Cycle 1
Health 2025-06-16 · Fire 2024-03-28
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Kenansville, NC
Kenansville Rehabilitation and Healthcare Center
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
209 Beasley Street, Kenansville, NC
(910) 296-1561
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
1979-11-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.31
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.22
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
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.93% · Performance 22.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.91% · Performance 8.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.73% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.09 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 12.68% · Lower 95% interval 7.95% |
| Discharge to community | 41.85% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 33.85% · Lower 95% interval 29.07% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.7% |
95.27%
1.4 pts better
|
Numerator 88 · Denominator 91 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 91 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 36 · Denominator 64 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 36 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 2.2% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 91 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 8.61% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 5.46% |
| Staff COVID-19 vaccination coverage | 36% |
8.2%
27.8 pts better
|
Numerator 36 · Denominator 100 |
| Staff flu vaccination coverage | 8.33% |
42%
33.7 pts worse
|
Numerator 11 · Denominator 132 |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 34 · Denominator 64 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 6.9% |
25.2%
18.3 pts worse
|
Numerator 4 · Denominator 58 |
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 3.0 · Expected 2.6 · 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 3.3 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.5%
7.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 100.0% · Q4 98.5% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.1%
3 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.7% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
4.8%
5.3 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 13.5% · Q3 5.5% · Q4 4.8% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
7.2%
1 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.0% · Q3 10.3% · Q4 10.6% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
21.6%
9.7 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 10.3% · Q3 12.1% · Q4 12.1% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.4% |
15.0%
9.4 pts worse
|
16.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 18.2% · Q3 23.4% · Q4 26.9% · 4Q avg 24.4% · 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 | 21.2% |
21.5%
0.3 pts better
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.8%
8.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 6.4% · Q3 6.1% · Q4 8.3% · 4Q avg 8.7% · 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 | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.2% |
21.2%
4 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 28.4% · Q3 8.1% · Q4 10.0% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.0%
1.5 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.7% · Q3 5.1% · Q4 8.3% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
79.9%
6.1 pts better
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 88.8% · Q3 86.0% · Q4 80.6% · 4Q avg 86.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
13.2%
6.1 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 21.4% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.4% · Q3 2.7% · Q4 4.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.6% |
78.1%
3.5 pts worse
|
79.7%
5.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
22.9%
2.3 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 29.8% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2022-11-14
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-14 · Fire 2021-03-19
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-03-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-03-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-03-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-04
F · Potential for more than minimal harm
2022-11-14
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-11-14
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-18
F · Potential for more than minimal harm
2021-03-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-05-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-02
C · Minimal harm
2025-06-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-02
B · Minimal harm
2024-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-19
D · Potential for more than minimal harm
2023-11-02
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-11-22
B · Minimal harm
2023-11-02
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 2023-11-22
J · Immediate jeopardy
2022-11-14
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 2022-12-12
F · Potential for more than minimal harm
2022-11-14
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 2022-12-12
F · Potential for more than minimal harm
2022-11-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-12
E · Potential for more than minimal harm
2022-11-14
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 2022-12-12
E · Potential for more than minimal harm
2022-11-14
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 2022-12-12
D · Potential for more than minimal harm
2022-11-14
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 2022-12-12
Penalties and ownership
What sits behind the stars
Ownership
Kenansville Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Alter, Tzvi
Corporate Director · Individual
Hulett, Jennifer
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Warsaw Rehabilitation and Healthcare Center
Warsaw, NC
1-star overall rating with 2-star inspections with abuse icon flag with $43,924 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Wallace Rehabilitation and Healthcare Center
Wallace, NC
4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Mount Olive Center
Mount Olive, NC
1-star overall rating with 1-star inspections with $172,957 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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