Warsaw Rehabilitation and Healthcare Center
214 Lanefield Road, Warsaw, NC 28398 · Duplin County · 100 certified beds · avg 86 residents/day · certified since Oct 23, 1986
Part of chain: YAD HEALTHCARE (13 facilities, chain avg rating 1.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 9, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 9, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 9, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 18, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 21, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 4, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (19)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 22, 2026 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 22, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Jun 22, 2026 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jun 22, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 22, 2026 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Mar 21, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 9, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 9, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 22, 2024 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Apr 22, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 4 | 2 | J ▲ |
| 2025 | 10 | 1 | G ▲ |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $43,924, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 21, 2025 | Fine | $26,078 |
| Dec 9, 2024 | Fine | $3,413 |
| Dec 9, 2024 | Fine | $7,216 |
| Dec 9, 2024 | Fine | $7,217 |
| Dec 9, 2024 | Payment Denial | 10 days from Jan 7, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.42 | 4.01 | 3.95 | bottom 31% in North Carolina; bottom 33% in the U.S. |
| Registered Nurse hours | 0.42 | 0.64 | 0.69 | bottom 30% in North Carolina; bottom 26% in the U.S. |
| Weekend total nurse staffing | 3.16 | 3.56 | 3.50 | bottom 43% in North Carolina; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.41 | 0.48 | bottom 47% in North Carolina; bottom 34% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 49.0 | 45.8 | — |
| RN turnover (%) | 0.0 | 45.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.22, RN 0.40, weekend 2.98. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Alter, Tzvi | Individual | 5% or Greater Indirect Ownership Interest | 80% | 07/01/2025 |
| Braun, Joseph | Individual | 5% or Greater Indirect Ownership Interest | 20% | 07/01/2025 |
| Warsaw Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2025 |
| Afrede, Momin | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2025 |
| Afrede, Momin | Individual | ADP of the SNF | NOT APPLICABLE | 07/15/2025 |
| Caquias Gonzalez, Eileen | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2025 |
| Caquias Gonzalez, Eileen | Individual | ADP of the SNF | NOT APPLICABLE | 08/04/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How is routine foot care handled here, and does a podiatrist visit regularly?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Kenansville Rehabilitation and Healthcare Center | 7.0 mi | Kenansville, NC | ★★★★☆ | 5/5 | |
| Mary Gran Nursing Center | 13.2 mi | Clinton, NC | ★☆☆☆☆ | 1/5 | abuse |
| Southwood Nursing and Retirement | 13.2 mi | Clinton, NC | ★★★☆☆ | 4/5 | |
| Mount Olive Center | 14.1 mi | Mount Olive, NC | ★☆☆☆☆ | 1/5 | |
| Wallace Rehabilitation and Healthcare Center | 19.1 mi | Wallace, NC | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 345252.