Cycle 1
Health 2025-01-24 · Fire 2025-01-24
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Wilmington, NC
Davis Health and Wellness Center at Cambridge Vill
3-star overall rating with 3-star inspections with $5,244 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
83 Cavalier Drive STE 200, Wilmington, NC
(910) 679-8300
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
17
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-06-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.09
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.89
Baseline 18.02% · Performance 17.77% · Measure score 7.89 · Achievement 7.89 · Improvement 2.02
Healthcare-associated infections
7.73
Baseline 5.05% · Performance 5.52% · Measure score 7.73 · Achievement 7.73 · Improvement 0
Total nurse turnover
0.9
Baseline 38.89% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
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 | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 211 · Observed rate 6.64% · Lower 95% interval 6.82% |
| Discharge to community | 74.72% |
50.57%
24.1 pts better
|
Better than the National Rate · Eligible stays 205 · Observed rate 77.56% · Lower 95% interval 70.29% |
| Medicare spending per beneficiary | 0.59 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.05% |
95.27%
3.8 pts better
|
Numerator 104 · Denominator 105 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 105 |
| Discharge self-care score | 48.89% |
53.69%
4.8 pts worse
|
Numerator 44 · Denominator 90 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 20 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 0.95% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 105 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 5.52% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 1.04% · Lower 95% interval 2.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 20 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.44% |
56.45%
22 pts worse
|
Numerator 31 · Denominator 90 |
| Transfer of health information to provider | 98.57% |
95.95%
2.6 pts better
|
Numerator 69 · Denominator 70 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 30.77% |
25.2%
5.6 pts better
|
Numerator 16 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.2% |
4.8%
13.4 pts worse
|
11.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 13.7% |
0.9%
12.8 pts worse
|
1.0%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.5% |
2.6%
9.9 pts worse
|
1.7%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.0%
1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
79.9%
12.1 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 86.5% · Q3 89.4% · Q4 94.7% · 4Q avg 92.0% |
| 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 | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
78.1%
11.6 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
22.9%
6.9 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 12.4% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
6 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-27 · Fire 2022-07-27
11 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-17
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 2025-12-04
F · Potential for more than minimal harm
2025-01-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-07
F · Potential for more than minimal harm
2023-11-30
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 2024-01-03
F · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-30
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 2024-01-05
D · Potential for more than minimal harm
2023-11-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-03
F · Potential for more than minimal harm
2022-07-27
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-27
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 2022-08-19
E · Potential for more than minimal harm
2022-07-27
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 2022-08-19
E · Potential for more than minimal harm
2022-07-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-27
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 2022-08-19
D · Potential for more than minimal harm
2022-07-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-08-19
B · Minimal harm
2022-07-27
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-08-19
B · Minimal harm
2022-07-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
$5,244
2023-05-30
Fine
Fine · fine $5,244
Fine
Ownership
Biehl, Joanna
Operational/Managerial Control · Individual
Caquias Gonzalez, Eileen
Operational/Managerial Control · Individual
Clements, Mary
Operational/Managerial Control · Individual
Cornelia Nixon Davis, Inc.
Operational/Managerial Control · Organization
Long, Charles
Operational/Managerial Control · Individual
Long, Charles
Corporate Officer · Individual
Mcadams Welsh, Melissa
Operational/Managerial Control · Individual
Unidine Corporation
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Davis Health Care Center
Wilmington, NC
2-star overall rating with 2-star inspections with $96,849 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Northchase Nursing and Rehabilitation Center
Wilmington, NC
2-star overall rating with 2-star inspections with $7,901 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Liberty Commons Rehabilitation Center
Wilmington, NC
2-star overall rating with 2-star inspections with abuse icon flag with $20,988 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out