Raleigh, NC
4-star overall rating with 4-star inspections with $7,901 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
311 Garden at North Hills Street, Raleigh, NC
(984) 204-8444
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
15
Certified beds
Average residents
13
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kisco Senior Living
Operator or chain grouping
Approved since
2017-06-28
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
2 facilities
Chain averages 3 overall / 4 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
8,819
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.88
Baseline 19.73% · Performance 20.56% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Healthcare-associated infections
0
Performance 8.63% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.79
Performance 40.00% · Measure score 5.79 · Achievement 5.79 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 5% · Lower 95% interval 6.27% |
| Discharge to community | 68.64% |
50.57%
18.1 pts better
|
Better than the National Rate · Eligible stays 64 · Observed rate 68.75% · Lower 95% interval 60.17% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 55.88% |
53.69%
2.2 pts better
|
Numerator 19 · Denominator 34 |
| Discharge mobility score | 41.18% |
50.94%
9.8 pts worse
|
Numerator 14 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 3% |
| Healthcare-associated infections requiring hospitalization | 8.63% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 44.12% |
56.45%
12.3 pts worse
|
Numerator 15 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.55% |
96.28%
2.7 pts worse
|
Numerator 29 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
91.5%
31.5 pts worse
|
93.4%
33.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 60.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.4% |
3.6%
7.8 pts worse
|
3.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.5% |
7.2%
5.3 pts worse
|
5.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 46.2% |
21.6%
24.6 pts worse
|
19.6%
26.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.2% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
21.2%
1 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 32.2% |
79.9%
47.7 pts worse
|
81.7%
49.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 29.0% · Q3 11.5% · Q4 11.1% · 4Q avg 32.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
13.2%
10.7 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 20.7% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.5% |
1.5%
5 pts worse
|
1.6%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 3.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.6% |
78.1%
37.5 pts worse
|
79.7%
39.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
22.9%
4.2 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 13.8% · Expected 17.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-17
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-17
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-16
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-10-13
Penalties and ownership
Fine · fine $7,901
Fine
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Nearby options
Raleigh, NC
3-star overall rating with 4-star inspections with $17,202 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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2-star overall rating with 3-star inspections with $77,760 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Raleigh, NC
2-star overall rating with 2-star inspections with $15,593 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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