3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Wilmington, NC
2-star overall rating with 2-star inspections with $24,470 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3800 Independence Boulevard, Wilmington, NC
(910) 392-3110
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
2013-02-13
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
RN hours / resident day
0.62
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
7,816
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.91
Baseline 23.50% · Performance 19.35% · Measure score 5.91 · Achievement 4.48 · Improvement 5.91
Healthcare-associated infections
3.36
Baseline 5.37% · Performance 6.83% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Total nurse turnover
0
Baseline 50.69% · Performance 72.73% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.21
Baseline 3.77 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 9.34% · Lower 95% interval 7.52% |
| Discharge to community | 66.5% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 245 · Observed rate 60.41% · Lower 95% interval 60.23% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.79% |
95.27%
1.5 pts better
|
Numerator 151 · Denominator 156 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 156 |
| Discharge self-care score | 42.4% |
53.69%
11.3 pts worse
|
Numerator 53 · Denominator 125 |
| Discharge mobility score | 28% |
50.94%
22.9 pts worse
|
Numerator 35 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 1.28% |
2.29%
1 pts better
|
Numerator 2 · Denominator 156 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 6.25% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 107 · Denominator 107 |
| Staff flu vaccination coverage | 5.66% |
42%
36.3 pts worse
|
Numerator 6 · Denominator 106 |
| Discharge function score | 24% |
56.45%
32.5 pts worse
|
Numerator 30 · Denominator 125 |
| Transfer of health information to provider | 92.59% |
95.95%
3.4 pts worse
|
Numerator 25 · Denominator 27 |
| Transfer of health information to patient | 98.11% |
96.28%
1.8 pts better
|
Numerator 104 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 20.43% |
25.2%
4.8 pts worse
|
Numerator 19 · Denominator 93 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.5% |
91.5%
11 pts worse
|
93.4%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.0% · Q2 69.8% · Q3 91.7% · Q4 98.2% · 4Q avg 80.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
94.1%
2.4 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.6%
0.7 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 0.0% · Q4 3.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.8%
3.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
7.2%
5.6 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.8% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
21.6%
1.7 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 14.9% · Q3 27.3% · Q4 20.0% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
15.0%
1.8 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 11.4% · Q3 11.9% · Q4 15.6% · 4Q avg 13.2% · 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 | 10.0% |
21.5%
11.5 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 12.8% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
16.8%
10.4 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.1% · Q3 2.6% · Q4 9.3% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
21.2%
3.8 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 34.8% · Q3 24.2% · Q4 21.6% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
6.0%
2.4 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.6% · Q3 2.5% · Q4 5.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.7% |
79.9%
35.2 pts worse
|
81.7%
37 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 34.4% · Q3 52.9% · Q4 71.9% · 4Q avg 44.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.0% |
13.2%
8.8 pts worse
|
12.0%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 21.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.7% · Q4 2.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.0% |
78.1%
46.1 pts worse
|
79.7%
47.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
22.9%
5.4 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-15
Fire Safety
Meet other general requirements.
Corrected 2025-07-15
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 2025-07-15
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-23
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-23
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-22
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-22
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-04-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-22
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-22
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-22
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-22
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-22
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-10
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-04-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-29
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-29
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-29
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-29
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-23
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-29
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 2024-04-23
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-04-29
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-04-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-23
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 2024-04-23
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-23
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 2024-04-23
Health
Post nurse staffing information every day.
Corrected 2024-04-23
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-23
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-19
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-19
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-19
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-04
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-01-04
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 2023-01-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-04
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-04
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-01-04
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 2023-01-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-04
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 2023-01-04
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-01-04
Penalties and ownership
Fine · fine $16,452
Fine
Fine · fine $8,018
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Limited Partnership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Wilmington, NC
3-star overall rating with 3-star inspections with $27,378 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Wilmington, NC
1-star overall rating with 2-star inspections with abuse icon flag with $35,483 in total fines with 7 recent health deficiencies
Wilmington, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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