Pine Crest Health & Rehabilitation
2727 Shamrock Drive, Charlotte, NC 28205 · Mecklenburg County · 100 certified beds · avg 72 residents/day · certified since Jun 9, 1989
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · May 7, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 7, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 7, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 7, 2024 · F-0812 · triggered by a complaint
The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Why it matters: Unsafe food handling is one of the most common causes of food poisoning, which can be dangerous for frail residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 7, 2024 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 30, 2022 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 10, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 30, 2022 · F-0677
The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Why it matters: Residents who don't get this help can suffer poor hygiene, skin breakdown, weight loss, and a loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 10, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 7, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 7, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 7, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 7, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| May 7, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Dec 30, 2022 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 30, 2022 | ▲ G · Actual harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 30, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 30, 2022 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Dec 30, 2022 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 30, 2022 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 30, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 30, 2022 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 8 | 2 | G ▲ |
| 2024 | 15 | 5 | K ▲ |
| 2025 | 5 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $144,199.
| Date | Type | Amount / length |
|---|---|---|
| May 7, 2024 | Fine | $144,199 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.38 | 4.01 | 3.95 | bottom 27% in North Carolina; bottom 30% in the U.S. |
| Registered Nurse hours | 0.65 | 0.64 | 0.69 | top 31% in North Carolina; top 42% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.56 | 3.50 | bottom 43% in North Carolina; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.55 | 0.41 | 0.48 | top 20% in North Carolina; top 27% in the U.S. |
| Total nursing staff turnover (%) | 73.4 | 49.0 | 45.8 | bottom 6% in North Carolina; bottom 4% in the U.S. |
| RN turnover (%) | 71.4 | 45.7 | 42.9 | bottom 14% in North Carolina; bottom 11% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.04, RN 0.59, weekend 2.86. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Asbury Health and Rehabilitation Center | 0.8 mi | Charlotte, NC | ★★☆☆☆ | 2/5 | |
| Peak Resources - Charlotte | 1.6 mi | Charlotte, NC | ★★★☆☆ | 3/5 | |
| Wilora Lake Healthcare | 2.7 mi | Charlotte, NC | ★★☆☆☆ | 2/5 | abuse |
| Pelican Health at Charlotte | 2.8 mi | Charlotte, NC | ★★☆☆☆ | 1/5 | SFF |
| Crown Haven Health and Rehabilitation | 2.9 mi | Charlotte, NC | ★★☆☆☆ | 1/5 | |
| Redwood Health & Rehab | 3.1 mi | Charlotte, NC | ★★★☆☆ | 3/5 | |
| Novant Health Presbyterian Medical Center-Snu | 3.1 mi | Charlotte, NC | ★★★★★ | 5/5 | |
| White Oak Manor - Charlotte | 3.6 mi | Charlotte, NC | ★☆☆☆☆ | 1/5 | |
| Rockwell Park Rehabilitation and Healthcare Center | 3.7 mi | Charlotte, NC | —/5 | SFF | |
| Pelican Health Randolph LLC | 4.7 mi | Charlotte, NC | ★☆☆☆☆ | 2/5 | |
| Sardis Oaks | 5.6 mi | Charlotte, NC | ★★★☆☆ | 3/5 | |
| University Place Nursing and Rehabilitation Center | 5.7 mi | Charlotte, NC | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 345304.