Cycle 1
Health 2025-02-20 · Fire 2025-02-20
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fayetteville, NC
Village Green Health and Rehabilitation
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1601 Purdue Drive, Fayetteville, NC
(910) 486-5000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1991-07-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 health / 3 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
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,824
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.48
Baseline 22.78% · Performance 21.07% · Measure score 2.48 · Achievement 0.78 · Improvement 2.48
Healthcare-associated infections
3.52
Baseline 7.93% · Performance 6.78% · Measure score 3.52 · Achievement 3.52 · Improvement 3.42
Total nurse turnover
5.46
Baseline 49.55% · Performance 41.35% · Measure score 5.46 · Achievement 5.46 · Improvement 2.82
Adjusted total nurse staffing
0
Baseline 3.52 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 375 · Observed rate 10.93% · Lower 95% interval 7.97% |
| Discharge to community | 65.75% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 415 · Observed rate 57.11% · Lower 95% interval 60.73% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 57.69% |
95.27%
37.6 pts worse
|
Numerator 180 · Denominator 312 |
| Falls with major injury | 0.32% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 312 |
| Discharge self-care score | 72.5% |
53.69%
18.8 pts better
|
Numerator 145 · Denominator 200 |
| Discharge mobility score | 45.5% |
50.94%
5.4 pts worse
|
Numerator 91 · Denominator 200 |
| Pressure ulcers or injuries, new or worsened | 0.32% |
2.29%
2 pts better
|
Numerator 1 · Denominator 312 · Adjusted rate 0.31% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 246 · Observed rate 6.5% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 0.6% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 166 |
| Staff flu vaccination coverage | 3.85% |
42%
38.1 pts worse
|
Numerator 6 · Denominator 156 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 150 · Denominator 200 |
| Transfer of health information to provider | 95.52% |
95.95%
0.4 pts worse
|
Numerator 128 · Denominator 134 |
| Transfer of health information to patient | 96.25% |
96.28%
About the same
|
Numerator 154 · Denominator 160 |
| Resident COVID-19 vaccinations up to date | 12.26% |
25.2%
12.9 pts worse
|
Numerator 19 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
91.5%
9.5 pts worse
|
93.4%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 76.7% · Q3 84.8% · Q4 79.0% · 4Q avg 82.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.8% |
94.1%
18.3 pts worse
|
95.5%
19.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.6%
2.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 3.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.9% |
4.8%
46.1 pts worse
|
11.4%
39.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.6% · Q2 48.1% · Q3 56.7% · Q4 51.8% · 4Q avg 50.9% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
7.2%
3.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.7% · Q3 6.7% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.8% |
21.6%
16.8 pts better
|
19.6%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.4% · Q3 3.3% · Q4 3.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
15.0%
10.8 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 4.0% · Q4 4.3% · 4Q avg 4.2% · 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 | 22.8% |
21.5%
1.3 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
16.8%
3.5 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.6% · Q3 14.3% · Q4 10.4% · 4Q avg 13.3% · 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 | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
21.2%
12.4 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.8% · Q3 9.1% · Q4 11.0% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 12.4% |
6.0%
6.4 pts worse
|
5.1%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.3% · Q3 12.0% · Q4 7.9% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
79.9%
8.6 pts better
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 96.3% · Q3 92.4% · Q4 68.4% · 4Q avg 88.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
13.2%
3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 8.9% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
78.1%
14.1 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
22.9%
4.9 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 28.0% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-08-03 · Fire 2022-08-03
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-20
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-02-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-02-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-27
E · Potential for more than minimal harm
2024-01-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-15
F · Potential for more than minimal harm
2022-08-03
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-27
B · Minimal harm
2024-01-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-08-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-08-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-12
C · Minimal harm
2022-08-03
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-08-12
Penalties and ownership
What sits behind the stars
Ownership
Ardent Health And Rehabilitation Co
5% Or Greater Direct Ownership Interest · Organization
Collins-Frye, Kaia
W-2 Managing Employee · Individual
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Village Green Healthcare Properties LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Haymount Rehabilitation & Nursing Center, Inc.
Fayetteville, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
The Carrolton of Fayetteville
Fayetteville, NC
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Carolina Rehab Center of Cumberland
Fayetteville, NC
2-star overall rating with 2-star inspections with $97,936 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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