Cycle 1
Health 2025-03-20 · Fire 2025-03-20
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Wilmington, NC
Cypress Pointe Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2006 South 16th Street, Wilmington, NC
(910) 763-6271
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1976-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 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
0.76
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.54
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
3.34
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,661
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 19.36% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Healthcare-associated infections
3.99
Baseline 7.24% · Performance 6.64% · Measure score 3.99 · Achievement 3.99 · Improvement 2.17
Total nurse turnover
4.23
Baseline 51.35% · Performance 46.38% · Measure score 4.23 · Achievement 4.23 · Improvement 1.38
Adjusted total nurse staffing
2.03
Baseline 2.9 hours · Performance 3.63 hours · Measure score 2.03 · Achievement 1.93 · Improvement 2.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 250 · Observed rate 8% · Lower 95% interval 7.25% |
| Discharge to community | 64.03% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 248 · Observed rate 58.47% · Lower 95% interval 57.76% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 220 · Denominator 220 |
| Falls with major injury | 0.45% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 220 |
| Discharge self-care score | 81.82% |
53.69%
28.1 pts better
|
Numerator 99 · Denominator 121 |
| Discharge mobility score | 81.82% |
50.94%
30.9 pts better
|
Numerator 99 · Denominator 121 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 5 · Denominator 220 · Adjusted rate 2.36% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 5.29% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 18.87% |
8.2%
10.7 pts better
|
Numerator 20 · Denominator 106 |
| Staff flu vaccination coverage | 23.78% |
42%
18.2 pts worse
|
Numerator 34 · Denominator 143 |
| Discharge function score | 85.12% |
56.45%
28.7 pts better
|
Numerator 103 · Denominator 121 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 160 · Denominator 170 |
| Transfer of health information to patient | 66.67% |
96.28%
29.6 pts worse
|
Numerator 16 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 36.07% |
25.2%
10.9 pts better
|
Numerator 44 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.5%
8 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.0% · Q3 3.8% · Q4 1.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.6% |
4.8%
19.8 pts worse
|
11.4%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 21.7% · Q3 22.9% · Q4 38.5% · 4Q avg 24.6% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
7.2%
6.2 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
21.6%
5.8 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 16.7% · Q3 17.6% · Q4 14.3% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
15.0%
2.9 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 9.5% · Q3 11.4% · Q4 14.0% · 4Q avg 12.1% · 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 | 9.1% |
21.5%
12.4 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · 4Q avg 9.1% · 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 17.8% · Q2 6.5% · Q3 6.1% · Q4 1.8% · 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 | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 12.8% |
21.2%
8.4 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 4.0% · Q3 19.1% · Q4 8.9% · 4Q avg 12.8% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.1% · Q3 7.7% · Q4 3.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
79.9%
19.6 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
13.2%
4.1 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 16.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
22.9%
5.2 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 15.7% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-14
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 2024-04-16
D · Potential for more than minimal harm
2024-02-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-16
E · Potential for more than minimal harm
2022-09-15
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 2022-12-18
D · Potential for more than minimal harm
2022-09-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-18
D · Potential for more than minimal harm
2022-09-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-18
D · Potential for more than minimal harm
2022-09-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-20
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 2025-03-28
E · Potential for more than minimal harm
2024-02-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-04
D · Potential for more than minimal harm
2022-09-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-09-15
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 2022-09-19
B · Minimal harm
2022-09-15
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 2022-09-19
Penalties and ownership
What sits behind the stars
Ownership
Cronquist, Royce
Operational/Managerial Control · Individual
Forrai, Angela
Operational/Managerial Control · Individual
Healthcare Financial Solutions LLC
5% Or Greater Security Interest · Organization
Melton, Donald
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Sovereign Healthcare Holdings LLC
Operational/Managerial Control · Organization
Williams, Mark
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Peak Resources-Wilmington, Inc
Wilmington, NC
1-star overall rating with 2-star inspections with abuse icon flag with $35,483 in total fines with 7 recent health deficiencies
#2
August Healthcare at Wilmington
Wilmington, NC
3-star overall rating with 3-star inspections with $27,378 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Azalea Health & Rehab Center
Wilmington, NC
2-star overall rating with 2-star inspections with $24,470 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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