6 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Jackson, NC
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
HWY 305 North, Jackson, NC
(252) 534-0131
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1990-02-27
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
RN hours / resident day
0.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
7,786
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.50
Baseline 20.92% · Performance 18.88% · Measure score 5.50 · Achievement 5.50 · Improvement 4.73
Healthcare-associated infections
4.68
Baseline 10.37% · Performance 7.59% · Measure score 4.68 · Achievement 0.83 · Improvement 4.68
Total nurse turnover
1.33
Baseline 62.07% · Performance 58.23% · Measure score 1.33 · Achievement 1.33 · Improvement 0.53
Adjusted total nurse staffing
0
Baseline 3.20 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 7.22% |
| Discharge to community | 48.49% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 40% · Lower 95% interval 31.47% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 50 |
| Staff flu vaccination coverage | 21.78% |
42%
20.2 pts worse
|
Numerator 22 · Denominator 101 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
91.5%
7.6 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.9% · Q2 86.1% · Q3 84.7% · Q4 79.7% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
94.1%
0.6 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 2.8% · Q4 4.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.8%
4.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
7.2%
7.2 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 23.4% |
21.6%
1.8 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 21.7% · Q3 23.5% · Q4 24.6% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
15.0%
7.9 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.4% · Q3 8.8% · Q4 8.0% · 4Q avg 7.1% · 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 | 7.2% |
21.5%
14.3 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
16.8%
12.2 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 8.1% · Q3 3.3% · Q4 5.1% · 4Q avg 4.6% · 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 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.8% · Q4 2.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
21.2%
12.4 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 13.5% · Q3 9.5% · Q4 6.3% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
6.0%
5.4 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 16.4% · Q3 10.0% · Q4 7.1% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.4% |
79.9%
60.5 pts worse
|
81.7%
62.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 30.0% · Q3 13.2% · Q4 10.0% · 4Q avg 19.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
13.2%
8.4 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 5.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.5%
2.2 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 4.3% · Q4 3.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.0% |
78.1%
49.1 pts worse
|
79.7%
50.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
22.9%
4.1 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 31.6% · Expected 27.9% · Used in QM five-star |
Survey summary
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-03-11
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-18
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-02
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-18
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-02-18
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 2025-02-18
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-18
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-02-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-18
Health
Dispose of garbage and refuse properly.
Corrected 2022-10-31
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-10-31
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-31
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
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