Cycle 1
Health 2025-07-24 · Fire 2024-05-23
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
High Point, NC
Westchester Manor at Providence Place
3-star overall rating with 3-star inspections with $8,018 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1795 Westchester Drive, High Point, NC
(336) 884-2222
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
122
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Everyage Senior Living
Operator or chain grouping
Approved since
1973-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 5 overall / 5 health / 5 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
0.57
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.63
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,784
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.42
Baseline 17.75% · Performance 19.38% · Measure score 4.42 · Achievement 4.42 · Improvement 0
Healthcare-associated infections
5.68
Baseline 5.00% · Performance 6.14% · Measure score 5.68 · Achievement 5.68 · Improvement 0
Total nurse turnover
1.90
Baseline 48.44% · Performance 55.92% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Adjusted total nurse staffing
5.07
Baseline 4.11 hours · Performance 4.52 hours · Measure score 5.07 · Achievement 5.07 · Improvement 1.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 8.27% · Lower 95% interval 6.41% |
| Discharge to community | 44.67% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 39.85% · Lower 95% interval 37.35% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 81.16% |
95.27%
14.1 pts worse
|
Numerator 56 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 35.19% |
53.69%
18.5 pts worse
|
Numerator 19 · Denominator 54 |
| Discharge mobility score | 20.37% |
50.94%
30.6 pts worse
|
Numerator 11 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 3.66% · Lower 95% interval 2.86% |
| Staff COVID-19 vaccination coverage | 3.55% |
8.2%
4.6 pts worse
|
Numerator 6 · Denominator 169 |
| Staff flu vaccination coverage | 14.74% |
42%
27.3 pts worse
|
Numerator 28 · Denominator 190 |
| Discharge function score | 42.59% |
56.45%
13.9 pts worse
|
Numerator 23 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 48.39% |
25.2%
23.2 pts better
|
Numerator 15 · Denominator 31 |
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 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.5%
7.6 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 99.0% · Q4 99.1% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.7% · Q3 5.8% · Q4 3.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.8%
2.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.1% · Q3 3.6% · Q4 1.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
7.2%
1.7 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.3% · Q3 16.5% · Q4 7.7% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
21.6%
8.8 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 30.5% · Q3 34.5% · Q4 28.3% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
15.0%
1.6 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 11.4% · Q3 15.2% · Q4 14.8% · 4Q avg 13.4% · 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 | 30.0% |
21.5%
8.5 pts worse
|
16.3%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 31.4% · Q4 25.2% · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
16.8%
5.4 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 28.0% · Q3 29.7% · Q4 17.5% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 3.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.9% |
2.6%
3.3 pts worse
|
1.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 5.9% · Q4 10.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
21.2%
0.9 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.6% · Q3 23.4% · Q4 22.5% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.4% · Q3 6.1% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
79.9%
6.1 pts better
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 85.4% · Q3 81.3% · Q4 87.7% · 4Q avg 86.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
13.2%
9.7 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 3.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.5% |
78.1%
10.4 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.9%
0.8 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 20.3% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2023-02-23
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-23 · Fire 2021-10-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
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 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
F · Potential for more than minimal harm
2023-02-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-07-24
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 2025-08-22
D · Potential for more than minimal harm
2025-07-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-24
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 2025-08-22
G · Actual harm
2024-05-23
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 2024-06-11
B · Minimal harm
2024-05-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-10
Penalties and ownership
What sits behind the stars
$8,018
2024-05-23
Fine
Fine · fine $8,018
Fine
Ownership
Abernethy, Julius
Corporate Director · Individual
Alcorn, Gregory
Corporate Director · Individual
Bolick, Lawrence
Corporate Director · Individual
Branch, Anthony
Corporate Director · Individual
Clapp, Kenneth
Corporate Director · Individual
Cutts, Dawn
Operational/Managerial Control · Individual
Erdman, Charles
Corporate Director · Individual
Everyage
5% Or Greater Direct Ownership Interest · Organization
Everyage
Operational/Managerial Control · Organization
Everyage
5% Or Greater Security Interest · Organization
Gilliam, Jeffrey J
Corporate Director · Individual
Gray, Paul
Corporate Director · Individual
Horton, Michelle
Corporate Director · Individual
Howell, Parker
Corporate Director · Individual
Jones, Tammy
Operational/Managerial Control · Individual
Jones, Tammy
Corporate Officer · Individual
Maddox, Lamont
Corporate Director · Individual
March, Mills
Corporate Director · Individual
Niles, Maria
Operational/Managerial Control · Individual
Reimann, Aimee
Operational/Managerial Control · Individual
Reimann, Aimee
Corporate Officer · Individual
Sloan, Heather
Corporate Officer · Individual
Smith, Shane
Corporate Director · Individual
Stone, Susan
Corporate Director · Individual
Street, Jody
Corporate Director · Individual
Sullivan, Diana
Corporate Director · Individual
Syria, Lee
Operational/Managerial Control · Individual
Syria, Lee
Corporate Officer · Individual
Thie, Ronald
Corporate Director · Individual
Tobin, Cory
Corporate Director · Individual
Wiley, Margaret
Corporate Director · Individual
Wood, Kathy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
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
#2
Magnolia Gardens Center for Nursing and Rehabilita
Thomasville, NC
2-star overall rating with 2-star inspections with $16,153 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Westwood Health and Rehabilitation
Archdale, NC
4-star overall rating with 3-star inspections with $15,642 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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