Cycle 1
Health 2025-08-21 · Fire 2024-05-17
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Raleigh, NC
Rex Rehab & Nursing Care Center
4-star overall rating with 4-star inspections with $15,646 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4210 Lake Boone Trail, Raleigh, NC
(919) 784-6600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
98
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-05-21
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.37
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,821
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0085
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.49
Baseline 16.21% · Performance 20.74% · Measure score 1.49 · Achievement 1.49 · Improvement 0
Healthcare-associated infections
10
Baseline 4.07% · Performance 4.67% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.64
Baseline 2.20 hours · Performance 4.04 hours · Measure score 4.64 · Achievement 3.40 · Improvement 4.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.54% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 557 · Observed rate 6.82% · Lower 95% interval 7.44% |
| Discharge to community | 68.03% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 551 · Observed rate 71.32% · Lower 95% interval 64.84% |
| 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 322 · Denominator 322 |
| Falls with major injury | 0.31% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 322 |
| Discharge self-care score | 39.69% |
53.69%
14 pts worse
|
Numerator 104 · Denominator 262 |
| Discharge mobility score | 37.4% |
50.94%
13.5 pts worse
|
Numerator 98 · Denominator 262 |
| Pressure ulcers or injuries, new or worsened | 1.55% |
2.29%
0.7 pts better
|
Numerator 5 · Denominator 322 · Adjusted rate 1.62% |
| Healthcare-associated infections requiring hospitalization | 4.66% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 1.94% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 1.24% |
8.2%
7 pts worse
|
Numerator 3 · Denominator 242 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 144 · Denominator 144 |
| Discharge function score | 41.6% |
56.45%
14.9 pts worse
|
Numerator 109 · Denominator 262 |
| Transfer of health information to provider | 99.13% |
95.95%
3.2 pts better
|
Numerator 229 · Denominator 231 |
| Transfer of health information to patient | 89.29% |
96.28%
7 pts worse
|
Numerator 50 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 35.86% |
25.2%
10.7 pts better
|
Numerator 52 · Denominator 145 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.4 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.8
1.4 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
94.1%
1.1 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.6%
0.5 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.0% · Q3 3.3% · Q4 5.1% · 4Q avg 4.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
7.2%
2.8 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.5% · Q3 12.5% · Q4 5.9% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
21.6%
10.4 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 11.3% · Q3 10.7% · Q4 5.8% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
15.0%
1.4 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.9% · Q3 13.7% · Q4 8.5% · 4Q avg 16.4% · 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 | 12.0% |
21.5%
9.5 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 12.8% · Q3 3.7% · Q4 14.8% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
16.8%
6.5 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 16.3% · Q3 4.0% · Q4 13.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.5% · Q4 4.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
2.6%
2 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 6.8% · Q3 4.9% · Q4 5.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.7% |
21.2%
13.5 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.3% · Q3 3.5% · Q4 15.0% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 11.8% |
6.0%
5.8 pts worse
|
5.1%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 12.5% · Q3 11.5% · Q4 10.5% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
79.9%
18.5 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.4% · Q3 97.9% · Q4 98.3% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
13.2%
2.3 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 9.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.4% · Q3 0.0% · Q4 0.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
78.1%
21.4 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
22.9%
2.5 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 18.8% · Expected 17.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2023-03-23
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2022-01-13
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-22
D · Potential for more than minimal harm
2023-03-23
K321 · Smoke Deficiencies
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 2023-05-05
D · Potential for more than minimal harm
2023-03-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-09-05
J · Immediate jeopardy
2024-05-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-16
E · Potential for more than minimal harm
2024-05-17
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-17
F761 · Pharmacy Service Deficiencies
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 2024-05-30
D · Potential for more than minimal harm
2024-05-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-30
E · Potential for more than minimal harm
2023-03-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F761 · Pharmacy Service Deficiencies
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 2023-04-14
Penalties and ownership
What sits behind the stars
$15,646
2024-05-17
Fine
Fine · fine $15,646
Fine
Ownership
The New Trustees Of The Rex Hospital Inc
5% Or Greater Direct Ownership Interest · Organization
University Of North Carolina Health Care System
5% Or Greater Indirect Ownership Interest · Organization
Anderson, Kevin
Corporate Director · Individual
Arrowood, Catharine
Corporate Director · Individual
Bryant, William
Corporate Director · Individual
Caroll, Ellen
Operational/Managerial Control · Individual
Collins, Ann
Corporate Director · Individual
Ewend, Matthew
Corporate Director · Individual
Fiscus, Lynne
Corporate Director · Individual
Fitzpatrick, Melissa
Corporate Director · Individual
Hobbs, Nedra
Operational/Managerial Control · Individual
James, Michael
Operational/Managerial Control · Individual
Kolacz, Nicole
Corporate Officer · Individual
Liebowitz, Steven
Operational/Managerial Control · Individual
Lindsay, Jeffrey
Corporate Director · Individual
Mathew, Benjamin
Corporate Officer · Individual
Matthews, Dayatra
Corporate Director · Individual
Mcneill, Caryn
Corporate Director · Individual
Mills, David
Corporate Director · Individual
Oakes, Robert
Corporate Director · Individual
Page, Cristen
Corporate Director · Individual
Pearson, Marilyn
Corporate Director · Individual
Sandner, Jason
Corporate Director · Individual
Scarborough, Tammy
Corporate Director · Individual
Setliff, Michael
Corporate Director · Individual
Setliff, Michael
Corporate Officer · Individual
Tempke, Roy
Corporate Officer · Individual
Udayakumar, Meera
Corporate Officer · Individual
York, Haylian
Operational/Managerial Control · Individual
Zinner, Tanya
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hillcrest Raleigh at Crabtree Valley
Raleigh, NC
3-star overall rating with 4-star inspections with $17,202 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Raleigh Rehabilitation Center
Raleigh, NC
2-star overall rating with 3-star inspections with $77,760 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Cardinal at North Hills
Raleigh, NC
4-star overall rating with 4-star inspections with $7,901 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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