Cary, NC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4000 Glenaire Circle, Cary, NC
(919) 460-8095
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
71
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-09-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.70
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.90
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
6.02
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.16
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
7.08
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
345
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.47
Composite VBP score used to determine payment impact.
Payment multiplier
1.0235
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.96
Baseline 19.20% · Performance 19.13% · Measure score 4.96 · Achievement 4.96 · Improvement 0
Healthcare-associated infections
6.77
Baseline 6.65% · Performance 5.81% · Measure score 6.77 · Achievement 6.77 · Improvement 4.56
Total nurse turnover
7.27
Baseline 42.34% · Performance 33.98% · Measure score 7.27 · Achievement 7.27 · Improvement 4.28
Adjusted total nurse staffing
10
Baseline 7.04 hours · Performance 6.79 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
| 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 116 · Observed rate 4.31% · Lower 95% interval 6.52% |
| Discharge to community | 60.37% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 109 · Observed rate 64.22% · Lower 95% interval 53.11% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.83% |
95.27%
1.6 pts better
|
Numerator 61 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 86% |
53.69%
32.3 pts better
|
Numerator 43 · Denominator 50 |
| Discharge mobility score | 72% |
50.94%
21.1 pts better
|
Numerator 36 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 2.64% |
| Healthcare-associated infections requiring hospitalization | 5.81% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 1.33% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 314 |
| Staff flu vaccination coverage | 20.23% |
42%
21.8 pts worse
|
Numerator 70 · Denominator 346 |
| Discharge function score | 82% |
56.45%
25.5 pts better
|
Numerator 41 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 62.5% |
25.2%
37.3 pts better
|
Numerator 15 · Denominator 24 |
Quality measures
| 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 1.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.8
1.2 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
91.5%
6.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.4% · Q3 98.3% · Q4 98.2% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.1%
4.3 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.6%
2.8 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.6% · Q3 5.1% · Q4 7.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 6.1% |
7.2%
1.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.8% · Q3 6.2% · Q4 4.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
21.6%
7.1 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 13.2% · Q3 16.7% · Q4 15.2% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
15.0%
6.5 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 20.0% · Q3 22.0% · Q4 19.5% · 4Q avg 21.5% · 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 | 13.5% |
21.5%
8 pts better
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 17.0% · Q3 6.3% · Q4 10.2% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
16.8%
1.1 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 18.4% · Q3 17.8% · Q4 19.0% · 4Q avg 15.7% · 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 | 0.0% |
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 | 32.6% |
21.2%
11.4 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 41.6% · Q3 31.7% · Q4 22.6% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
6.0%
1.1 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.4% · Q3 6.4% · Q4 6.2% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
79.9%
15.3 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 97.8% · Q3 96.5% · Q4 94.7% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
13.2%
2.3 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 9.1% · Expected 9.3% · 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 | 91.3% |
78.1%
13.2 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
22.9%
3.2 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 18.2% · Expected 16.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-09
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-31
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-31
Fire Safety
Meet other general requirements.
Corrected 2022-07-23
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-23
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-23
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-23
Inspection history
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 2026-01-22
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2026-01-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-01-22
Penalties and ownership
Contracted Managing Employee · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
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