Cycle 1
Health 2024-11-08 · Fire 2024-11-08
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Clemmons, NC
Cedar Hills Center for Nursing and Rehabilitation
1-star overall rating with 2-star inspections with $70,269 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
3905 Clemmons Road, Clemmons, NC
(336) 766-9158
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Alliance Health Group
Operator or chain grouping
Approved since
1974-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.20
Registered nurse staffing
LPN hours / resident day
0.94
Licensed practical nurse staffing
Aide hours / resident day
2.49
Nurse aide staffing
Weekend hours
3.43
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
67%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 27.0% |
91.5%
64.5 pts worse
|
93.4%
66.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 17.3% |
94.1%
76.8 pts worse
|
95.5%
78.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.8%
4.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.0% |
7.2%
4.8 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
15.0%
7.2 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 52.0% |
21.5%
30.5 pts worse
|
16.3%
35.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.6% |
16.8%
11.8 pts worse
|
14.9%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
21.2%
1.2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 18.9% |
79.9%
61 pts worse
|
81.7%
62.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
13.2%
6.2 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 21.8% |
78.1%
56.3 pts worse
|
79.7%
57.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.9% |
22.9%
12 pts worse
|
23.9%
11 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-17 · Fire 2023-11-17
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-07-29 · Fire 2022-07-29
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-08
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
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 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-07
D · Potential for more than minimal harm
2023-11-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-11-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-19
D · Potential for more than minimal harm
2022-07-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-29
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-09
Inspection history
Recent health citations
G · Actual harm
2024-11-08
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 2024-12-10
E · Potential for more than minimal harm
2024-11-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
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 2024-12-10
D · Potential for more than minimal harm
2024-11-08
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 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-08
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-12-10
C · Minimal harm
2024-11-08
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-20
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 2024-10-11
D · Potential for more than minimal harm
2024-09-20
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 2024-10-11
D · Potential for more than minimal harm
2024-09-20
F690 · Quality of Life and Care Deficiencies
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 2024-10-11
D · Potential for more than minimal harm
2024-09-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-20
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 2024-10-11
E · Potential for more than minimal harm
2023-11-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
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 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
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 2023-12-15
E · Potential for more than minimal harm
2023-11-17
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 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
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 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
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 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-15
B · Minimal harm
2023-11-17
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 2023-12-15
J · Immediate jeopardy
2023-04-27
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 2023-05-11
B · Minimal harm
2023-04-27
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 2023-05-11
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-25
D · Potential for more than minimal harm
2022-07-29
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 2022-08-25
D · Potential for more than minimal harm
2022-07-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-25
Penalties and ownership
What sits behind the stars
$11,333
2024-11-08
Fine
Fine · fine $11,333
Fine
$58,936
2023-04-27
Fine
Fine · fine $58,936
Fine
Ownership
Alignment Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Coalition Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Emanuel, Yosef
5% Or Greater Indirect Ownership Interest · Individual
Emanuel, Yosef
Corporate Officer · Individual
Stover, Kristin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Trinity Elms
Clemmons, NC
2-star overall rating with 3-star inspections with $15,646 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bermuda Village Retirement Center
Bermuda Run, NC
3-star overall rating with 3-star inspections with $12,184 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Bermuda Commons Nursing and Rehabilitation Center
Advance, NC
1-star overall rating with 2-star inspections with $28,043 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
Jump out