Cycle 1
Health 2026-02-12 · Fire 2024-11-01
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Eastover, NC
Bethesda Health Care Facility
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3532 Dunn Road, Eastover, NC
(910) 323-3223
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-10-01
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
0.31
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.93
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
0.84
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,751
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.26
Baseline 20.40% · Performance 20.85% · Measure score 1.26 · Achievement 1.26 · Improvement 0
Healthcare-associated infections
0
Baseline 7.02% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.91
Baseline 40.91% · Performance 47.69% · Measure score 3.91 · Achievement 3.91 · Improvement 0
Adjusted total nurse staffing
1.01
Baseline 3.13 hours · Performance 3.36 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 12.12% · Lower 95% interval 7.73% |
| Discharge to community | 44.22% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 37.25% · Lower 95% interval 34.27% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 92.11% |
95.27%
3.2 pts worse
|
Numerator 35 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 14 · Denominator 21 |
| Discharge mobility score | 85.71% |
50.94%
34.8 pts better
|
Numerator 18 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 10.53% |
2.29%
8.2 pts worse
|
Numerator 4 · Denominator 38 · Adjusted rate 7.61% |
| Healthcare-associated infections requiring hospitalization | 7.77% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 4.86% |
| Staff COVID-19 vaccination coverage | 1.22% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 82 |
| Staff flu vaccination coverage | 19.1% |
42%
22.9 pts worse
|
Numerator 17 · Denominator 89 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 14 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 6 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| 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 | 93.2% |
94.1%
0.9 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.6%
0.1 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.4% · Q3 4.3% · Q4 2.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.7% |
4.8%
20.9 pts worse
|
11.4%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 17.2% · Q3 28.4% · Q4 33.8% · 4Q avg 25.7% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
7.2%
1.1 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 15.2% · Q3 2.9% · Q4 4.2% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
21.6%
1.7 pts worse
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 20.6% · Q3 23.2% · Q4 24.7% · 4Q avg 23.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
15.0%
0.4 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 11.7% · Q3 18.0% · Q4 23.3% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.4% |
0.0%
1.4 pts worse
|
0.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.5% |
21.5%
6 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 41.0% · Q3 31.0% · Q4 12.0% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.5% |
16.8%
14.7 pts worse
|
14.9%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 31.0% · Q3 22.8% · Q4 21.1% · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · 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 4.2% · Q2 1.5% · Q3 0.0% · Q4 6.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.2% |
21.2%
11 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.4% · Q3 11.5% · Q4 8.1% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
6.0%
0.1 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.3% · Q3 4.0% · Q4 7.9% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.9%
20.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
13.2%
9.2 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 3.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
78.1%
15 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
22.9%
4.2 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.9% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2023-08-18
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-08-18 · Fire 2022-03-04
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-06
D · Potential for more than minimal harm
2023-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-02-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
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.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
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.
Not marked corrected
D · Potential for more than minimal harm
2024-11-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-14
Penalties and ownership
What sits behind the stars
Ownership
Gatewood, Elizabeth
5% Or Greater Direct Ownership Interest · Individual
Gatewood, Thomas
5% Or Greater Direct Ownership Interest · Individual
Horne, Caroline
Corporate Director · Individual
Horne, Caroline
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Whispering Pines Nursing & Rehab Center
Fayetteville, NC
5-star overall rating with 5-star inspections with $8,512 in total fines with 6 fire-safety deficiencies in the latest cycle
#2
Woodlands Nursing & Rehabilitation Center
Fayetteville, NC
4-star overall rating with 4-star inspections with $4,709 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Haymount Rehabilitation & Nursing Center, Inc.
Fayetteville, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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