Cycle 1
Health 2026-01-13 · Fire 2024-10-15
22 health deficiencies
Top issue: Resident Rights (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Windsor, NC
Windsor Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $249,991 in total fines with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1306 South King Street, Windsor, NC
(252) 794-5146
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1990-12-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 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
0.46
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
1.88
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.95
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
82%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,258
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.97
Baseline 18.42% · Performance 19.13% · Measure score 4.97 · Achievement 4.97 · Improvement 0
Healthcare-associated infections
3.42
Baseline 6.94% · Performance 6.81% · Measure score 3.42 · Achievement 3.42 · Improvement 0.13
Total nurse turnover
0
Baseline 62.90% · Performance 83.53% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.62 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.57% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 17% · Lower 95% interval 8.72% |
| Discharge to community | 36.41% |
50.57%
14.2 pts worse
|
Worse than the National Rate · Eligible stays 83 · Observed rate 25.3% · Lower 95% interval 28.39% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 74 |
| Discharge self-care score | 52.83% |
53.69%
0.9 pts worse
|
Numerator 28 · Denominator 53 |
| Discharge mobility score | 50.94% |
50.94%
About the same
|
Numerator 27 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 13.51% |
2.29%
11.2 pts worse
|
Numerator 10 · Denominator 74 · Adjusted rate 8.83% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 30.95% |
8.2%
22.8 pts better
|
Numerator 13 · Denominator 42 |
| Staff flu vaccination coverage | 60.78% |
42%
18.8 pts better
|
Numerator 31 · Denominator 51 |
| Discharge function score | 60.38% |
56.45%
3.9 pts better
|
Numerator 32 · Denominator 53 |
| Transfer of health information to provider | 87.5% |
95.95%
8.5 pts worse
|
Numerator 21 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 30.77% |
25.2%
5.6 pts better
|
Numerator 12 · Denominator 39 |
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 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.8
2.2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.5%
7.3 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 98.8% |
| 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 | 5.3% |
3.6%
1.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.8% · Q3 6.3% · Q4 3.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.8%
3.9 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 17.7% |
7.2%
10.5 pts worse
|
5.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 32.8% · Q3 16.9% · Q4 14.0% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
21.6%
3.1 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 26.2% · Q3 15.9% · Q4 30.5% · 4Q avg 24.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
15.0%
10.4 pts worse
|
16.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.0% · Q3 30.4% · Q4 29.5% · 4Q avg 25.4% · 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 | 34.1% |
21.5%
12.6 pts worse
|
16.3%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
16.8%
10.1 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 33.3% · Q4 24.0% · 4Q avg 26.9% · 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 | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.8% · Q3 3.4% · Q4 3.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
21.2%
10.7 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 36.2% · Q3 23.9% · Q4 36.0% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
6.0%
3.3 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 10.4% · Q3 11.4% · Q4 7.8% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.3% |
79.9%
10.6 pts worse
|
81.7%
12.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 86.1% · Q3 86.4% · Q4 70.4% · 4Q avg 69.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 23.7% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
78.1%
3.8 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
22.9%
7.6 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 16.9% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-15 · Fire 2023-08-10
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2022-05-19
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-02-03
D · Potential for more than minimal harm
2024-10-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-08-10
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-06
F · Potential for more than minimal harm
2022-05-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-05-19
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 2022-08-31
D · Potential for more than minimal harm
2022-05-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-05-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-13
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 2026-02-04
E · Potential for more than minimal harm
2026-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
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 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-02-04
C · Minimal harm
2026-01-13
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-11-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-11-14
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 2025-11-20
F · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-28
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-28
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-06-13
G · Actual harm
2025-05-06
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 2025-05-28
G · Actual harm
2025-05-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-24
J · Immediate jeopardy
2024-11-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-14
J · Immediate jeopardy
2024-11-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-14
J · Immediate jeopardy
2024-10-15
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 2024-11-14
F · Potential for more than minimal harm
2024-10-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
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 2024-11-14
D · Potential for more than minimal harm
2024-10-15
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 2024-11-14
D · Potential for more than minimal harm
2024-10-15
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 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
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 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-14
B · Minimal harm
2024-08-06
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 2024-08-16
E · Potential for more than minimal harm
2023-08-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
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 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
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 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-30
C · Minimal harm
2023-08-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-03-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-21
Penalties and ownership
What sits behind the stars
$70,220
2025-05-06
Fine
Fine · fine $70,220
Fine
$0
2025-05-06
Payment Denial
Payment Denial · denial start 2025-05-27 · 17 days
17 day denial
$179,771
2024-10-15
Fine
Fine · fine $179,771
Fine
Ownership
Nc East Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Hc Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Zanziper Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Murray, Chris
W-2 Managing Employee · Individual
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2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Chowan River Nursing and Rehabilitation Center
Edenton, NC
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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