Cycle 1
Health 2025-07-24 · Fire 2024-05-16
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Garner, NC
Bellarose Nursing And Rehab
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
200 Bellarose Lake Way, Garner, NC
(919) 985-8400
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.42
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.51
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,022
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.77
Baseline 19.25% · Performance 17.83% · Measure score 7.77 · Achievement 7.77 · Improvement 5.88
Healthcare-associated infections
6.93
Baseline 4.54% · Performance 5.76% · Measure score 6.93 · Achievement 6.93 · Improvement 0
Total nurse turnover
5.88
Baseline 66.67% · Performance 40.00% · Measure score 5.88 · Achievement 5.79 · Improvement 5.88
Adjusted total nurse staffing
3.84
Baseline 4.64 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 352 · Observed rate 7.39% · Lower 95% interval 7.15% |
| Discharge to community | 54.92% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 346 · Observed rate 51.73% · Lower 95% interval 48.79% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.56% |
95.27%
4.3 pts better
|
Numerator 225 · Denominator 226 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 226 |
| Discharge self-care score | 64.74% |
53.69%
11 pts better
|
Numerator 112 · Denominator 173 |
| Discharge mobility score | 57.8% |
50.94%
6.9 pts better
|
Numerator 100 · Denominator 173 |
| Pressure ulcers or injuries, new or worsened | 3.98% |
2.29%
1.7 pts worse
|
Numerator 9 · Denominator 226 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 5.76% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 232 · Observed rate 4.31% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 21.79% |
8.2%
13.6 pts better
|
Numerator 34 · Denominator 156 |
| Staff flu vaccination coverage | 25.15% |
42%
16.9 pts worse
|
Numerator 41 · Denominator 163 |
| Discharge function score | 61.85% |
56.45%
5.4 pts better
|
Numerator 107 · Denominator 173 |
| Transfer of health information to provider | 97.96% |
95.95%
2 pts better
|
Numerator 48 · Denominator 49 |
| Transfer of health information to patient | 98.08% |
96.28%
1.8 pts better
|
Numerator 153 · Denominator 156 |
| Resident COVID-19 vaccinations up to date | 25.2% |
25.2%
About the same
|
Numerator 31 · Denominator 123 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.5%
8.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.6% |
| 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 | 2.2% |
3.6%
1.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 1.4% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 10.6% |
7.2%
3.4 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 10.4% · Q3 11.6% · Q4 10.9% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
21.6%
1.1 pts better
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.4% · Q3 23.9% · Q4 18.5% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
15.0%
6.5 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 9.1% · Q3 9.8% · Q4 3.9% · 4Q avg 8.5% · 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 | 46.6% |
21.5%
25.1 pts worse
|
16.3%
30.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.6% |
16.8%
2.8 pts worse
|
14.9%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 21.3% · Q3 14.3% · Q4 19.3% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 2.2% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.4% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
21.2%
4.4 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 27.1% · Q3 28.5% · Q4 24.1% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.0%
1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.7% · Q3 1.1% · Q4 5.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
79.9%
17 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 96.3% · Q3 96.6% · Q4 97.5% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
13.2%
2.2 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 12.9% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 0.9% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
78.1%
14.9 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
22.9%
2.8 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 22.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2022-12-09
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-12-09 · Fire 2021-07-16
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-13
D · Potential for more than minimal harm
2022-12-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-12-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-01-05
B · Minimal harm
2022-12-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-01-05
Penalties and ownership
What sits behind the stars
Ownership
Sherrill, Debbie
5% Or Greater Direct Ownership Interest · Individual
Evans, Kisa
5% Or Greater Direct Ownership Interest · Individual
Evans, Riley
5% Or Greater Direct Ownership Interest · Individual
Evans, Robert
5% Or Greater Direct Ownership Interest · Individual
Burroughs, William
Operational/Managerial Control · Individual
Burroughs, William
W-2 Managing Employee · Individual
Dixon, Justin
Operational/Managerial Control · Individual
Dixon, Justin
W-2 Managing Employee · Individual
Evans, Kisa
Operational/Managerial Control · Individual
Evans, Kisa
Corporate Officer · Individual
Evans, Kisa
W-2 Managing Employee · Individual
Evans, Riley
Corporate Officer · Individual
Evans, Robert
Operational/Managerial Control · Individual
Evans, Robert
Corporate Officer · Individual
Evans, Robert
W-2 Managing Employee · Individual
Evans, Toni
5% Or Greater Direct Ownership Interest · Individual
Evans, Toni
Corporate Officer · Individual
Miller, Rosemary
5% Or Greater Direct Ownership Interest · Individual
Miller, William
5% Or Greater Direct Ownership Interest · Individual
Richardson, Sandra
Operational/Managerial Control · Individual
Richardson, Sandra
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Laurels of Forest Glenn
Garner, NC
3-star overall rating with 2-star inspections with $182,083 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
PruittHealth-Raleigh
Raleigh, NC
3-star overall rating with 3-star inspections with $24,850 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Clayton Rehabilitation and Healthcare Center
Clayton, NC
1-star overall rating with 1-star inspections with $255,500 in total fines with 25 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out