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
Staffing
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
1.93
Nurse aide staffing
Weekend hours
2.70
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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