Cycle 1
Health 2025-01-24 · Fire 2025-01-24
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Smithfield, NC
Smithfield Manor Rehabilitation and Healthcare Cen
1-star overall rating with 2-star inspections with $272,752 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
902 Berkshire Road, Smithfield, NC
(919) 934-3171
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-12-01
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
0.51
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,551
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.90% · Performance 23.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.33% · Performance 8.65% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.94
Baseline 34.91% · Performance 39.42% · Measure score 5.94 · Achievement 5.94 · Improvement 0
Adjusted total nurse staffing
3.39
Baseline 3.84 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 330 · Observed rate 9.7% · Lower 95% interval 7.71% |
| Discharge to community | 53.7% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 302 · Observed rate 49.34% · Lower 95% interval 48.96% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 199 · Denominator 202 |
| Falls with major injury | 2.97% |
0.77%
2.2 pts worse
|
Numerator 6 · Denominator 202 |
| Discharge self-care score | 51.39% |
53.69%
2.3 pts worse
|
Numerator 74 · Denominator 144 |
| Discharge mobility score | 28.47% |
50.94%
22.5 pts worse
|
Numerator 41 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 2.48% |
2.29%
0.2 pts worse
|
Numerator 5 · Denominator 202 · Adjusted rate 2.63% |
| Healthcare-associated infections requiring hospitalization | 8.65% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 8.88% · Lower 95% interval 5.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 169 |
| Staff flu vaccination coverage | 20.5% |
42%
21.5 pts worse
|
Numerator 33 · Denominator 161 |
| Discharge function score | 46.53% |
56.45%
9.9 pts worse
|
Numerator 67 · Denominator 144 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 113 · Denominator 113 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 30.3% |
25.2%
5.1 pts better
|
Numerator 30 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
91.5%
2.2 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 97.3% · Q4 78.3% · 4Q avg 93.7% |
| 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 | 4.8% |
3.6%
1.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.4% · Q3 5.5% · Q4 6.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.8%
3.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
7.2%
0.8 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.0% · Q3 8.7% · Q4 7.0% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
21.6%
0.8 pts better
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 21.4% · Q3 23.4% · Q4 17.6% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
15.0%
3 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 10.6% · Q3 9.5% · Q4 11.9% · 4Q avg 12.0% · 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 | 28.5% |
21.5%
7 pts worse
|
16.3%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 34.7% · Q3 29.6% · Q4 27.0% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
16.8%
12.3 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 36.4% · Q3 34.7% · Q4 22.2% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.9% · Q3 1.2% · Q4 0.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.3% |
2.6%
6.7 pts worse
|
1.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 13.0% · Q3 10.3% · Q4 4.7% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
21.2%
0.3 pts worse
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 26.7% · Q3 18.5% · Q4 20.9% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
6.0%
4 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.1% · Q3 10.5% · Q4 12.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
79.9%
19.9 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.2% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
13.2%
0.5 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 1.4% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
78.1%
17.6 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.9%
0.7 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 21.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-24
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
F · Potential for more than minimal harm
2023-09-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-09-28
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 2023-09-08
D · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-09-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-08
Inspection history
Recent health citations
G · Actual harm
2025-11-04
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.
Not marked corrected
J · Immediate jeopardy
2025-09-12
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.
Not marked corrected
E · Potential for more than minimal harm
2025-01-24
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 2025-02-10
E · Potential for more than minimal harm
2025-01-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-24
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 2025-02-10
D · Potential for more than minimal harm
2025-01-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-24
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 2025-02-10
J · Immediate jeopardy
2024-04-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-09
J · Immediate jeopardy
2024-04-19
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 2024-05-09
D · Potential for more than minimal harm
2023-09-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-20
D · Potential for more than minimal harm
2022-03-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-18
D · Potential for more than minimal harm
2022-03-31
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 2022-04-18
Penalties and ownership
What sits behind the stars
$26,130
2025-09-12
Fine
Fine · fine $26,130
Fine
$4,147
2025-02-26
Fine
Fine · fine $4,147
Fine
$242,475
2024-04-19
Fine
Fine · fine $242,475
Fine
Ownership
Nearby options
Other facilities in reach
#1
Barbour Court Nursing and Rehabilitation Center
Smithfield, NC
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Springbrook Nursing and Rehabilitation Center
Clayton, NC
2-star overall rating with 2-star inspections with abuse icon flag with $25,625 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Clayton Rehabilitation and Healthcare Center
Clayton, NC
1-star overall rating with 1-star inspections with $255,500 in total fines with 25 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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