Cycle 1
Health 2025-07-24 · Fire 2024-05-28
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lillington, NC
Emerald Health & Rehab Center
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
54 Red Mulberry Way, Lillington, NC
(910) 814-8030
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1978-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 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
0.39
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.74
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
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.37
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
8,736
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.34% · Performance 21.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.28
Baseline 5.67% · Performance 6.26% · Measure score 5.28 · Achievement 5.28 · Improvement 0
Total nurse turnover
5.05
Baseline 52.38% · Performance 43.04% · Measure score 5.05 · Achievement 5.05 · Improvement 2.89
Adjusted total nurse staffing
0
Baseline 3.30 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 10.64% · Lower 95% interval 7.99% |
| Discharge to community | 61.49% |
50.57%
10.9 pts better
|
Better than the National Rate · Eligible stays 187 · Observed rate 55.61% · Lower 95% interval 53.39% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 74.02% |
95.27%
21.2 pts worse
|
Numerator 94 · Denominator 127 |
| Falls with major injury | 1.57% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 127 |
| Discharge self-care score | 36.84% |
53.69%
16.8 pts worse
|
Numerator 35 · Denominator 95 |
| Discharge mobility score | 29.47% |
50.94%
21.5 pts worse
|
Numerator 28 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 127 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 5.34% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0.81% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 124 |
| Staff flu vaccination coverage | 84.33% |
42%
42.3 pts better
|
Numerator 183 · Denominator 217 |
| Discharge function score | 28.42% |
56.45%
28 pts worse
|
Numerator 27 · Denominator 95 |
| Transfer of health information to provider | 84.21% |
95.95%
11.7 pts worse
|
Numerator 32 · Denominator 38 |
| Transfer of health information to patient | 86.57% |
96.28%
9.7 pts worse
|
Numerator 58 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 7.02% |
25.2%
18.2 pts worse
|
Numerator 4 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
91.5%
4.3 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 97.2% · Q3 98.6% · Q4 100.0% · 4Q avg 95.8% |
| 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 | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.8% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.8%
3.7 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 1.4% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
7.2%
1.3 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.5% · Q3 10.0% · Q4 12.1% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
21.6%
4.6 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.1% · Q3 20.0% · Q4 15.2% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
15.0%
0.5 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 15.8% · Q3 17.9% · Q4 13.6% · 4Q avg 14.5% · 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 | 6.1% |
21.5%
15.4 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
16.8%
11.3 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 8.6% · Q3 5.4% · Q4 4.6% · 4Q avg 5.5% · 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 | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
21.2%
1.1 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 28.9% · Q3 22.9% · Q4 21.7% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
6.0%
4.2 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.8% · Q3 2.7% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.2% |
79.9%
20.7 pts worse
|
81.7%
22.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 57.7% · Q3 74.4% · Q4 82.3% · 4Q avg 59.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
13.2%
4.8 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 8.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.7% · Q3 1.7% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.2% |
78.1%
14.9 pts worse
|
79.7%
16.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
22.9%
4.2 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 27.0% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-28 · Fire 2023-01-06
11 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2021-11-18
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2024-05-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-05-28
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-05-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-05-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-05-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-23
D · Potential for more than minimal harm
2023-01-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-06
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 2023-03-10
D · Potential for more than minimal harm
2023-01-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-06
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-30
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 2025-10-17
D · Potential for more than minimal harm
2025-09-30
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 2025-09-09
F · Potential for more than minimal harm
2025-07-24
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 2025-08-18
F · Potential for more than minimal harm
2025-07-24
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 2025-08-18
D · Potential for more than minimal harm
2025-07-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-18
E · Potential for more than minimal harm
2024-05-28
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 2024-06-14
E · Potential for more than minimal harm
2024-05-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-28
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 2024-06-14
E · Potential for more than minimal harm
2024-05-28
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-28
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 2024-06-14
D · Potential for more than minimal harm
2024-05-28
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 2024-06-14
D · Potential for more than minimal harm
2024-05-28
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 2024-06-14
D · Potential for more than minimal harm
2024-05-28
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 2024-06-14
D · Potential for more than minimal harm
2024-05-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-14
C · Minimal harm
2024-05-28
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-06-14
D · Potential for more than minimal harm
2023-01-06
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 2023-01-27
D · Potential for more than minimal harm
2023-01-06
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 2023-01-20
Penalties and ownership
What sits behind the stars
Ownership
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Jackson, Christina
W-2 Managing Employee · Individual
Joiner, Brian
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Shh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Wwbv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lillington Health and Rehabilitation Center
Lillington, NC
1-star overall rating with 1-star inspections with abuse icon flag with $30,538 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Harnett Woods Nursing and Rehabilitation Center
Dunn, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Carrolton of Dunn
Dunn, NC
1-star overall rating with 1-star inspections with $61,389 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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