Cycle 1
Health 2025-05-08 · Fire 2024-04-18
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Louisburg, NC
Franklin Oaks Nursing and Rehabilitation Center
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1704 NC Highway 39 N, Louisburg, NC
(919) 496-7222
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
166
Certified beds
Average residents
138
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1990-11-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 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
0.46
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.24
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
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
15%
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
6,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.20
Baseline 19.28% · Performance 19.02% · Measure score 5.20 · Achievement 5.20 · Improvement 0.63
Healthcare-associated infections
0.74
Baseline 7.65% · Performance 7.61% · Measure score 0.74 · Achievement 0.74 · Improvement 0
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
3.41
Baseline 4.18 hours · Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 6.35% · Lower 95% interval 6.33% |
| Discharge to community | 51.61% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 45.37% · Lower 95% interval 42.45% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.29% |
95.27%
1 pts worse
|
Numerator 66 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 35.85% |
53.69%
17.8 pts worse
|
Numerator 19 · Denominator 53 |
| Discharge mobility score | 39.62% |
50.94%
11.3 pts worse
|
Numerator 21 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 70 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 8.64% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 137 |
| Staff flu vaccination coverage | 33.51% |
42%
8.5 pts worse
|
Numerator 64 · Denominator 191 |
| Discharge function score | 41.51% |
56.45%
14.9 pts worse
|
Numerator 22 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 74.19% |
25.2%
49 pts better
|
Numerator 23 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.0% · Q3 5.8% · Q4 4.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.8%
1.6 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.8% · Q3 1.9% · Q4 4.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
7.2%
2.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 8.6% · Q3 14.0% · Q4 7.9% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
21.6%
6 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 27.6% · Q3 26.1% · Q4 23.7% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
15.0%
3.1 pts worse
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 18.2% · Q3 16.7% · Q4 17.2% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.0%
0.8 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
21.5%
13.6 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 11.7% · Q3 10.8% · Q4 5.7% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
16.8%
5 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.5% · Q3 12.5% · Q4 8.1% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.7% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
21.2%
16.2 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.2% · Q3 4.2% · Q4 5.9% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
6.0%
2.3 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.6% · Q3 5.4% · Q4 2.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
79.9%
16 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 96.8% · Q3 96.0% · Q4 93.5% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
13.2%
1.7 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
78.1%
18.8 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
22.9%
7.9 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.6% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2023-01-12
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-01-12 · Fire 2022-02-04
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-04-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-18
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-12
F · Potential for more than minimal harm
2023-01-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-02
F · Potential for more than minimal harm
2022-02-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-04-14
E · Potential for more than minimal harm
2022-02-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-02-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-05
E · Potential for more than minimal harm
2024-04-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-04-18
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-04-18
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 2024-05-14
E · Potential for more than minimal harm
2024-04-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
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 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-14
G · Actual harm
2023-01-12
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 2023-02-14
E · Potential for more than minimal harm
2023-01-12
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 2023-02-14
E · Potential for more than minimal harm
2023-01-12
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
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 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-14
Penalties and ownership
What sits behind the stars
Ownership
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Hill, Robert
5% Or Greater Indirect Ownership Interest · Individual
Hill, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Hill, Raymond
5% Or Greater Indirect Ownership Interest · Individual
Boice, Gale
Corporate Officer · Individual
Bullock, Lynn
Operational/Managerial Control · Individual
Hill, Raymond
Operational/Managerial Control · Individual
Hill, Robert
Operational/Managerial Control · Individual
Hill, Stephen
Operational/Managerial Control · Individual
Johnson, Dianne
Corporate Officer · Individual
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Louisburg Healthcare & Rehabilitation Center
Louisburg, NC
1-star overall rating with 2-star inspections with $153,104 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Hillside Nursing Center of Wake Forest
Wake Forest, NC
5-star overall rating with 5-star inspections
#3
Kerr Lake Nursing and Rehabilitation Center
Henderson, NC
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
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