20 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Pembroke, NC
1-star overall rating with 1-star inspections with abuse icon flag with $79,765 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
310 E Wardell Drive, Pembroke, NC
(910) 521-1273
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
84
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1992-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 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
RN hours / resident day
0.44
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.72
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
94%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
12,335
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.91% · Performance 23.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.13
Baseline 8.56% · Performance 6.55% · Measure score 5.13 · Achievement 4.29 · Improvement 5.13
Total nurse turnover
0
Baseline 62.32% · Performance 67.86% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.90 hours · Performance 2.92 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.05% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 6.53% |
| Discharge to community | 42.35% |
50.57%
8.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 27.78% · Lower 95% interval 29.02% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 90.63% |
95.27%
4.6 pts worse
|
Numerator 29 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 9 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 2 · Denominator 31 · Adjusted rate 4.35% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 1.18% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 85 |
| Staff flu vaccination coverage | 43.38% |
42%
1.4 pts better
|
Numerator 59 · Denominator 136 |
| Discharge function score | 38.1% |
56.45%
18.4 pts worse
|
Numerator 8 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.8
2.2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
91.5%
13.6 pts worse
|
93.4%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.8% · Q2 80.0% · Q3 75.0% · Q4 72.7% · 4Q avg 77.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.8% |
94.1%
6.3 pts worse
|
95.5%
7.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.5% · Q4 3.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.6% |
4.8%
10.8 pts worse
|
11.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 23.3% · Q3 17.2% · Q4 16.9% · 4Q avg 15.6% |
| Percentage of long-stay residents who lose too much weight | 14.2% |
7.2%
7 pts worse
|
5.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.0% · Q3 15.3% · Q4 15.3% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
21.6%
5.6 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.0% · Q3 12.9% · Q4 25.8% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
15.0%
6.8 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.7% · Q3 11.3% · Q4 9.6% · 4Q avg 8.2% · 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 | 31.9% |
21.5%
10.4 pts worse
|
16.3%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
16.8%
0.6 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 24.5% · Q3 15.4% · Q4 9.4% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.6%
0.9 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.8% · Q3 4.6% · Q4 3.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
21.2%
12.9 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.0% · Q2 29.9% · Q3 28.4% · Q4 24.2% · 4Q avg 34.1% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.0%
0.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.3% · Q3 5.6% · Q4 8.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.6% |
79.9%
58.3 pts worse
|
81.7%
60.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 23.9% · Q3 19.2% · Q4 14.1% · 4Q avg 21.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 22.2% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.8% |
78.1%
36.3 pts worse
|
79.7%
37.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
22.9%
6.6 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 16.7% · Expected 24.4% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-01-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-02
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-16
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-20
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-20
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-20
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-20
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-01-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-20
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2026-01-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-10
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-20
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-20
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-28
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-06-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-18
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-18
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-18
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 2024-12-18
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-18
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-12-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-14
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-14
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-14
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-14
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-17
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-17
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-29
Penalties and ownership
Fine · fine $10,868
Fine
Fine · fine $16,136
Fine
Fine · fine $7,634
Fine
Fine · fine $7,634
Fine
Fine · fine $37,493
Fine
Payment Denial · denial start 2023-06-20 · 58 days
58 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Lumberton, NC
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Lumberton, NC
1-star overall rating with 1-star inspections with $128,210 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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