Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Cypress Valley Center for Nursing and Rehabilitati
REIDSVILLE, NC · 110 certified beds · Last Life Safety survey June 20, 2024
CMS Certification Number 345227 · first certified October 1982
Ownership
Operated by ALLIANCE HEALTH GROUP · For profit - Corporation
- Ownership changed August 1, 2024 (change of ownership)to CYPRESS VALLEY CENTER FOR NURSING AND REHABILITATION from PELICAN HEALTH REIDSVILLE LLC
Position within NC
17 citations — more than 82% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to October 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was June 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0924 Put firmly secured handrails on each side of hallways.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 2, 2021 | 0 |
| April 20, 2023 | 10 |
| June 20, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-06-20 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-06-20 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-06-20 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-06-20 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-04-20 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-04-20 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-04-20 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-04-20 |
What the citations cover
- Smoke Deficiencies 8
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 20, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 13, 2024) |
April 20, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 18, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.