Penick Village
401 East Rhode Island Avenue, Southern Pines, NC 28387
Penick Village, a 32-bed non profit - other nursing facility in Southern Pines, NC, holds a 5-star CMS overall rating - well above the 3.0-star national average, with nurse staffing above the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9106920306
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- 5 / 5
- Much above average · CMS overall · nat'l 3.0
- 6.65
- Well above average · nurse hrs/day · nat'l 3.89
- 18
- Inspection findings · 3 serious
- $15K
- Federal penalties (3)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 345111
- Ownership
- Non profit - Other
- Provider Type
- Medicare and Medicaid
- Beds
- 32
- Residents
- 24
- In Hospital
- No
- County
- Moore
- Last Inspection
- Jan 23, 2025
Staffing Data
How the 6.65 total nursing hours per resident-day are staffed:
- RN Hours
- 1.32 (nat'l avg: 0.68)
- LPN Hours
- 1.30
- CNA Hours
- 4.04
- Total Nursing Hours
- 6.65 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 43.8%
- RN Turnover
- 33.3%
What the CMS Record Reveals About Penick Village
Penick Village operates 32 certified beds in Southern Pines, NC with approximately 24 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars (health inspection 4★ · staffing 5★ · quality 4★).
The inspection file contains 18 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS enforcement records show 3 penalties totaling $15K levied against this facility. Reported nurse staffing runs 6.65 total hours per resident day (national average 3.89); RN hours specifically are 1.32 per resident day.
Classified as "Non profit - Other" ownership and operating as a "Medicare and Medicaid" provider, Penick Village falls into a category where comparative context matters. Reported nursing turnover at this facility is 43.8%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (18 most recent)
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: Feb 6, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 6, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Nov 10, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 10, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 10, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 12, 2023
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Sep 9, 2022
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Sep 9, 2022
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 9, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 9, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 9, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 9, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2022
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Sep 9, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Sep 9, 2022
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Sep 9, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 16.7% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.4% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 16.2% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.8% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 92.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 23.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 93.3% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
Penalty History 3 penalties totaling $15K
| Date | Type | Amount |
|---|---|---|
| Aug 23, 2023 | Fine | $9K |
| May 15, 2023 | Fine | $2K |
| Apr 24, 2023 | Fine | $4K |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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