Cycle 1
Health 2025-08-14 · Fire 2024-09-19
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Greenville, NC
Cypress Glen Retirement Community
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
1000 Hickory Street, Greenville, NC
(252) 830-0036
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
6
Certified beds
Average residents
3
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
2002-01-10
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
1.10
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.50
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.53
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,704
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.52% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.19
Performance 7.18% · Measure score 2.19 · Achievement 2.19 · This facility did not have sufficient data to calculate a baseline period measure result.
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 6.49% |
| Discharge to community | 60.09% |
50.57%
9.5 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 59.62% · Lower 95% interval 48.97% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 88.89% |
95.27%
6.4 pts worse
|
Numerator 24 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 14 · Denominator 23 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 12 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 1.28% |
42%
40.7 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
79.9%
2.7 pts worse
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
13.2%
5.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.5%
1.9 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
22.9%
7 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 13.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2023-07-26
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-07-26 · Fire 2022-06-01
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
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
D · Potential for more than minimal harm
2023-07-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-07-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-10
Penalties and ownership
What sits behind the stars
Ownership
The United Methodist Retirement Homes, Incorporated
5% Or Greater Direct Ownership Interest · Organization
Davison, John
Corporate Director · Individual
Dobson, Stacy
Corporate Officer · Individual
Erickson, Jonathan
Corporate Director · Individual
Erickson, Jonathan
Corporate Officer · Individual
Evans, Spence
Corporate Director · Individual
Gonzalez Rodriguez, Gerardo
Operational/Managerial Control · Individual
Harriss, William
Corporate Director · Individual
Harriss, William
Corporate Officer · Individual
Hayes, Terry
Operational/Managerial Control · Individual
Lee, Woo
Corporate Director · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Little, Nancy
Corporate Director · Individual
Martin, James
Corporate Director · Individual
Parker, Mack
Corporate Director · Individual
Parker, Mack
Corporate Officer · Individual
Patterson, Gaynelle
Corporate Director · Individual
Southern, Harvey
Corporate Director · Individual
Southern, Harvey
Corporate Officer · Individual
Stallings, Laurie
Operational/Managerial Control · Individual
Steinweg, Kenneth
Corporate Director · Individual
Taylor, Sheryl
Corporate Director · Individual
Us Bank National Association
5% Or Greater Security Interest · Organization
Van Antwerp, Nancy
Corporate Director · Individual
Van Antwerp, Nancy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Greenville Health and Rehabilitation Center
Greenville, NC
1-star overall rating with 1-star inspections with $64,002 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
East Carolina Health and Rehabilitation Center
Greenville, NC
2-star overall rating with 2-star inspections with $66,765 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Macgregor Downs Health Center by Harborview
Greenville, NC
2-star overall rating with 2-star inspections with $10,023 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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