Cycle 1
Health 2025-04-02 · Fire 2025-04-02
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Edenton, NC
Chowan River Nursing and Rehabilitation Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies
1341 Paradise Road, Edenton, NC
(252) 482-7481
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1977-05-01
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
0.40
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.37
Baseline 19.02% · Performance 18.48% · Measure score 6.37 · Achievement 6.37 · Improvement 2.19
Healthcare-associated infections
0.98
Baseline 6.39% · Performance 7.54% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Total nurse turnover
5.64
Baseline 53.25% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 3.94
Adjusted total nurse staffing
2.13
Baseline 3.52 hours · Performance 3.68 hours · Measure score 2.13 · Achievement 2.13 · Improvement 0.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 10.91% · Lower 95% interval 7.8% |
| Discharge to community | 53.24% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 50% · Lower 95% interval 44.1% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.28% |
95.27%
5 pts worse
|
Numerator 65 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 46.3% |
53.69%
7.4 pts worse
|
Numerator 25 · Denominator 54 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 32 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 9.72% |
2.29%
7.4 pts worse
|
Numerator 7 · Denominator 72 · Adjusted rate 8.16% |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 7.79% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 10.34% |
42%
31.7 pts worse
|
Numerator 12 · Denominator 116 |
| Discharge function score | 64.81% |
56.45%
8.4 pts better
|
Numerator 35 · Denominator 54 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 18.75% |
25.2%
6.4 pts worse
|
Numerator 6 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
1.8
3.4 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 4.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.4% |
91.5%
13.1 pts worse
|
93.4%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.4% · Q2 72.7% · Q3 85.7% · Q4 79.4% · 4Q avg 78.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.1%
4.2 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.6%
0.6 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.6% · Q3 3.6% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.8%
3.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
7.2%
4 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.8% · Q3 14.8% · Q4 5.3% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
21.6%
11.8 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 11.8% · Q3 7.4% · Q4 3.5% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
15.0%
5.2 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.3% · Q3 8.5% · Q4 14.0% · 4Q avg 9.8% · 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 | 15.4% |
21.5%
6.1 pts better
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
16.8%
9.1 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.5% · Q3 10.2% · Q4 9.4% · 4Q avg 7.7% · 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 | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 3.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.8% |
21.2%
17.4 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 5.8% · Q4 5.3% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
6.0%
3.6 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.8% · Q3 13.0% · Q4 12.0% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.2% |
79.9%
1.7 pts worse
|
81.7%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.7% · Q2 72.6% · Q3 84.2% · Q4 81.4% · 4Q avg 78.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.9% |
13.2%
12.7 pts worse
|
12.0%
13.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 24.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
78.1%
5.9 pts better
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
22.9%
1 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 19.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
2 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-22
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 2024-04-12
D · Potential for more than minimal harm
2024-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-02-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-12
F · Potential for more than minimal harm
2022-12-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-02-18
F · Potential for more than minimal harm
2022-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-18
F · Potential for more than minimal harm
2022-12-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-18
F · Potential for more than minimal harm
2022-12-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-18
D · Potential for more than minimal harm
2022-12-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-02
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 2025-04-30
D · Potential for more than minimal harm
2025-04-02
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-30
B · Minimal harm
2025-04-02
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 2025-04-30
D · Potential for more than minimal harm
2024-05-30
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 2024-06-14
D · Potential for more than minimal harm
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-02-22
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 2024-03-11
D · Potential for more than minimal harm
2022-12-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-22
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 Officer · 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
Turner, Meredith
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hertford Rehabilitation and Healthcare Center
Hertford, NC
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Carrolton of Plymouth
Plymouth, NC
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Three Rivers Health and Rehabilitation Center
Windsor, NC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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