Cycle 1
Health 2025-06-19 · Fire 2024-04-05
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Elizabeth City, NC
Elizabeth City Health and Rehabilitation
2-star overall rating with 2-star inspections with $77,760 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1075 US Highway 17 South, Elizabeth City, NC
(252) 338-3975
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1967-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 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
0.29
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.33
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9990
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.44
Baseline 18.87% · Performance 17.98% · Measure score 7.44 · Achievement 7.44 · Improvement 4.32
Healthcare-associated infections
0.80
Baseline 7.36% · Performance 7.59% · Measure score 0.80 · Achievement 0.80 · Improvement 0
Total nurse turnover
9.04
Baseline 39.50% · Performance 26.71% · Measure score 9.04 · Achievement 9.04 · Improvement 8.23
Adjusted total nurse staffing
0.99
Baseline 3.10 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 599 · Observed rate 10.68% · Lower 95% interval 8.54% |
| Discharge to community | 62.44% |
50.57%
11.9 pts better
|
Better than the National Rate · Eligible stays 629 · Observed rate 56.12% · Lower 95% interval 57.36% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.85% |
95.27%
2.6 pts better
|
Numerator 318 · Denominator 325 |
| Falls with major injury | 2.46% |
0.77%
1.7 pts worse
|
Numerator 8 · Denominator 325 |
| Discharge self-care score | 53.48% |
53.69%
0.2 pts worse
|
Numerator 123 · Denominator 230 |
| Discharge mobility score | 51.3% |
50.94%
0.4 pts better
|
Numerator 118 · Denominator 230 |
| Pressure ulcers or injuries, new or worsened | 0.31% |
2.29%
2 pts better
|
Numerator 1 · Denominator 325 · Adjusted rate 0.36% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 384 · Observed rate 7.29% · Lower 95% interval 5.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 236 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 138 · Denominator 230 |
| Transfer of health information to provider | 98.7% |
95.95%
2.8 pts better
|
Numerator 76 · Denominator 77 |
| Transfer of health information to patient | 99.06% |
96.28%
2.8 pts better
|
Numerator 211 · Denominator 213 |
| Resident COVID-19 vaccinations up to date | 19.21% |
25.2%
6 pts worse
|
Numerator 34 · Denominator 177 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.5%
8.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 2.1% · Q4 4.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.1% |
4.8%
4.3 pts worse
|
11.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 4.5% · Q3 5.9% · Q4 8.3% · 4Q avg 9.1% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
7.2%
0.4 pts better
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.1% · Q3 3.6% · Q4 3.4% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
21.6%
1.2 pts better
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 18.5% · Q3 21.7% · Q4 21.3% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
15.0%
8.1 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.7% · Q3 8.6% · Q4 6.6% · 4Q avg 6.9% · 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 | 15.8% |
21.5%
5.7 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.4% · Q3 23.3% · Q4 17.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
16.8%
0.9 pts better
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 16.5% · Q3 13.2% · Q4 17.5% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.2% · Q4 1.0% · 4Q avg 1.2% · 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 | 18.0% |
21.2%
3.2 pts better
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 17.3% · Q3 11.9% · Q4 21.9% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 14.9% |
6.0%
8.9 pts worse
|
5.1%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 13.3% · Q3 13.4% · Q4 15.9% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
79.9%
13.6 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 95.0% · Q3 94.1% · Q4 91.1% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
13.2%
5.1 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 15.5% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
78.1%
17.8 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
22.9%
About the same
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 19.7% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2023-01-27
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-27 · Fire 2021-11-18
18 health deficiencies
Top issue: Quality of Life and Care (5 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
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-04-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-10
Inspection history
Recent health citations
B · Minimal harm
2025-06-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
E · Potential for more than minimal harm
2024-04-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-06
B · Minimal harm
2024-04-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-13
B · Minimal harm
2024-04-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-13
J · Immediate jeopardy
2023-11-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-30
J · Immediate jeopardy
2023-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-30
J · Immediate jeopardy
2023-11-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-22
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 2023-11-30
D · Potential for more than minimal harm
2023-11-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-30
G · Actual harm
2023-10-28
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 2023-11-06
D · Potential for more than minimal harm
2023-10-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-06
G · Actual harm
2023-01-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-09
E · Potential for more than minimal harm
2023-01-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-27
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 2023-03-01
E · Potential for more than minimal harm
2023-01-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-27
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 2023-03-01
D · Potential for more than minimal harm
2023-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-01
C · Minimal harm
2023-01-27
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-02-23
C · Minimal harm
2023-01-27
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-02-13
C · Minimal harm
2023-01-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
$77,760
2023-10-28
Fine
Fine · fine $77,760
Fine
$0
2023-10-28
Payment Denial
Payment Denial · denial start 2023-11-16 · 14 days
14 day denial
Ownership
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Elizabeth City Healthcare Properties, LLC
5% Or Greater Mortgage Interest · Organization
Waring, Tina
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Laurel Park Rehabilitation and Healthcare Center
Elizabeth City, NC
1-star overall rating with 2-star inspections with $16,720 in total fines with 12 recent health deficiencies
#2
Hertford Rehabilitation and Healthcare Center
Hertford, NC
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Currituck Health & Rehab Center
Barco, NC
1-star overall rating with 1-star inspections with abuse icon flag with $130,293 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out