Cycle 1
Health 2026-01-07 · Fire 2024-09-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Lexington, NC
Abbotts Creek Center
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
877 Hill Everhart Road, Lexington, NC
(336) 248-6644
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1990-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,469
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.37
Baseline 21.60% · Performance 21.20% · Measure score 0.37 · Achievement 0 · Improvement 0.37
Healthcare-associated infections
0
Baseline 5.79% · Performance 8.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.58
Baseline 71.91% · Performance 62.12% · Measure score 1.58 · Achievement 0 · Improvement 1.58
Adjusted total nurse staffing
0
Baseline 3.53 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 13.64% · Lower 95% interval 8.39% |
| Discharge to community | 49.07% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 43.82% · Lower 95% interval 39.46% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 38 · Denominator 39 |
| Falls with major injury | 5.13% |
0.77%
4.4 pts worse
|
Numerator 2 · Denominator 39 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 14 · Denominator 27 |
| Discharge mobility score | 40.74% |
50.94%
10.2 pts worse
|
Numerator 11 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.68% |
| Healthcare-associated infections requiring hospitalization | 8.27% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 4 · Denominator 68 |
| Staff flu vaccination coverage | 42.97% |
42%
1 pts better
|
Numerator 55 · Denominator 128 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 14 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 87.5% |
96.28%
8.8 pts worse
|
Numerator 21 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.1% |
91.5%
4.4 pts worse
|
93.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.9% · Q2 88.1% · Q3 89.5% · Q4 91.9% · 4Q avg 87.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.1%
3.6 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.6%
2.9 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.1% · Q3 7.9% · Q4 5.4% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.7% |
4.8%
3.9 pts worse
|
11.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 17.5% · Q3 8.6% · Q4 2.8% · 4Q avg 8.7% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
7.2%
3.1 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.5% · Q3 2.7% · Q4 5.7% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
21.6%
4.7 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.0% · Q3 16.2% · Q4 17.1% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
15.0%
12.7 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.9% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 40.7% |
21.5%
19.2 pts worse
|
16.3%
24.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.1% |
16.8%
16.3 pts worse
|
14.9%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 30.8% · Q3 22.9% · Q4 58.8% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.6%
0.6 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 2.6% · Q4 5.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.0% |
21.2%
14.8 pts worse
|
19.8%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 56.7% · Q3 23.1% · Q4 34.8% · 4Q avg 36.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.0%
1.3 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.9% · Q3 2.8% · Q4 6.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.1% |
79.9%
2.8 pts worse
|
81.7%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.0% · Q2 79.4% · Q3 86.2% · Q4 87.9% · 4Q avg 77.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
13.2%
8.3 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.9% |
78.1%
1.8 pts better
|
79.7%
0.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
22.9%
6.1 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 16.3% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2023-12-13
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-12-13 · Fire 2022-07-11
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-25
D · Potential for more than minimal harm
2023-12-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-02
F · Potential for more than minimal harm
2022-07-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-02-04
C · Minimal harm
2026-01-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-02-04
D · Potential for more than minimal harm
2024-09-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-27
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-10-24
D · Potential for more than minimal harm
2023-12-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-10
Penalties and ownership
What sits behind the stars
Ownership
Regency Health Services, LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Compton, Angela
W-2 Managing Employee · Individual
Fc Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Sukkasem, Yuthapong
W-2 Managing Employee · Individual
Sun Healthcare Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Sunbridge Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lexington Health Care Center
Lexington, NC
1-star overall rating with 2-star inspections with abuse icon flag with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Pine Acres Center for Nursing and Rehabilitation
Lexington, NC
1-star overall rating with 1-star inspections with $122,460 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Piedmont Crossing
Thomasville, NC
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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