Cycle 1
Health 2025-03-21 · Fire 2025-03-21
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Warsaw, NC
Warsaw Rehabilitation and Healthcare Center
1-star overall rating with 2-star inspections with abuse icon flag with $43,924 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
214 Lanefield Road, Warsaw, NC
(910) 293-3144
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
1986-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.27
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
2.00
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.17
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
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,827
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.52
Baseline 20.73% · Performance 20.73% · Measure score 1.52 · Achievement 1.52 · Improvement 0
Healthcare-associated infections
0
Baseline 8.20% · Performance 9.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.47
Baseline 49.35% · Performance 49.48% · Measure score 3.47 · Achievement 3.47 · Improvement 0
Adjusted total nurse staffing
3.96
Baseline 3.89 hours · Performance 4.21 hours · Measure score 3.96 · Achievement 3.96 · Improvement 1.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.76% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 19.05% · Lower 95% interval 8.94% |
| Discharge to community | 41.24% |
50.57%
9.3 pts worse
|
Worse than the National Rate · Eligible stays 87 · Observed rate 32.18% · Lower 95% interval 32.94% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 56.41% |
95.27%
38.9 pts worse
|
Numerator 22 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | 36% |
53.69%
17.7 pts worse
|
Numerator 9 · Denominator 25 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 10 · Denominator 25 |
| 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 | 9.11% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 18.75% · Lower 95% interval 5.18% |
| Staff COVID-19 vaccination coverage | 1.6% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 125 |
| Staff flu vaccination coverage | 2.26% |
42%
39.7 pts worse
|
Numerator 4 · Denominator 177 |
| Discharge function score | 52% |
56.45%
4.5 pts worse
|
Numerator 13 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
91.5%
6.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 98.6% · Q4 97.3% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
94.1%
3.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.6%
2.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · 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 | 3.0% |
7.2%
4.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.8% · Q3 4.9% · Q4 3.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
21.6%
5 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 15.1% · Q3 16.1% · Q4 16.7% · 4Q avg 16.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
15.0%
0.1 pts better
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 19.6% · Q3 7.3% · Q4 13.2% · 4Q avg 14.9% · 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 | 14.8% |
21.5%
6.7 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.1% · Q3 12.7% · Q4 21.0% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
16.8%
7.7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.6% · Q3 14.5% · Q4 10.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.6% · Q3 1.4% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
21.2%
2.7 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 21.1% · Q3 33.5% · Q4 23.4% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 13.2% |
6.0%
7.2 pts worse
|
5.1%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 12.5% · Q3 12.6% · Q4 9.2% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.9% |
79.9%
19 pts worse
|
81.7%
20.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 67.4% · Q3 62.0% · Q4 50.8% · 4Q avg 60.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
13.2%
0.6 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.5%
1.4 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.8% |
78.1%
14.3 pts worse
|
79.7%
15.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
22.9%
4.3 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 26.1% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-22 · Fire 2024-04-22
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
5 health deficiencies
Top issue: Administration (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-04-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-04-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-03-23
K222 · Egress Deficiencies
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 2023-07-17
E · Potential for more than minimal harm
2023-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-03-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-03-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-03-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-03-23
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 2023-07-17
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 2023-07-17
Inspection history
Recent health citations
G · Actual harm
2025-03-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-21
F688 · Quality of Life and Care Deficiencies
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 2025-04-04
D · Potential for more than minimal harm
2025-03-21
F758 · Pharmacy Service Deficiencies
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 2025-04-04
D · Potential for more than minimal harm
2025-01-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-17
D · Potential for more than minimal harm
2025-01-09
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 2025-01-17
D · Potential for more than minimal harm
2025-01-09
F761 · Pharmacy Service Deficiencies
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 2025-01-17
J · Immediate jeopardy
2024-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-09
J · Immediate jeopardy
2024-12-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-04-22
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 2024-05-17
E · Potential for more than minimal harm
2024-04-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-17
D · Potential for more than minimal harm
2023-03-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-23
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 2023-04-20
D · Potential for more than minimal harm
2023-03-23
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 2023-04-20
D · Potential for more than minimal harm
2023-03-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-20
Penalties and ownership
What sits behind the stars
$26,078
2025-03-21
Fine
Fine · fine $26,078
Fine
$3,413
2024-12-09
Fine
Fine · fine $3,413
Fine
$7,216
2024-12-09
Fine
Fine · fine $7,216
Fine
$7,217
2024-12-09
Fine
Fine · fine $7,217
Fine
$0
2024-12-09
Payment Denial
Payment Denial · denial start 2025-01-07 · 10 days
10 day denial
Ownership
Warsaw Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Braun, Joseph
5% Or Greater Indirect Ownership Interest · Individual
Afrede, Momin
Operational/Managerial Control · Individual
Caquias Gonzalez, Eileen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Kenansville Rehabilitation and Healthcare Center
Kenansville, NC
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Mary Gran Nursing Center
Clinton, NC
1-star overall rating with 1-star inspections with abuse icon flag with $68,172 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Southwood Nursing and Retirement
Clinton, NC
3-star overall rating with 4-star inspections with $8,512 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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