Cycle 1
Health 2025-01-30 · Fire 2025-01-30
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Reidsville, NC
Penn Nursing Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
618-A S Main Street, Reidsville, NC
(336) 951-6090
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-09-02
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
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.55
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
3.29
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,179
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.15
Composite VBP score used to determine payment impact.
Payment multiplier
1.0144
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.59
Baseline 19.07% · Performance 18.84% · Measure score 5.59 · Achievement 5.59 · Improvement 0.62
Healthcare-associated infections
5.02
Baseline 5.46% · Performance 6.33% · Measure score 5.02 · Achievement 5.02 · Improvement 0
Total nurse turnover
10
Baseline 16.98% · Performance 22.64% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
3.05
Baseline 4.81 hours · Performance 3.94 hours · Measure score 3.05 · Achievement 3.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 6.1% · Lower 95% interval 6.68% |
| Discharge to community | 63.61% |
50.57%
13 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 62.96% · Lower 95% interval 49.55% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 53 |
| Discharge self-care score | 58.7% |
53.69%
5 pts better
|
Numerator 27 · Denominator 46 |
| Discharge mobility score | 71.74% |
50.94%
20.8 pts better
|
Numerator 33 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 53 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 11.32% |
8.2%
3.1 pts better
|
Numerator 12 · Denominator 106 |
| Staff flu vaccination coverage | 99.07% |
42%
57.1 pts better
|
Numerator 107 · Denominator 108 |
| Discharge function score | 67.39% |
56.45%
10.9 pts better
|
Numerator 31 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 3.57% |
25.2%
21.6 pts worse
|
Numerator 1 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.5%
6.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 100.0% · Q4 93.2% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 6.9% · Q4 3.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.8%
0.1 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.4% · Q3 4.3% · Q4 4.3% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
7.2%
4 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.7% · Q3 16.1% · Q4 8.6% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
21.6%
5.2 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 17.9% · Q3 14.3% · Q4 15.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
15.0%
0.2 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 16.7% · Q3 13.7% · Q4 9.8% · 4Q avg 15.2% · 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 | 6.7% |
21.5%
14.8 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
16.8%
11.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.7% · Q3 3.8% · Q4 7.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 2.7% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
21.2%
5.2 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 12.9% · Q3 14.3% · Q4 14.1% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
6.0%
4.1 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.2% · Q4 3.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
79.9%
10.6 pts better
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 90.6% · Q3 90.5% · Q4 88.2% · 4Q avg 90.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
13.2%
4.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.7% · Expected 10.4% · 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 1.6% · Q2 2.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
78.1%
8.1 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
22.9%
6.8 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 13.5% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-01-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-01-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-31
E · Potential for more than minimal harm
2023-10-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-10-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-10-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-23
F · Potential for more than minimal harm
2022-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-08-18
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-08-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-30
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 2025-02-26
D · Potential for more than minimal harm
2022-08-18
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-09-07
D · Potential for more than minimal harm
2022-08-18
F690 · Quality of Life and Care Deficiencies
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 2022-09-07
Penalties and ownership
What sits behind the stars
Ownership
Risant Health, Inc.
5% Or Greater Indirect Ownership Interest · Organization
The Moses H. Cone Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Antrum, Vi-Anne
Corporate Director · Individual
Barrow, Andrew
Operational/Managerial Control · Individual
Barrow, Andrew
Corporate Officer · Individual
Boylston, Yun
Corporate Director · Individual
Brandon, Ashley
Corporate Director · Individual
Campbell, Lenora
Corporate Director · Individual
Carey, Elise
Corporate Director · Individual
Carter, Robert
Corporate Officer · Individual
Chu, Benjamin
Corporate Officer · Individual
Cone, Thomas
Corporate Director · Individual
Cooper, Raymond
Operational/Managerial Control · Individual
Cornue, Christopher
Corporate Director · Individual
Douglas, Mae
Corporate Director · Individual
Fortney, Catherine
Corporate Director · Individual
French, David
Corporate Director · Individual
Hayes, William
Corporate Director · Individual
Hopper, William
Operational/Managerial Control · Individual
Kitzmiller, David
Corporate Officer · Individual
Mcivor, William
Corporate Director · Individual
Miller, John
Corporate Officer · Individual
Nelms, Jason
Corporate Director · Individual
Samet, Arthur
Corporate Director · Individual
Sherry, Bernie
Corporate Officer · Individual
Stringer, Arthur
Corporate Director · Individual
Stuckey, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Cypress Valley Center for Nursing and Rehabilitati
Reidsville, NC
1-star overall rating with 2-star inspections with $32,911 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
UNC Rockingham Rehab & Nursing Care Center
Eden, NC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Eden Rehabilitation and Healthcare Center
Eden, NC
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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