Cycle 1
Health 2025-03-13 · Fire 2025-03-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Biscoe, NC
Autumn Care Of Biscoe
3-star overall rating with 3-star inspections with $15,350 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
401 Lambert Road, Biscoe, NC
(910) 428-2117
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
141
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1980-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.04
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
1.24
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,362
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.93
Baseline 21.13% · Performance 19.15% · Measure score 4.93 · Achievement 4.93 · Improvement 4.33
Healthcare-associated infections
2.68
Baseline 7.06% · Performance 7.03% · Measure score 2.68 · Achievement 2.68 · Improvement 0
Total nurse turnover
5.74
Performance 40.21% · Measure score 5.74 · Achievement 5.74 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.76
Baseline 2.91 hours · Performance 3.84 hours · Measure score 2.76 · Achievement 2.69 · Improvement 2.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 8.93% · Lower 95% interval 6.9% |
| Discharge to community | 49.3% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 41.86% · Lower 95% interval 39.88% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 42.59% |
53.69%
11.1 pts worse
|
Numerator 23 · Denominator 54 |
| Discharge mobility score | 35.19% |
50.94%
15.8 pts worse
|
Numerator 19 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.73% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 0.66% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 151 |
| Staff flu vaccination coverage | 60.69% |
42%
18.7 pts better
|
Numerator 105 · Denominator 173 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 28 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 18 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.6% · Q3 3.3% · Q4 2.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.8%
3.5 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.2% · Q4 2.5% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
7.2%
2.8 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 4.8% · Q3 2.3% · Q4 1.2% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
21.6%
0.4 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 22.1% · Q3 20.7% · Q4 22.1% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
15.0%
2.5 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.5% · Q3 9.9% · Q4 9.7% · 4Q avg 12.5% · 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 | 16.2% |
21.5%
5.3 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 17.0% · Q3 16.5% · Q4 15.5% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
16.8%
2.7 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.0% · Q3 16.9% · Q4 12.3% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
2.6%
1.6 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.7% · Q3 4.4% · Q4 3.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
21.2%
1.2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 24.1% · Q3 11.2% · Q4 30.3% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
6.0%
3.4 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.3% · Q3 3.0% · Q4 2.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
79.9%
19.8 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
13.2%
7.7 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.8% · Q3 0.0% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
78.1%
19.5 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.9%
1.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 22.2% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-10-31 · Fire 2022-10-31
11 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
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 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
D · Potential for more than minimal harm
2024-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-03-20
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 2024-05-07
C · Minimal harm
2024-03-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-28
D · Potential for more than minimal harm
2022-10-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-13
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 2025-03-25
G · Actual harm
2024-03-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-20
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 2024-03-28
E · Potential for more than minimal harm
2024-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-20
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 2024-03-28
J · Immediate jeopardy
2022-10-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-31
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-31
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 2022-11-15
D · Potential for more than minimal harm
2022-10-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-31
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 2022-11-15
B · Minimal harm
2022-10-31
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 2022-11-15
B · Minimal harm
2022-10-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-15
Penalties and ownership
What sits behind the stars
$15,350
2024-03-20
Fine
Fine · fine $15,350
Fine
Ownership
Autumn Corporation
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Billings, Christina
W-2 Managing Employee · Individual
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Joiner, Brian
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Saber Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shg Autumn, LLC
5% Or Greater Indirect Ownership Interest · Organization
Shh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Wwbv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
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