Cycle 1
Health 2025-03-12 · Fire 2025-03-12
1 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Pittsboro, NC
The Arbor
4-star overall rating with 4-star inspections with $6,350 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
300 Clynelish Close, Pittsboro, NC
(919) 545-2690
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
16
Certified beds
Average residents
11
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-09-28
CMS approved date
Coverage
Medicare
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
1.00
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.10
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
1.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
5.04
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 QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 5.71% |
| Discharge to community | 50.44% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 47.37% · Lower 95% interval 36.68% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 14 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.94% |
8.2%
4.3 pts worse
|
Numerator 5 · Denominator 127 |
| Staff flu vaccination coverage | 93.87% |
42%
51.9 pts better
|
Numerator 153 · Denominator 163 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 14 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.9%
20.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
13.2%
2.7 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 12.9% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.1% · Q3 4.2% · Q4 0.0% · 4Q avg 4.0% · 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 | 22.6% |
22.9%
0.3 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 16.1% · Expected 17.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-08-30 · Fire 2022-08-30
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-03-12
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-01-10
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
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 2024-03-07
D · Potential for more than minimal harm
2024-01-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-07
D · Potential for more than minimal harm
2022-08-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-08-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-08-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
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 2024-11-14
E · Potential for more than minimal harm
2024-01-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
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 2024-02-07
D · Potential for more than minimal harm
2024-01-10
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-02-07
B · Minimal harm
2024-01-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-07
Penalties and ownership
What sits behind the stars
$2,117
2023-10-02
Fine
Fine · fine $2,117
Fine
$4,233
2023-09-11
Fine
Fine · fine $4,233
Fine
Ownership
Boylan-Walker, Dana
Operational/Managerial Control · Individual
Boylan-Walker, Dana
Corporate Officer · Individual
Cannon, Rob
Operational/Managerial Control · Individual
Cannon, Rob
Corporate Director · Individual
Chapman, Lisa
Operational/Managerial Control · Individual
Chapman, Lisa
Corporate Director · Individual
De St. Aubin, Denis
Operational/Managerial Control · Individual
De St. Aubin, Denis
Corporate Director · Individual
Kahler, H. Richard
Operational/Managerial Control · Individual
Kahler, H. Richard
Corporate Director · Individual
Kendra, Victoria
Operational/Managerial Control · Individual
Marshall, Robert
Operational/Managerial Control · Individual
Marshall, Robert
Corporate Director · Individual
Mckenna, Gary
Operational/Managerial Control · Individual
Mckenna, Gary
Corporate Director · Individual
Meyer Austin, Leah
Operational/Managerial Control · Individual
Meyer Austin, Leah
Corporate Director · Individual
Perry, David
Operational/Managerial Control · Individual
Perry, David
Corporate Director · Individual
Rimer, Alan
Operational/Managerial Control · Individual
Rimer, Alan
Corporate Director · Individual
Wilson, Stan
Operational/Managerial Control · Individual
Wilson, Stan
Corporate Director · Individual
Winter, Christina
Corporate Director · Individual
Zimmer, Robert
Operational/Managerial Control · Individual
Zimmer, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Laurels of Chatham
Pittsboro, NC
2-star overall rating with 2-star inspections with $10,527 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
The Cedars of Chapel Hill
Chapel Hill, NC
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare of Chapel Hill
Chapel Hill, NC
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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