Cycle 1
Health 2025-09-25 · Fire 2024-06-26
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Pleasant Garden, NC
Clapps Nursing Center Inc
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
5229 Appomattox Road, Pleasant Garden, NC
(336) 674-2252
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-10-01
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
0.40
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,693
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.84
Baseline 17.26% · Performance 20.11% · Measure score 2.84 · Achievement 2.84 · Improvement 0
Healthcare-associated infections
6
Baseline 5.48% · Performance 6.04% · Measure score 6 · Achievement 6 · Improvement 0
Total nurse turnover
5.75
Baseline 49.47% · Performance 40.20% · Measure score 5.75 · Achievement 5.75 · Improvement 3.27
Adjusted total nurse staffing
2.65
Baseline 3.29 hours · Performance 3.83 hours · Measure score 2.65 · Achievement 2.65 · Improvement 1.69
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 8.66% · Lower 95% interval 7.06% |
| Discharge to community | 49.02% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 46.03% · Lower 95% interval 40.08% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 69 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 47.69% |
53.69%
6 pts worse
|
Numerator 31 · Denominator 65 |
| Discharge mobility score | 58.46% |
50.94%
7.5 pts better
|
Numerator 38 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 6.04% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 3.03% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 1.06% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 188 |
| Staff flu vaccination coverage | 20% |
42%
22 pts worse
|
Numerator 41 · Denominator 205 |
| Discharge function score | 41.54% |
56.45%
14.9 pts worse
|
Numerator 27 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 45.95% |
25.2%
20.8 pts better
|
Numerator 17 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · 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 | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.2% · Q4 3.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
4.8%
2.9 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.1% · Q3 1.1% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
7.2%
2.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 2.8% · Q3 1.4% · Q4 7.1% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
21.6%
3.2 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 23.3% · Q3 27.1% · Q4 30.0% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
15.0%
0.2 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.7% · Q3 18.8% · Q4 13.4% · 4Q avg 14.8% · 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 · Q1 19.3% · Q2 25.3% · Q3 8.6% · Q4 8.6% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
16.8%
3.7 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 30.4% · Q3 15.6% · Q4 12.5% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
21.2%
11 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 32.4% · Q3 25.8% · Q4 43.9% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
6.0%
2.2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.6% · Q3 10.3% · Q4 4.8% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
79.9%
19.9 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
13.2%
5.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 6.7% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.8% · Q3 0.0% · Q4 1.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
78.1%
17.7 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.3% |
22.9%
8.6 pts better
|
23.9%
9.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 11.7% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2023-05-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-24 · Fire 2022-03-31
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
F · Potential for more than minimal harm
2024-06-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-06-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-06-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-06-26
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 2024-09-23
D · Potential for more than minimal harm
2024-06-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-06-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-06-26
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-06-26
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 2024-09-23
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Clapp Health Care LLC
5% Or Greater Direct Ownership Interest · Organization
Hollowell, Danielle
5% Or Greater Direct Ownership Interest · Individual
Hollowell, Danielle
Corporate Officer · Individual
Hollowell, Grant
5% Or Greater Direct Ownership Interest · Individual
Hollowell, Grant
Operational/Managerial Control · Individual
Hollowell, Grant
Corporate Officer · Individual
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#2
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1-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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