Cycle 1
Health 2024-12-05 · Fire 2024-12-05
6 health deficiencies
Top issue: Administration (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Henderson, NC
Senior Citizens Home
2-star overall rating with 2-star inspections with $55,760 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2275 Ruin Creek Road, Henderson, NC
(252) 492-0066
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
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Maximus Healthcare Group
Operator or chain grouping
Approved since
1990-05-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 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
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
89%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,081
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0153
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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
5.62
Baseline 89.66% · Performance 50.00% · Measure score 5.62 · Achievement 3.35 · Improvement 5.62
Adjusted total nurse staffing
6.40
Baseline 1.56 hours · Performance 4.48 hours · Measure score 6.40 · Achievement 4.91 · Improvement 6.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 5.83% |
| Discharge to community | 45.02% |
50.57%
5.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 33.33% · Lower 95% interval 30.51% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 22 · Denominator 24 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 1 · Denominator 24 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 5 · Denominator 20 |
| Discharge mobility score | 15% |
50.94%
35.9 pts worse
|
Numerator 3 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 2 · Denominator 24 · Adjusted rate 5.55% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.08% |
8.2%
5.1 pts worse
|
Numerator 2 · Denominator 65 |
| Staff flu vaccination coverage | 20% |
42%
22 pts worse
|
Numerator 13 · Denominator 65 |
| Discharge function score | 35% |
56.45%
21.5 pts worse
|
Numerator 7 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · 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 | 15% |
25.2%
10.2 pts worse
|
Numerator 3 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.5%
5.1 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 95.3% · Q3 95.7% · Q4 97.8% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.1%
3.6 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 | 5.5% |
7.2%
1.7 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.9% · Q3 9.1% · Q4 0.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
21.6%
1.5 pts better
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 20.9% · Q3 21.7% · Q4 18.2% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
15.0%
5.1 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 10.5% · Q3 7.7% · Q4 10.0% · 4Q avg 9.9% · 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 | 46.9% |
21.5%
25.4 pts worse
|
16.3%
30.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.7% |
16.8%
6.9 pts worse
|
14.9%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 8.8% · Q3 24.3% · Q4 13.9% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 0.0% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
21.2%
10.7 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 22.1% · Q3 29.8% · Q4 41.0% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.0%
0.2 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.9% · Q3 5.2% · Q4 7.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.0% |
79.9%
2.9 pts worse
|
81.7%
4.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.7% · Q2 76.4% · Q3 79.7% · Q4 80.0% · 4Q avg 77.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.0% |
13.2%
14.8 pts worse
|
12.0%
16 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 27.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.1% |
78.1%
4 pts worse
|
79.7%
5.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.9%
5 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 29.5% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-27 · Fire 2023-09-27
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
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
2024-12-05
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
E · Potential for more than minimal harm
2024-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-31
D · Potential for more than minimal harm
2024-12-05
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
2024-12-05
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 2025-03-31
D · Potential for more than minimal harm
2024-12-05
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
2024-12-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-31
D · Potential for more than minimal harm
2024-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-31
F · Potential for more than minimal harm
2023-09-27
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-09-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-09-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-09-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-09-27
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 2024-01-14
D · Potential for more than minimal harm
2023-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-09-27
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-01-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-05
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 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-31
C · Minimal harm
2024-12-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-31
D · Potential for more than minimal harm
2023-11-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-11-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-16
G · Actual harm
2023-09-27
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 2023-11-15
G · Actual harm
2023-09-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-09-27
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-15
E · Potential for more than minimal harm
2023-09-27
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 2023-11-15
E · Potential for more than minimal harm
2023-09-27
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-15
E · Potential for more than minimal harm
2023-09-27
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 2023-11-15
E · Potential for more than minimal harm
2023-09-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-27
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-27
F758 · Pharmacy Service Deficiencies
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 2023-11-15
D · Potential for more than minimal harm
2023-09-27
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 2023-11-15
D · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-15
C · Minimal harm
2023-09-27
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-10-14
C · Minimal harm
2023-09-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-27
F · Potential for more than minimal harm
2022-05-12
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 2022-06-03
F · Potential for more than minimal harm
2022-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-16
E · Potential for more than minimal harm
2022-05-12
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 2022-06-03
D · Potential for more than minimal harm
2022-05-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-06-03
Penalties and ownership
What sits behind the stars
$55,760
2023-09-27
Fine
Fine · fine $55,760
Fine
$0
2023-09-27
Payment Denial
Payment Denial · denial start 2023-10-25 · 22 days
22 day denial
Ownership
Bornstein, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Henderson Emac LLC
5% Or Greater Indirect Ownership Interest · Organization
Lbs Capital Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Bornstein, Yisroel
Operational/Managerial Control · Individual
Bornstein, Yisroel
Corporate Director · Individual
Henderson Sch Operating LLC.
Operational/Managerial Control · Organization
Hirsch, Nisson
5% Or Greater Indirect Ownership Interest · Individual
Hirsch, Nisson
Operational/Managerial Control · Individual
Hirsch, Nisson
Corporate Director · Individual
Klein, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Klein, Eliezer
Operational/Managerial Control · Individual
Klein, Eliezer
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kerr Lake Nursing and Rehabilitation Center
Henderson, NC
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
#2
Camellia Gardens Center for Nursing and Rehab
Henderson, NC
1-star overall rating with 1-star inspections with $74,576 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Brantwood Nh & Retirement Center
Oxford, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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