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
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.63
Nurse aide staffing
Weekend hours
3.46
Weekend nurse staffing
RN turnover
89%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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