Cycle 1
Health 2025-06-19 · Fire 2025-06-19
4 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Eden, NC
UNC Rockingham Rehab & Nursing Care Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
205 East Kings Highway, Eden, NC
(336) 623-9711
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-04-09
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
1.02
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.66
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.68
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.61
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,171
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0144
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.13
Baseline 18.58% · Performance 19.05% · Measure score 5.13 · Achievement 5.13 · Improvement 0
Healthcare-associated infections
5.24
Baseline 5.75% · Performance 6.27% · Measure score 5.24 · Achievement 5.24 · Improvement 0
Total nurse turnover
6.68
Performance 36.36% · Measure score 6.68 · Achievement 6.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.63
Baseline 3.88 hours · Performance 4.97 hours · Measure score 6.63 · Achievement 6.63 · Improvement 5.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 8.11% |
| Discharge to community | 50.15% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 48.84% · Lower 95% interval 42.13% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.74% |
95.27%
5.5 pts worse
|
Numerator 35 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 16 · Denominator 34 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 17 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 2.08% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 1.15% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 87 |
| Staff flu vaccination coverage | 96.19% |
42%
54.2 pts better
|
Numerator 101 · Denominator 105 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 18 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 6 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
91.5%
19.9 pts worse
|
93.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.6% · Q2 75.0% · Q3 69.2% · Q4 71.4% · 4Q avg 71.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.1%
4 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.6%
0.7 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 3.8% · Q4 2.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
4.8%
3.2 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
7.2%
0.3 pts better
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 14.0% · Q4 10.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.9% |
21.6%
8.3 pts worse
|
19.6%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 26.7% · Q3 27.3% · Q4 28.2% · 4Q avg 29.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
15.0%
4.8 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 22.0% · Q3 17.5% · Q4 17.9% · 4Q avg 19.8% · 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 | 46.5% |
21.5%
25 pts worse
|
16.3%
30.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.5% · 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 25.6% · Q2 39.5% · Q3 27.5% · Q4 17.1% · 4Q avg 28.0% · 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 1.4% · Q2 0.0% · Q3 1.5% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
2.6%
4.3 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 5.8% · Q3 5.9% · Q4 6.1% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
21.2%
3.5 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 20.8% · Q3 15.1% · Q4 16.4% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.0%
0.9 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.4% · Q3 5.2% · Q4 4.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.7% |
79.9%
5.2 pts worse
|
81.7%
7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.8% · Q2 64.9% · Q3 72.3% · Q4 87.1% · 4Q avg 74.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
13.2%
3.8 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 8.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 1.3% · Q4 1.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
78.1%
13.4 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
22.9%
0.7 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 17.6% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-22 · Fire 2024-05-22
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-19
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-06-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-08
E · Potential for more than minimal harm
2024-05-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-05-22
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 2024-08-25
E · Potential for more than minimal harm
2024-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-05-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-05-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-05-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-25
D · Potential for more than minimal harm
2023-03-23
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-23
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-06-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-06-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-07-31
B · Minimal harm
2024-05-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-03
E · Potential for more than minimal harm
2023-03-23
F756 · Pharmacy Service Deficiencies
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 2023-04-10
D · Potential for more than minimal harm
2023-03-23
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-04-10
Penalties and ownership
What sits behind the stars
Ownership
University Of North Carolina Health Care System
5% Or Greater Direct Ownership Interest · Organization
Bowen, Elizabeth
Corporate Officer · Individual
Burnette, James
Corporate Director · Individual
Bus, Mary
Corporate Director · Individual
Cathey, Reginald
Corporate Director · Individual
Clark, Joel
Corporate Director · Individual
Dabbs, John
Corporate Director · Individual
Daniel, Terry
Operational/Managerial Control · Individual
Edwards, Angela
Corporate Officer · Individual
Flynt, William
Corporate Director · Individual
Hazlewood, Sara
Corporate Director · Individual
Howard, Kevin
Operational/Managerial Control · Individual
Lester, Jodi
Corporate Director · Individual
Mcleod, William
Corporate Director · Individual
Mcnaull, Peggy
Corporate Director · Individual
Parris, Jeffrey
Corporate Director · Individual
Pyrtle, Armor
Corporate Director · Individual
Scarborough, Tammy
Corporate Director · Individual
Shadowens, Karen
Corporate Officer · Individual
Silvers, Micky
Corporate Director · Individual
Stetler, Phillip
Corporate Director · Individual
Strickler, Jeffery
Corporate Officer · Individual
Vincent, Casey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Eden Rehabilitation and Healthcare Center
Eden, NC
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Penn Nursing Center
Reidsville, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cypress Valley Center for Nursing and Rehabilitati
Reidsville, NC
1-star overall rating with 2-star inspections with $32,911 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out