Cycle 1
Health 2024-12-19 · Fire 2024-12-19
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Albemarle, NC
Bethany Woods Nursing and Rehabilitation Center
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
33426 Old Salisbury Road, Albemarle, NC
(704) 983-1195
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1975-03-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 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
0.34
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.20
Baseline 20.99% · Performance 20.41% · Measure score 2.20 · Achievement 2.20 · Improvement 0.96
Healthcare-associated infections
1.09
Baseline 7.11% · Performance 7.51% · Measure score 1.09 · Achievement 1.09 · Improvement 0
Total nurse turnover
0
Baseline 67.15% · Performance 76.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.37
Baseline 4.11 hours · Performance 3.75 hours · Measure score 2.37 · Achievement 2.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.05% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 6.02% |
| Discharge to community | 51.16% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 45.83% · Lower 95% interval 38.9% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.88% |
95.27%
1.4 pts worse
|
Numerator 46 · Denominator 49 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 49 |
| Discharge self-care score | 61.76% |
53.69%
8.1 pts better
|
Numerator 21 · Denominator 34 |
| Discharge mobility score | 38.24% |
50.94%
12.7 pts worse
|
Numerator 13 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 49 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 125 |
| Staff flu vaccination coverage | 14.2% |
42%
27.8 pts worse
|
Numerator 25 · Denominator 176 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 17 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4% |
25.2%
21.2 pts worse
|
Numerator 1 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
91.5%
9 pts worse
|
93.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 87.0% · Q3 89.0% · Q4 81.6% · 4Q avg 82.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
94.1%
4.3 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.1% · Q3 0.0% · Q4 2.0% · 4Q avg 1.6% · 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 | 5.6% |
7.2%
1.6 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.0% · Q3 4.3% · Q4 7.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
21.6%
11.4 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 31.7% · Q3 31.9% · Q4 27.6% · 4Q avg 33.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
15.0%
6.3 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 10.6% · Q3 7.7% · Q4 8.9% · 4Q avg 8.7% · 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 | 6.1% |
21.5%
15.4 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 0.0% · Q3 0.0% · Q4 6.1% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
16.8%
7.1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.0% · Q3 1.6% · Q4 15.2% · 4Q avg 9.7% · 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 | 2.5% |
2.6%
0.1 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 2.5% · Q4 4.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.8% |
21.2%
13.4 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 6.9% · Q3 7.3% · Q4 6.9% · 4Q avg 7.8% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.0%
1.9 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.0% · Q3 1.1% · Q4 8.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.7% |
79.9%
17.2 pts worse
|
81.7%
19 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 64.2% · Q3 59.7% · Q4 59.6% · 4Q avg 62.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
13.2%
6.6 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.7% · Q3 2.6% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.3% |
78.1%
24.8 pts worse
|
79.7%
26.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
22.9%
1.9 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 18.4% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-01 · Fire 2023-09-01
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-02-03 · Fire 2022-02-03
21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-13
D · Potential for more than minimal harm
2024-12-19
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2025-03-13
D · Potential for more than minimal harm
2024-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-13
D · Potential for more than minimal harm
2023-09-01
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 2023-10-17
D · Potential for more than minimal harm
2023-09-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-17
F · Potential for more than minimal harm
2022-02-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-03-03
F · Potential for more than minimal harm
2022-02-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-03-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
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 2025-01-16
E · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-16
E · Potential for more than minimal harm
2023-09-01
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 2023-09-29
E · Potential for more than minimal harm
2023-09-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-01
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 2023-09-29
D · Potential for more than minimal harm
2023-09-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-01
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 2023-09-29
D · Potential for more than minimal harm
2023-09-01
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-29
B · Minimal harm
2023-09-01
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 2023-09-29
B · Minimal harm
2023-09-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-29
B · Minimal harm
2023-09-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-29
E · Potential for more than minimal harm
2022-02-03
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 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
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 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
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 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
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 2022-03-03
E · Potential for more than minimal harm
2022-02-03
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 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-03-03
E · Potential for more than minimal harm
2022-02-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-03-03
D · Potential for more than minimal harm
2022-02-03
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-03-03
D · Potential for more than minimal harm
2022-02-03
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 2022-03-03
D · Potential for more than minimal harm
2022-02-03
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 2022-03-03
D · Potential for more than minimal harm
2022-02-03
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 2022-03-03
D · Potential for more than minimal harm
2022-02-03
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 2022-03-03
D · Potential for more than minimal harm
2022-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-03
D · Potential for more than minimal harm
2022-02-03
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 2022-03-03
D · Potential for more than minimal harm
2022-02-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-03
B · Minimal harm
2022-02-03
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 2022-03-03
Penalties and ownership
What sits behind the stars
Ownership
Boice, Gale
Corporate Officer · Individual
Hill, Raymond
5% Or Greater Direct Ownership Interest · Individual
Hill, Robert
5% Or Greater Direct Ownership Interest · Individual
Hill, Stephen
5% Or Greater Direct Ownership Interest · Individual
Johnson, Dianne
Corporate Director · Individual
Johnson, Dianne
W-2 Managing Employee · Individual
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Stanly Manor
Albemarle, NC
2-star overall rating with 2-star inspections with $12,054 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Trinity Place
Albemarle, NC
5-star overall rating with 4-star inspections with $13,520 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Forrest Oakes Healthcare
Albemarle, NC
2-star overall rating with 2-star inspections with $5,242 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out