4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pinehurst, NC
3-star overall rating with 3-star inspections with $41,844 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
205 Rattlesnake Trail, Pinehurst, NC
(910) 295-1781
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cch Healthcare
Operator or chain grouping
Approved since
1977-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
32 facilities
Chain averages 3 overall / 2 health / 2 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
0.50
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
9,466
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.83
Baseline 18.57% · Performance 21.05% · Measure score 0.83 · Achievement 0.83 · Improvement 0
Healthcare-associated infections
5.71
Baseline 9.32% · Performance 6.64% · Measure score 5.71 · Achievement 4.01 · Improvement 5.71
Total nurse turnover
1.20
Baseline 57.65% · Performance 58.76% · Measure score 1.20 · Achievement 1.20 · Improvement 0
Adjusted total nurse staffing
1.69
Baseline 3.07 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 1.32
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 16.11% · Lower 95% interval 9.97% |
| Discharge to community | 50.5% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 44.35% · Lower 95% interval 41.81% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 103 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 32 · Denominator 68 |
| Discharge mobility score | 41.18% |
50.94%
9.8 pts worse
|
Numerator 28 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 6.19% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 114 · Denominator 114 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.47% |
56.45%
5 pts worse
|
Numerator 35 · Denominator 68 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 32 · Denominator 34 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 44 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 51 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 15.6% |
91.5%
75.9 pts worse
|
93.4%
77.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.3% · Q3 18.3% · Q4 19.2% · 4Q avg 15.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.9% |
94.1%
18.2 pts worse
|
95.5%
19.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.6%
1.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.8% · Q4 1.3% · 4Q avg 1.7% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
7.2%
0.4 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.2% · Q3 9.2% · Q4 11.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
21.6%
11.3 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.5% · Q3 12.3% · Q4 8.2% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
15.0%
0.5 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 13.3% · Q3 14.0% · Q4 13.8% · 4Q avg 15.5% · 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 | 0.0% |
21.5%
21.5 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.8% |
16.8%
16 pts better
|
14.9%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 1.4% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
21.2%
5.8 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 6.3% · Q3 24.7% · Q4 10.5% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
6.0%
4.2 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 14.4% · Q3 5.2% · Q4 10.0% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 1.2% |
79.9%
78.7 pts worse
|
81.7%
80.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 1.6% · Q4 1.9% · 4Q avg 1.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
13.2%
1.1 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 14.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 1.6% |
78.1%
76.5 pts worse
|
79.7%
78.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 1.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
22.9%
4.6 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 28.6% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
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 2023-12-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-15
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-12
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-12
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-16
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-16
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 2024-12-16
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 2024-12-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-19
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-19
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-10-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-20
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 2023-10-19
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-19
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 2023-10-19
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-08-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-03-09
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-08-08
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-08-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-08
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-08
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-08
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-08-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-08
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-08
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-08-08
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2022-08-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-08
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-08
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-08-08
Health
Post nurse staffing information every day.
Corrected 2022-08-08
Penalties and ownership
Fine · fine $41,844
Fine
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Nearby options
Pinehurst, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Pinehurst, NC
3-star overall rating with 3-star inspections with $9,620 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Pinehurst, NC
2-star overall rating with 2-star inspections with abuse icon flag with $10,517 in total fines with 4 recent health deficiencies
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