Cycle 1
Health 2025-04-03 · Fire 2025-04-03
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jamestown, NC
The Shannon Gray Rehabilitation & Recovery Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2005 Shannon Gray Court, Jamestown, NC
(336) 307-4729
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-07-09
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
0.98
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,014
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.98% · Performance 22.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.84
Baseline 6.88% · Performance 6.09% · Measure score 5.84 · Achievement 5.84 · Improvement 3.71
Total nurse turnover
2.20
Baseline 61.11% · Performance 54.70% · Measure score 2.20 · Achievement 2.20 · Improvement 1.27
Adjusted total nurse staffing
4.37
Baseline 4.13 hours · Performance 4.32 hours · Measure score 4.37 · Achievement 4.37 · Improvement 0.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 10.75% · Lower 95% interval 8.19% |
| Discharge to community | 49.4% |
50.57%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 46% · Lower 95% interval 39.68% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.37% |
95.27%
0.9 pts worse
|
Numerator 67 · Denominator 71 |
| Falls with major injury | 2.82% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 71 |
| Discharge self-care score | 54.35% |
53.69%
0.7 pts better
|
Numerator 25 · Denominator 46 |
| Discharge mobility score | 65.22% |
50.94%
14.3 pts better
|
Numerator 30 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 2.82% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 71 · Adjusted rate 2.32% |
| Healthcare-associated infections requiring hospitalization | 6.09% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 3.13% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 8.48% |
42%
33.5 pts worse
|
Numerator 14 · Denominator 165 |
| Discharge function score | 73.91% |
56.45%
17.5 pts better
|
Numerator 34 · Denominator 46 |
| Transfer of health information to provider | 98.33% |
95.95%
2.4 pts better
|
Numerator 59 · Denominator 60 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 7 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.5%
4.2 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 98.8% · Q3 98.8% · Q4 96.4% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.1%
4.7 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 2.4% · Q4 2.4% · 4Q avg 1.8% · 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 | 9.0% |
7.2%
1.8 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.9% · Q3 7.0% · Q4 4.1% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
21.6%
5.6 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 16.4% · Q3 14.1% · Q4 17.3% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
15.0%
8.1 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.7% · Q3 6.6% · Q4 4.5% · 4Q avg 6.9% · 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 | 27.0% |
21.5%
5.5 pts worse
|
16.3%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 25.1% · Q3 32.1% · Q4 35.4% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.0% |
16.8%
11.2 pts worse
|
14.9%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 31.1% · Q3 36.2% · Q4 29.7% · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.9% · Q3 1.9% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.6% · Q3 4.8% · Q4 3.6% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.9% |
21.2%
5.3 pts better
|
19.8%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 12.5% · Q3 12.4% · Q4 24.5% · 4Q avg 15.9% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.0%
1.8 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.5% · Q3 11.0% · Q4 5.9% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
79.9%
9.9 pts better
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.2% · Q2 87.3% · Q3 94.7% · Q4 93.3% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
13.2%
1.6 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.3% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
78.1%
11.3 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.9% |
22.9%
12 pts worse
|
23.9%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.9% · Observed 31.0% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-02 · Fire 2022-09-02
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-03
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 2025-05-24
D · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-16
D · Potential for more than minimal harm
2022-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Not marked corrected
D · Potential for more than minimal harm
2025-04-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
D · Potential for more than minimal harm
2022-09-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-09-02
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-09-30
D · Potential for more than minimal harm
2022-09-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-30
Penalties and ownership
What sits behind the stars
Ownership
Bennett, Jennifer
5% Or Greater Direct Ownership Interest · Individual
Lawver, Melissa
5% Or Greater Direct Ownership Interest · Individual
Bennett, Jennifer
Corporate Director · Individual
Bennett, Richard
5% Or Greater Direct Ownership Interest · Individual
Bennett, Richard
Corporate Director · Individual
Bennett, Sarah
5% Or Greater Direct Ownership Interest · Individual
Bennett, Sarah
Corporate Director · Individual
Bullins, Vivkie
W-2 Managing Employee · Individual
Canyon Management Consultants Inc
Operational/Managerial Control · Organization
Lawver, Melissa
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Maryfield Nursing Home
High Point, NC
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Adams Farm Living & Rehabilitation
Jamestown, NC
2-star overall rating with 2-star inspections with $37,310 in total fines with 6 recent health deficiencies
#3
Meridian Center
High Point, NC
1-star overall rating with 2-star inspections with $118,162 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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