Huntersville Health & Rehab: Mental Health Screening Missed - NC
Federal inspectors documented the lapse in a June 2026 report. The resident at the center of it, identified only as Resident 10 to protect their identity, is cognitively intact and living with dementia, depression, anxiety, and, since October 2025, bipolar disorder.
The evaluation in question is called a Level II PASRR, a federally required screening designed to ensure that nursing home residents with serious mental illness are actually receiving the psychiatric services they need. Resident 10 had been screened years earlier, in August 2009, under a different set of diagnoses. When a hospital physician added bipolar disorder to the resident's chart on October 22, 2025, that earlier screening became outdated. A new one was required.
Nobody caught it for months.
Resident 10 had been hospitalized from October 18 to October 22, 2025. The hospital discharge paperwork included the bipolar disorder diagnosis. The facility added it to the resident's official diagnosis list that same day. A physician ordered two antidepressants and an anti-anxiety medication. The facility's own Minimum Data Set assessment, completed after the admission, coded Resident 10 with bipolar disorder and noted that no Level II PASRR evaluation had been completed.
The discharge planning director, whose job it was to track these evaluations, said she missed the diagnosis addition entirely.
She didn't become aware the evaluation was overdue until Resident 10 was hospitalized again, from April 26 to May 8, 2026, for reasons unrelated to psychiatric care. Reading through the hospital discharge summary, she spotted the bipolar disorder notation. That was the moment she realized the screening had never been requested.
Even then, the process moved slowly. The discharge planning director obtained an updated form from the Medical Director, signed on May 19, 2026. A physician order from that same date added lorazepam, a medication used to treat anxiety, and mirtazapine, an antidepressant. But the director did not submit the form to NC MUST, the state's online screening system, until June 9, 2026, three weeks after obtaining it. She uploaded the supporting clinical documents the following morning, June 10, the same day inspectors interviewed her.
In that interview, conducted at 10:25 a.m. on June 10, the discharge planning director acknowledged the evaluation was her responsibility. She said she had missed the October 2025 diagnosis by mistake and described the submission she had just completed as the action that would trigger an in-person Level II evaluation with the resident.
The administrator, interviewed the next morning, confirmed that the discharge planning director was responsible for the evaluations. He said she had missed Resident 10's screening by mistake and that his expectation was that all Level II PASRR evaluations would be accurate and current. He said the evaluation should have been initiated immediately once the director recognized the diagnosis warranted one.
Inspectors classified the violation as causing minimal harm or potential for actual harm and found it affected one of three residents reviewed for PASRR compliance.
What the report does not say is whether Resident 10, cognitively intact and living with a serious mental illness in a long-term care facility, ever asked about their care plan, or whether anyone explained why the evaluation that was supposed to protect their access to psychiatric services had been sitting incomplete for the better part of a year.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Huntersville Health & Rehabilitation Center from 2026-06-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Huntersville Health & Rehabilitation Center in Huntersville, NC was cited for violations during a health inspection on June 12, 2026.
Federal inspectors documented the lapse in a June 2026 report.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.