Cycle 1
Health 2025-06-05 · Fire 2024-06-20
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Reidsville, NC
Cypress Valley Center for Nursing and Rehabilitati
1-star overall rating with 2-star inspections with $32,911 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
543 Maple Avenue, Reidsville, NC
(336) 342-1382
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1982-10-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.31
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.16
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
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,722
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.9
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.22
Baseline 24.68% · Performance 20.30% · Measure score 5.22 · Achievement 2.44 · Improvement 5.22
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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
1.16
Baseline 3.83 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 6.58% |
| Discharge to community | 34.36% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 47 · Observed rate 23.4% · Lower 95% interval 23.31% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 84.09% |
95.27%
11.2 pts worse
|
Numerator 37 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 40.74% |
53.69%
12.9 pts worse
|
Numerator 11 · Denominator 27 |
| Discharge mobility score | 37.04% |
50.94%
13.9 pts worse
|
Numerator 10 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 6.82% |
2.29%
4.5 pts worse
|
Numerator 3 · Denominator 44 · Adjusted rate 4.89% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 128 |
| Staff flu vaccination coverage | 4.65% |
42%
37.4 pts worse
|
Numerator 8 · Denominator 172 |
| Discharge function score | 44.44% |
56.45%
12 pts worse
|
Numerator 12 · Denominator 27 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 6 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.3% |
91.5%
20.2 pts worse
|
93.4%
22.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.6% · Q2 71.7% · Q3 68.8% · Q4 71.4% · 4Q avg 71.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.7% |
94.1%
5.4 pts worse
|
95.5%
6.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 4.3% · Q4 4.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.8% |
4.8%
16 pts worse
|
11.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 25.0% · Q3 21.7% · Q4 18.8% · 4Q avg 20.8% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
7.2%
2.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.2% · Q3 9.9% · Q4 4.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.2% |
21.6%
9.6 pts worse
|
19.6%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 25.0% · Q3 32.5% · Q4 34.9% · 4Q avg 31.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
15.0%
0.3 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 12.3% · Q3 17.2% · Q4 20.5% · 4Q avg 15.3% · 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 | 28.3% |
21.5%
6.8 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
16.8%
1 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 10.8% · Q3 13.5% · Q4 19.7% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 2.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
2.6%
2.4 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.3% · Q3 3.3% · Q4 7.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
21.2%
1 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 13.8% · Q3 13.1% · Q4 31.1% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
6.0%
0.9 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.1% · Q3 6.5% · Q4 7.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 32.2% |
79.9%
47.7 pts worse
|
81.7%
49.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 39.0% · Q3 26.7% · Q4 23.7% · 4Q avg 32.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.7% |
13.2%
13.5 pts worse
|
12.0%
14.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 28.1% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.6% |
78.1%
30.5 pts worse
|
79.7%
32.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.9%
0.7 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 22.8% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2023-04-20
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2021-12-02
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
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
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-06-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-06-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-06-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-06-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-04-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-04-20
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 2023-08-18
F · Potential for more than minimal harm
2023-04-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-04-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-04-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-04-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-04-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-04-20
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 2023-08-18
D · Potential for more than minimal harm
2023-04-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-05
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 2025-06-27
F · Potential for more than minimal harm
2025-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-05
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 2025-06-27
E · Potential for more than minimal harm
2024-06-20
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 2024-07-18
E · Potential for more than minimal harm
2024-06-20
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 2024-07-18
E · Potential for more than minimal harm
2024-06-20
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 2024-07-18
E · Potential for more than minimal harm
2024-06-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-20
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-20
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-07-18
B · Minimal harm
2024-06-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-18
G · Actual harm
2023-09-07
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 2023-10-05
D · Potential for more than minimal harm
2023-09-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-07
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 2023-10-05
G · Actual harm
2023-05-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-29
G · Actual harm
2023-05-25
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 2023-05-29
G · Actual harm
2023-04-20
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 2023-05-25
F · Potential for more than minimal harm
2023-04-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-04-20
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 2023-05-25
E · Potential for more than minimal harm
2023-04-20
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 2023-05-25
E · Potential for more than minimal harm
2023-04-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-20
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 2023-05-25
D · Potential for more than minimal harm
2023-04-20
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 2023-05-25
D · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
$9,770
2023-09-07
Fine
Fine · fine $9,770
Fine
$3,728
2023-04-20
Fine
Fine · fine $3,728
Fine
$4,423
2023-04-20
Fine
Fine · fine $4,423
Fine
$7,443
2023-04-20
Fine
Fine · fine $7,443
Fine
$7,547
2023-04-20
Fine
Fine · fine $7,547
Fine
$0
2023-04-20
Payment Denial
Payment Denial · denial start 2023-05-20 · 9 days
9 day denial
Ownership
Nearby options
Other facilities in reach
#1
Penn Nursing Center
Reidsville, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
UNC Rockingham Rehab & Nursing Care Center
Eden, NC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Eden Rehabilitation and Healthcare Center
Eden, NC
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out