the fractures. The administrator confirmed that, based on the determination of pathological fractures, the facility did not report the incident or conduct the required investigation, despite the policy's stipulations for injuries of unknown source.
Failure to Follow Two-Person Mechanical Lift Transfer Policy
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, dependence on renal dialysis, and dementia, who was assessed as severely cognitively impaired and dependent on staff for all activities of daily living including transfers, was transferred using a mechanical lift by only one nurse aide. The resident's care guide and facility policy both required two-person assistance for mechanical lift transfers. Despite this, the nurse aide performed the transfer alone after the resident complained of leg pain, believing she could transfer the resident more gently by herself. The transfer was completed without incident, but the nurse aide acknowledged she was aware of the policy requiring two staff members and did not request assistance. Staff interviews confirmed that the second nurse aide, who was assigned to the resident, did not assist with the transfer. Both the Assistant Director of Nursing and the Administrator confirmed that facility policy mandates two staff members for all mechanical lift transfers to ensure resident safety. The failure to follow this policy resulted in a deficiency related to providing adequate supervision and ensuring a safe environment free from accident hazards.
Failure to Accurately Code MDS for Chemotherapy Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was receiving chemotherapy. The resident, admitted with diagnoses including colorectal cancer and heart failure, began chemotherapy every two weeks and had a chemotherapy infusion pump placed for a continuous two-day infusion. Nursing and oncologist notes documented the administration of chemotherapy and the presence of the infusion pump during the assessment period. Despite this documentation, the quarterly MDS assessment did not indicate that the resident had received chemotherapy while in the facility or within the last 14 days. Interviews with the Regional MDS Coordinator and other MDS staff revealed that the information was missed during the assessment process, even though they used daily clinical meetings, progress notes, and physician consults to gather assessment data. The Interim DON and Administrator both confirmed that the MDS should be coded accurately, but the error occurred due to missed information.
Failure to Follow Insulin Pen Administration Protocol
Penalty
Summary
A deficiency was identified when the Unit Coordinator failed to administer an insulin pen injection according to the facility's policy and professional standards. During a medication administration observation, the Unit Coordinator did not wait the required 6-10 seconds after fully depressing the insulin pen plunger before removing the needle from the resident's skin. Instead, the pen was removed immediately after the dose was delivered, which was observed to result in clear fluid draining from the injection site. The facility's policy specifically directs staff to keep the needle in the skin for up to 6-10 seconds after the dose is administered to ensure proper delivery of the medication. The resident involved had a diagnosis of type 2 diabetes and a physician's order for Novolog FlexPen insulin to be administered with meals. The Unit Coordinator, while preparing and administering the insulin, did not adhere to the required hold time after injection, and was unable to confirm how long the pen was held in place. Both the Unit Coordinator and the DON acknowledged that the policy was not followed during this administration, as the pen should not have been removed immediately after the dose was delivered.
Expired Medications Found in Central Supply Storage
Penalty
Summary
Surveyors observed that expired medications were not removed from storage in one of three medication storage rooms, specifically the Central Supply room. During an inspection, a box of hemorrhoidal suppositories with an expiration date of July 2025 was found, containing 12 suppositories. The Unit Coordinator confirmed the expiration date and stated that staff responsible for administering medications were expected to check expiration dates before removing medications from the Central Supply room and prior to administration. The Central Supply Coordinator reported that while she checked the room monthly to reorder supplies, she did not check for expired medications. Interviews with facility staff, including the DON and Administrator, revealed that the expectation was for staff to review expiration dates and dispose of expired medications before they left the Central Supply room. However, the presence of expired medication in the storage area indicated that this process was not consistently followed, resulting in expired drugs being available in the facility's medication storage.
Failure to Perform Hand Hygiene Prior to Glove Use During Diabetes Care
Penalty
Summary
A deficiency was identified when the Unit Coordinator failed to follow the facility's Handwashing/Hand Hygiene policy during the provision of care to two residents. Specifically, the Unit Coordinator did not perform hand hygiene prior to donning clean gloves before conducting blood glucose fingerstick and insulin injections. During one observation, the Unit Coordinator entered a resident's room, removed personal protective equipment to retrieve supplies, and upon returning, donned a new gown and gloves without performing hand hygiene. The insulin injection was then administered without the required hand hygiene step. In another instance, the Unit Coordinator applied antiseptic gel before the initial procedure, but after removing gloves and retrieving additional supplies, again donned clean gloves without performing hand hygiene before continuing with blood glucose testing and insulin administration. Staff interviews confirmed that the Unit Coordinator was aware of the hand hygiene requirements but failed to comply, citing nervousness as the reason for the lapse. The Infection Preventionist and Director of Nursing both acknowledged that hand hygiene should have been performed after glove removal and before subsequent procedures, in accordance with facility policy. The residents involved were receiving routine diabetes care, including blood glucose monitoring and insulin injections, at the time of the observed deficiencies.
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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 Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pineville Rehabilitation And Living Center | 4.7 mi | ★★★★★ | 0 | 0 |
| The Stewart Health Center | 5.1 mi | ★★★★★ | 1 | 1 |
| Briar Creek Health Center | 5.8 mi | ★★★★★ | 0 | 0 |
| The Sharon At Southpark | 6.1 mi | ★★★★★ | 0 | 0 |
| The Lodge At Wellmore- Tega Cay | 6.6 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 August 2026) and official state health department websites.