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
195 Springbrook Avenue, Clayton, NC
(919) 550-7200
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
100
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
2015-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 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
RN hours / resident day
0.75
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
11,607
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.58% · Performance 22.92% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.17
Baseline 8.02% · Performance 7.81% · Measure score 0.17 · Achievement 0 · Improvement 0.17
Total nurse turnover
2.52
Baseline 83.97% · Performance 66.13% · Measure score 2.52 · Achievement 0 · Improvement 2.52
Adjusted total nurse staffing
3.75
Baseline 3.92 hours · Performance 4.14 hours · Measure score 3.75 · Achievement 3.75 · Improvement 0.71
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 276 · Observed rate 11.23% · Lower 95% interval 8.46% |
| Discharge to community | 59.32% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 283 · Observed rate 54.06% · Lower 95% interval 55.6% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 72.46% |
95.27%
22.8 pts worse
|
Numerator 100 · Denominator 138 |
| Falls with major injury | 0.72% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 138 |
| Discharge self-care score | 58.43% |
53.69%
4.7 pts better
|
Numerator 52 · Denominator 89 |
| Discharge mobility score | 42.7% |
50.94%
8.2 pts worse
|
Numerator 38 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 3.62% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 138 · Adjusted rate 4.19% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 7.95% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 116 |
| Staff flu vaccination coverage | 10.62% |
42%
31.4 pts worse
|
Numerator 24 · Denominator 226 |
| Discharge function score | 51.69% |
56.45%
4.8 pts worse
|
Numerator 46 · Denominator 89 |
| Transfer of health information to provider | 84.48% |
95.95%
11.5 pts worse
|
Numerator 49 · Denominator 58 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 13.24% |
25.2%
12 pts worse
|
Numerator 9 · Denominator 68 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
91.5%
2.8 pts worse
|
93.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 86.5% · Q3 88.7% · Q4 86.5% · 4Q avg 88.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
94.1%
0.3 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 7.0% · Q4 6.8% · 4Q avg 4.5% · 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 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
7.2%
4.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 3.4% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
21.6%
2.8 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.9% · Q3 15.6% · Q4 16.7% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
15.0%
6.1 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 23.2% · Q3 23.6% · Q4 19.4% · 4Q avg 21.1% · 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 | 40.3% |
21.5%
18.8 pts worse
|
16.3%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.8% · Q2 29.1% · 4Q avg 40.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
16.8%
9.2 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 18.5% · Q3 24.2% · Q4 29.7% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 1.1% · Q4 1.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 2.8% · Q4 4.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
21.2%
5.1 pts better
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.6% · Q3 16.3% · Q4 10.1% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.0%
1 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 6.8% · Q3 6.3% · Q4 1.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
79.9%
5 pts better
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.3% · Q2 83.1% · Q3 87.8% · Q4 90.7% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
13.2%
1.4 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.5% · Expected 10.3% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.4% |
78.1%
1.7 pts worse
|
79.7%
3.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
22.9%
0.6 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 22.2% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-28
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 2022-11-28
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-21
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-18
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-11
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-11
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-11
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-03-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
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 2024-03-11
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-11
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 2024-03-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-18
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-18
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 2022-10-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-18
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 2022-10-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-18
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-10-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-18
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-10-18
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 2022-10-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-18
Penalties and ownership
Fine · fine $8,824
Fine
Fine · fine $16,801
Fine
Payment Denial · denial start 2024-03-02 · 9 days
9 day denial
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Nearby options
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
Smithfield, NC
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Garner, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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