Cycle 1
Health 2025-04-17 · Fire 2025-04-17
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fayetteville, NC
Whispering Pines Nursing & Rehab Center
5-star overall rating with 5-star inspections with $8,512 in total fines with 6 fire-safety deficiencies in the latest cycle
523 Country Club Drive, Fayetteville, NC
(910) 488-0711
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
86
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Century Care Management
Operator or chain grouping
Approved since
1991-01-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 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
0.42
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,901
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.02
Baseline 21.31% · Performance 17.71% · Measure score 8.02 · Achievement 8.02 · Improvement 7.90
Healthcare-associated infections
5.66
Baseline 8.20% · Performance 6.23% · Measure score 5.66 · Achievement 5.38 · Improvement 5.66
Total nurse turnover
2.69
Baseline 38.46% · Performance 52.69% · Measure score 2.69 · Achievement 2.69 · Improvement 0
Adjusted total nurse staffing
4.89
Baseline 3.87 hours · Performance 4.47 hours · Measure score 4.89 · Achievement 4.89 · Improvement 2.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 6.69% |
| Discharge to community | 45.73% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 38.98% · Lower 95% interval 37.68% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 56.82% |
53.69%
3.1 pts better
|
Numerator 25 · Denominator 44 |
| Discharge mobility score | 63.64% |
50.94%
12.7 pts better
|
Numerator 28 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 4.29% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 3.33% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 31.15% |
42%
10.9 pts worse
|
Numerator 38 · Denominator 122 |
| Discharge function score | 70.45% |
56.45%
14 pts better
|
Numerator 31 · Denominator 44 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 30 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
91.5%
0.7 pts better
|
93.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.2% · Q2 92.1% · Q3 93.8% · Q4 98.3% · 4Q avg 92.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.1%
4.4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.3% · Q3 4.7% · Q4 1.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.1% |
4.8%
6.3 pts worse
|
11.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 8.5% · Q3 18.6% · Q4 14.5% · 4Q avg 11.1% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
7.2%
0.5 pts better
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 4.8% · Q3 4.9% · Q4 6.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
21.6%
13.7 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 9.5% · Q3 4.8% · Q4 6.8% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
15.0%
2.6 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 10.9% · Q3 14.5% · Q4 10.0% · 4Q avg 12.4% · 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 | 25.5% |
21.5%
4 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
16.8%
3.4 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 23.6% · Q3 25.5% · Q4 14.3% · 4Q avg 20.2% · 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 | 3.3% |
2.6%
0.7 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.8% · Q3 1.6% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
21.2%
7.9 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 37.6% · Q3 23.2% · Q4 19.1% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.0%
1 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.7% · Q3 7.2% · Q4 7.9% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.7% |
79.9%
0.2 pts worse
|
81.7%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 71.4% · Q3 88.9% · Q4 88.7% · 4Q avg 79.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
13.2%
8 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.1% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.0% |
78.1%
15.1 pts worse
|
79.7%
16.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.5% |
22.9%
8.4 pts better
|
23.9%
9.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 15.4% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
2 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-10-14 · Fire 2021-10-15
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-27
F · Potential for more than minimal harm
2024-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-15
F · Potential for more than minimal harm
2021-10-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-22
F · Potential for more than minimal harm
2021-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-22
Inspection history
Recent health citations
G · Actual harm
2024-02-16
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 2023-09-08
D · Potential for more than minimal harm
2024-02-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-01
D · Potential for more than minimal harm
2022-10-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
$8,512
2024-02-16
Fine
Fine · fine $8,512
Fine
Ownership
Noah K Duncan Fam Tr
5% Or Greater Direct Ownership Interest · Organization
Boyette, Barbara
Corporate Director · Individual
Fontaine, Michelle
Corporate Director · Individual
Gilliam, Robert
Corporate Director · Individual
Gilliam, Robert
Corporate Officer · Individual
Gilliam, Robert
W-2 Managing Employee · Individual
Pagan, Jessica
Operational/Managerial Control · Individual
Schmidlin, James
Corporate Officer · Individual
Schroeder, Teresa
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Woodlands Nursing & Rehabilitation Center
Fayetteville, NC
4-star overall rating with 4-star inspections with $4,709 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Highland House Rehabilitation and Healthcare
Fayetteville, NC
1-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Haymount Rehabilitation & Nursing Center, Inc.
Fayetteville, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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