Jefferson, NC
2-star overall rating with 2-star inspections with $28,973 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
540 Waugh Street, Jefferson, NC
(336) 246-5581
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
Beds
210
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-03-02
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
0.51
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
1.93
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
2,469
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0036
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.66
Baseline 18.10% · Performance 17.88% · Measure score 7.66 · Achievement 7.66 · Improvement 1.56
Healthcare-associated infections
10
Baseline 6.64% · Performance 4.50% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
0
Baseline 40.98% · Performance 96.69% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.18
Baseline 3.55 hours · Performance 3.70 hours · Measure score 2.18 · Achievement 2.18 · Improvement 0.18
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 260 · Observed rate 6.92% · Lower 95% interval 7.08% |
| Discharge to community | 60.15% |
50.57%
9.6 pts better
|
Better than the National Rate · Eligible stays 250 · Observed rate 61.6% · Lower 95% interval 55.08% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.74% |
95.27%
3.5 pts better
|
Numerator 157 · Denominator 159 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 159 |
| Discharge self-care score | 64.49% |
53.69%
10.8 pts better
|
Numerator 89 · Denominator 138 |
| Discharge mobility score | 63.77% |
50.94%
12.8 pts better
|
Numerator 88 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 159 · Adjusted rate 2.03% |
| Healthcare-associated infections requiring hospitalization | 4.5% |
7.12%
2.6 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 0% · Lower 95% interval 2.48% |
| Staff COVID-19 vaccination coverage | 1.41% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 142 |
| Staff flu vaccination coverage | 71.43% |
42%
29.4 pts better
|
Numerator 95 · Denominator 133 |
| Discharge function score | 63.77% |
56.45%
7.3 pts better
|
Numerator 88 · Denominator 138 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 112 · Denominator 112 |
| Resident COVID-19 vaccinations up to date | 13.68% |
25.2%
11.5 pts worse
|
Numerator 13 · Denominator 95 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.7 |
1.8
2.9 pts worse
|
1.8
2.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 3.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
91.5%
2.6 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 93.3% · Q3 95.7% · Q4 92.8% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.6% |
94.1%
16.5 pts worse
|
95.5%
17.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.6%
2.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.8% · Q3 6.4% · Q4 4.1% · 4Q avg 5.7% · 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 | 6.4% |
7.2%
0.8 pts better
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 2.2% · Q3 4.9% · Q4 6.0% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
21.6%
7.4 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 30.1% · Q3 28.9% · Q4 26.2% · 4Q avg 29.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
15.0%
7.1 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 23.2% · Q3 20.3% · Q4 16.4% · 4Q avg 22.1% · 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 | 31.0% |
21.5%
9.5 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 41.2% · Q3 18.1% · Q4 17.9% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
16.8%
3.3 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 20.7% · Q3 17.9% · Q4 12.7% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.0% · Q4 1.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.9% · Q3 1.1% · Q4 6.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
21.2%
12 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 29.1% · Q3 30.9% · Q4 36.6% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
6.0%
2.7 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.7% · Q3 1.0% · Q4 3.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
79.9%
14.3 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 95.3% · Q3 96.1% · Q4 89.9% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
13.2%
3.1 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 8.3% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 1.7% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.8% |
78.1%
12.7 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
22.9%
9 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 11.0% · Expected 18.9% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-11
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-11
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-25
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 2024-12-31
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-31
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-12-31
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-12-31
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-31
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-03
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-26
Health
Post nurse staffing information every day.
Corrected 2023-07-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-07
Penalties and ownership
Fine · fine $4,271
Fine
Fine · fine $8,400
Fine
Fine · fine $8,401
Fine
Payment Denial · denial start 2024-12-21 · 13 days
13 day denial
Fine · fine $7,901
Fine
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