9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Rockingham, NC
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
804 South Long Drive, Rockingham, NC
(910) 997-4493
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pruitthealth
Operator or chain grouping
Approved since
1991-06-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
95 facilities
Chain averages 3 overall / 3 health / 2 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
0.61
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.35
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
8,968
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.51
Performance 21.19% · Measure score 0.51 · Achievement 0.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.13
Baseline 77.19% · Performance 42.47% · Measure score 6.13 · Achievement 5.19 · Improvement 6.13
Adjusted total nurse staffing
0.89
Baseline 2.85 hours · Performance 3.26 hours · Measure score 0.89 · Achievement 0.65 · Improvement 0.89
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.53% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 23.81% · Lower 95% interval 9.07% |
| Discharge to community | 39.91% |
50.57%
10.7 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 28.89% · Lower 95% interval 27.49% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 31 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| 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 | 12.5% |
2.29%
10.2 pts worse
|
Numerator 4 · Denominator 32 · Adjusted rate 11.76% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.08% |
8.2%
4.1 pts worse
|
Numerator 4 · Denominator 98 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| 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 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.5%
8.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 2.6% |
3.6%
1 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 2.9% · Q4 3.0% · 4Q avg 2.6% · 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 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
7.2%
About the same
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 10.0% · Q3 6.1% · Q4 4.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
21.6%
2.4 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 21.3% · Q3 25.8% · Q4 26.2% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
15.0%
3.2 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 14.0% · Q3 18.4% · Q4 18.9% · 4Q avg 18.2% · 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 | 11.8% |
21.5%
9.7 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
16.8%
5.3 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 14.0% · Q3 1.7% · Q4 3.3% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 2.2% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 0.0% · Q4 4.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
21.2%
4.4 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 8.9% · Q3 9.8% · Q4 21.0% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
6.0%
2.1 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.7% · Q3 8.5% · Q4 6.6% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
79.9%
15.6 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 93.0% · Q3 95.7% · Q4 97.7% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.6% |
13.2%
9.4 pts worse
|
12.0%
10.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 25.7% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
78.1%
17.2 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
22.9%
1.9 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 22.9% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Resident Assessment and Care Planning (7 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
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 2025-05-14
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-14
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-14
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-14
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-12-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-17
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-12-02
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-02
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-02
Inspection history
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 2025-03-13
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-12
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-12
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 2025-03-12
Health
Post nurse staffing information every day.
Corrected 2025-03-12
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-14
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-14
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-12-14
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-12-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-14
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 2023-12-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-14
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-14
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 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
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-15
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-20
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 2022-09-20
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-20
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 2022-09-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-20
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 2022-09-20
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-20
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-20
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 2022-09-20
Health
Post nurse staffing information every day.
Corrected 2022-09-20
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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