Cycle 1
Health 2025-09-13 · Fire 2024-11-01
33 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Greensboro, NC
Blumenthal Health and Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $233,306 in total fines with 33 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3724 Wireless Drive, Greensboro, NC
(828) 459-2977
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
134
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
0.53
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.73
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
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
84%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,481
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.19
Baseline 20.70% · Performance 20.42% · Measure score 2.19 · Achievement 2.19 · Improvement 0.26
Healthcare-associated infections
4.99
Baseline 9.77% · Performance 7.15% · Measure score 4.99 · Achievement 2.29 · Improvement 4.99
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.81
Baseline 2.76 hours · Performance 3.16 hours · Measure score 0.81 · Achievement 0 · Improvement 0.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 10.81% · Lower 95% interval 6.94% |
| Discharge to community | 54.62% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 48.1% · Lower 95% interval 44.49% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 91.55% |
95.27%
3.7 pts worse
|
Numerator 65 · Denominator 71 |
| Falls with major injury | 4.23% |
0.77%
3.5 pts worse
|
Numerator 3 · Denominator 71 |
| Discharge self-care score | 68.09% |
53.69%
14.4 pts better
|
Numerator 32 · Denominator 47 |
| Discharge mobility score | 68.09% |
50.94%
17.2 pts better
|
Numerator 32 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 2.82% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 71 · Adjusted rate 2.86% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 4.35% |
42%
37.6 pts worse
|
Numerator 16 · Denominator 368 |
| Discharge function score | 68.09% |
56.45%
11.6 pts better
|
Numerator 32 · Denominator 47 |
| Transfer of health information to provider | 82.35% |
95.95%
13.6 pts worse
|
Numerator 28 · Denominator 34 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 3 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
91.5%
5.5 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 99.0% · Q3 100.0% · Q4 96.8% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
94.1%
0.2 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.0% · Q3 2.0% · Q4 3.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
4.8%
7.5 pts worse
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 17.4% · Q3 5.6% · Q4 19.3% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
7.2%
1.7 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 10.0% · Q3 7.1% · Q4 4.0% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
21.6%
0.6 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 20.9% · Q3 23.3% · Q4 24.0% · 4Q avg 22.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
15.0%
1.9 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 12.8% · Q3 12.7% · Q4 11.7% · 4Q avg 13.1% · 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 | 33.1% |
21.5%
11.6 pts worse
|
16.3%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 43.8% · Q3 28.7% · Q4 23.3% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
16.8%
15.9 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 43.6% · Q3 36.7% · Q4 13.2% · 4Q avg 32.7% · 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 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
21.2%
8.2 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 33.5% · Q3 23.3% · Q4 30.0% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.0%
1.6 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 2.7% · Q3 3.2% · Q4 4.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.2% |
79.9%
2.3 pts better
|
81.7%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 88.1% · Q3 86.3% · Q4 80.6% · 4Q avg 82.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
13.2%
About the same
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.4% · Q4 3.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
78.1%
5.8 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
22.9%
4.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 27.8% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2023-05-25
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2022-08-04
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-09
D · Potential for more than minimal harm
2024-11-01
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-05-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-13
F · Potential for more than minimal harm
2023-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-05-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-05-25
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 2023-07-13
D · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-13
D · Potential for more than minimal harm
2022-08-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-04
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 2022-09-30
D · Potential for more than minimal harm
2022-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-16
G · Actual harm
2025-09-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-09
F · Potential for more than minimal harm
2025-09-13
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 2025-12-09
E · Potential for more than minimal harm
2025-09-13
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 2025-12-09
E · Potential for more than minimal harm
2025-09-13
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 2025-12-16
E · Potential for more than minimal harm
2025-09-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-09-13
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
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 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
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 2025-12-09
D · Potential for more than minimal harm
2025-09-13
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 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-09-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
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 2025-12-09
D · Potential for more than minimal harm
2025-09-13
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 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-12-09
C · Minimal harm
2025-09-13
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-10-20
B · Minimal harm
2025-09-13
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-11
B · Minimal harm
2025-09-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-10-20
B · Minimal harm
2025-09-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-10-20
B · Minimal harm
2025-09-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-05-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-30
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-26
J · Immediate jeopardy
2025-01-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-09
J · Immediate jeopardy
2025-01-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-09
J · Immediate jeopardy
2025-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-09
J · Immediate jeopardy
2025-01-09
F714 · Nursing and Physician Services Deficiencies
Health
Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist.
Corrected 2025-01-09
G · Actual harm
2025-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-09
D · Potential for more than minimal harm
2025-01-09
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 2025-01-09
D · Potential for more than minimal harm
2025-01-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-09
K · Immediate jeopardy
2024-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-11-01
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 2025-01-09
E · Potential for more than minimal harm
2024-11-01
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 2025-01-09
E · Potential for more than minimal harm
2024-11-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-09
B · Minimal harm
2024-11-01
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 2024-11-27
B · Minimal harm
2024-11-01
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 2024-11-27
D · Potential for more than minimal harm
2023-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-01
G · Actual harm
2023-06-14
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 2023-07-14
F · Potential for more than minimal harm
2023-05-25
F809 · Nutrition and Dietary Deficiencies
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 2023-07-14
F · Potential for more than minimal harm
2023-05-25
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 2023-07-14
F · Potential for more than minimal harm
2023-05-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-25
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 2023-07-14
E · Potential for more than minimal harm
2023-05-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
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 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
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 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
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 2023-07-14
D · Potential for more than minimal harm
2023-05-25
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 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
$17,710
2025-09-13
Fine
Fine · fine $17,710
Fine
$26,685
2025-09-13
Fine
Fine · fine $26,685
Fine
$0
2025-09-13
Payment Denial
Payment Denial · denial start 2025-10-17 · 60 days
60 day denial
$181,468
2024-11-01
Fine
Fine · fine $181,468
Fine
$0
2024-11-01
Payment Denial
Payment Denial · denial start 2024-11-30 · 40 days
40 day denial
$7,443
2023-05-25
Fine
Fine · fine $7,443
Fine
Ownership
Blumenthal Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bridgewater Nc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Cruz, Lasaro
Operational/Managerial Control · Individual
Draper, Rhonda
Corporate Officer · Individual
Hl Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ib Mimi 2022 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ib Mimi 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
James, Jada
Corporate Officer · Individual
Jk 2022 Grantor Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Johnson, Christopher
Corporate Officer · Individual
Kelley, Travisha
Corporate Officer · Individual
Maher, Cindy
Operational/Managerial Control · Individual
Milano Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ml Milano 2022 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ml Milano 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mustain, Brooke
Corporate Officer · Individual
Rodriguez, Catherine
Corporate Officer · Individual
Shaw, Vera
Corporate Officer · Individual
Shayo, Julius
Corporate Officer · Individual
Summer, Megan
Corporate Officer · Individual
Tj Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Tol Opco Investco LLC
5% Or Greater Indirect Ownership Interest · Organization
Uh Carolina SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Universal Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Will Family 2016 Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Linden Place Center for Nursing and Rehabilitation
Greensboro, NC
1-star overall rating with 2-star inspections with $11,518 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Heartland Living & Rehab at the Moses H Cone Memor
Greensboro, NC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Piedmont Hills Center for Nursing and Rehab
Greensboro, NC
1-star overall rating with 1-star inspections with abuse icon flag with $249,761 in total fines with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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