Cycle 1
Health 2025-04-17 · Fire 2025-04-17
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Greensboro, NC
Whitestone a Masonic and Eastern Star Community
3-star overall rating with 3-star inspections with $25,490 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
700 South Holden Road, Greensboro, NC
(336) 299-0031
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-10-26
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
0.80
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.31
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
1,654
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0099
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.34
Performance 18.49% · Measure score 6.34 · Achievement 6.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7.78
Performance 5.51% · Measure score 7.78 · Achievement 7.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 65.45% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.88
Baseline 6.65 hours · Performance 5.32 hours · Measure score 7.88 · Achievement 7.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.45% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 8.03% · Lower 95% interval 7.37% |
| Discharge to community | 62.21% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 135 · Observed rate 62.22% · Lower 95% interval 54.13% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.56% |
95.27%
3.3 pts better
|
Numerator 137 · Denominator 139 |
| Falls with major injury | 1.44% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 139 |
| Discharge self-care score | 47.12% |
53.69%
6.6 pts worse
|
Numerator 49 · Denominator 104 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 48 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 2.88% |
2.29%
0.6 pts worse
|
Numerator 4 · Denominator 139 · Adjusted rate 3.27% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 2.08% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 5.33% |
8.2%
2.9 pts worse
|
Numerator 17 · Denominator 319 |
| Staff flu vaccination coverage | 32.98% |
42%
9 pts worse
|
Numerator 126 · Denominator 382 |
| Discharge function score | 45.19% |
56.45%
11.3 pts worse
|
Numerator 47 · Denominator 104 |
| Transfer of health information to provider | 87.5% |
95.95%
8.5 pts worse
|
Numerator 35 · Denominator 40 |
| Transfer of health information to patient | 98.8% |
96.28%
2.5 pts better
|
Numerator 82 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 24.05% |
25.2%
1.1 pts worse
|
Numerator 19 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.9% |
91.5%
22.6 pts worse
|
93.4%
24.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 72.0% · Q3 69.2% · Q4 63.0% · 4Q avg 68.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.9% |
94.1%
17.2 pts worse
|
95.5%
18.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.7% |
3.6%
5.1 pts worse
|
3.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 8.0% · Q3 7.7% · Q4 3.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.8%
3.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
7.2%
4.3 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
21.6%
2.3 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 23.8% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
15.0%
5.9 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · 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 | 35.1% |
21.5%
13.6 pts worse
|
16.3%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
16.8%
11.3 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 27.6% |
21.2%
6.4 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 17.6% · Q3 20.0% · Q4 33.1% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.0%
1.8 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.6% · Q3 10.0% · Q4 11.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.9% |
79.9%
46 pts worse
|
81.7%
47.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 29.9% · Q3 37.6% · Q4 41.7% · 4Q avg 33.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
13.2%
2.5 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 13.4% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.9% · Q3 1.3% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.3% |
78.1%
49.8 pts worse
|
79.7%
51.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
22.9%
6.2 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 25.2% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-08-05 · Fire 2022-08-05
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-18
F · Potential for more than minimal harm
2023-12-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-12-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-12-21
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 2024-02-29
E · Potential for more than minimal harm
2023-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-12-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-29
D · Potential for more than minimal harm
2022-08-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-19
Inspection history
Recent health citations
G · Actual harm
2025-04-17
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 2025-05-07
E · Potential for more than minimal harm
2025-04-17
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 2025-05-07
E · Potential for more than minimal harm
2025-04-17
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-17
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-29
D · Potential for more than minimal harm
2025-04-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-07
K · Immediate jeopardy
2022-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-25
D · Potential for more than minimal harm
2022-08-05
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 2022-08-17
Penalties and ownership
What sits behind the stars
$25,490
2025-04-17
Fine
Fine · fine $25,490
Fine
Ownership
Masonic And Eastern Star Home Of North Carolina, Incorporated
5% Or Greater Direct Ownership Interest · Organization
Amin, Saad
Operational/Managerial Control · Individual
Bailey, Gilbert
Corporate Director · Individual
Browning, Jerry
Corporate Director · Individual
Burris, Linda
Corporate Director · Individual
Edwards, Dennis
Corporate Director · Individual
Edwards, Dennis
Corporate Officer · Individual
Fischer, Amy -Jo
Corporate Director · Individual
Fischer, Amy -Jo
Corporate Officer · Individual
Griffith, David
Corporate Director · Individual
Hillegass, Joshua
Operational/Managerial Control · Individual
Hughes, James
Corporate Director · Individual
Jernigan, Gene
Corporate Director · Individual
Jernigan, Gene
Corporate Officer · Individual
Johnson, Edward
Corporate Director · Individual
Lewis, Mark
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Mills, Tommy
Corporate Director · Individual
Norris, Steve
Corporate Director · Individual
Owen, Debra
Corporate Director · Individual
Patton, Carl
Corporate Director · Individual
Public Finance Authority
5% Or Greater Security Interest · Organization
Public Finance Authority
5% Or Greater Mortgage Interest · Organization
Rideout, Robert
Corporate Director · Individual
Sawyer, David
Corporate Director · Individual
Transou, Joseph
Corporate Director · Individual
Underwood, Norma
Corporate Director · Individual
Webster, Bryant
Corporate Director · Individual
Wells, Edward
Corporate Director · Individual
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#3
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