Pine Crest Health & Rehabilitation
Charlotte, North Carolina · CCN 345304
20 surveys since 2011. The first finding at harm level was recorded in 2020.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 118
- Surveys
- 20
- Harm or worse
- 11
- Immediate jeopardy
- 8
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 100
- Ownership
- For profit - Limited Liability company
- Chain
- Independent
- County
- Mecklenburg
- Medicare-certified since
- 1989
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 125 for-profit facilities of 100–127 beds in North Carolina.
Last survey on record
Aug 7, 2025
459 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.04 | 3.47 |
| Registered-nurse hours per resident day | 0.59 | — |
| Annual nurse turnover | 73.4% | 49.8% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $144,199 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J13.6% | K414.3% | L— |
| Actual harm | G27.1% | H— | I— |
| No harm, potential for more than minimal | D1346.4% | E828.6% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F8672×
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F8802×
Provide and implement an infection prevention and control program.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
In the surveyor’s words
From the most serious findings on record at Pine Crest Health & Rehabilitation, in the surveyor’s own words.
- Immediate jeopardy, patternF580May 7, 2024
Based on record reviews, staff, responsible person (RP) and Medical Director (MD) interviews, the facility failed to notify the MD when multiple doses of significant morning medications (seizure medication, insulin, depression medication, and chronic kidney and heart failure medication) were not administered due to Resident #20 being out of facility for dialysis treatment and not administered her morning medications. There was a high likelihood of failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. […]
- Immediate jeopardy, patternF689May 7, 2024
Based on observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with a handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. […]
- Immediate jeopardy, patternF760May 7, 2024
Based on record review, resident, staff, and Medical Doctor (MD) interview the facility failed to prevent a significant medication error by failing to administer morning medications for a dialysis resident (Resident #20) for 1 of 3 residents reviewed for assuring the facility was free of medication errors. Resident #20 attended dialysis treatments on Tuesday, Thursday, and Saturday from 5:30 AM to 10:30 AM and was not administered her significant morning medications. Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. […]
- Immediate jeopardy, patternF812May 7, 2024
Based on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays by 1 of 2 cooks (Cook #1). Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. […]
- Immediate jeopardy, isolatedF880May 7, 2024
Based on observations, record review, picture, manufacturer's instructions, resident, family member #5, staff, consultant pharmacist, and Medical Director interviews the facility failed to ensure that single resident insulin pens were not shared between residents. On 07/10/23 Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Regurgitation (emission) of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed. […]
Read 26 findings in full →The most serious and the most recent: 26 of 118 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 7, 2025Standard and complaint5 findings
- May 7, 2024Standard and complaint15 findings · 5 harm
- Feb 23, 2023Complaint2 findings · 2 harm
- Dec 30, 2022Standard and complaint9 findings · 3 harm
- Apr 8, 2022Complaint2 findings
- Dec 16, 2021Standard and complaint22 findings
- Aug 27, 2020Complaint4 findings · 1 harm
- Oct 5, 2019Standard and complaint2 findings
Show the 12 earlier surveys
- Dec 6, 2018Standard and complaint9 findings
- Dec 9, 2017Standard and complaint7 findings
- Oct 20, 2017Complaint1 finding
- Apr 12, 2017Complaint2 findings
- Sep 30, 2016Standard and complaint6 findings
- Mar 23, 2016Complaint2 findings
- Nov 5, 2015Standard and complaint2 findings
- Jan 16, 2015Standard and complaint8 findings
- Sep 13, 2013—8 findings
- Jul 12, 2012—8 findings
- Dec 6, 2011—2 findings
- Aug 18, 2011—2 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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