Ahoskie Health and Rehabilitation Center
604 Stokes Street East, Ahoskie, NC 27910 · For profit - Corporation · 151 certified beds · (252) 332-2126 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- about 26% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.1% | 15.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.6% | 7.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.5% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 13.6% | 5.9% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.2% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.2% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.6% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.2% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 50.0% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.1% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.8% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.49 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.52 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
39.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 45% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.5%CMS range 28.2–53.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 16.8%CMS range 12.7–21.3 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 92.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 11.4%CMS range 6.3–17.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 151 beds and averages 120.2 residents a day — about 80% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.67 hrs/resident/day on weekends vs 4.08 on weekdays — 10% thinner on weekends. RN hours go from 0.43 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2025-12-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to update the resident's code status information when Resident #12's Responsible Party requested a change from do not resuscitate to full code. This was for 1 of 4 residents reviewed for advanced directives (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE].Resident #12's care plan revised 3/19/25 revealed he had a goal status of do not resuscitate.Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was assessed as being severely cognitively impaired.Review of a care plan meeting note dated 11/25/25 written by the MDS Nurse indicated Resident #12's responsible party stated she would like to change Resident #12's code status from do not resuscitate to full code.An attempt to contact Resident #12's responsible party was not successful on 12/18/25 at 9:39 AM.An observation of Resident #12's electronic medical record showed on the communication bar a code…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set Assessments (MDS) for 2 of 32 residents whose MDS assessments were reviewed for accuracy (Resident #22, and Resident #25). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities, schizophreniform disorder, depression, anxiety and dementia. Review of Resident #22's electronic health record revealed a Preadmission Screening and Resident Review (PASRR, a federal requirement for Medicaid-certified nursing facilities to assess individuals for serious mental illness) was completed prior to his admission and indicated Resident #22 was screened as Level II determination (a comprehensive evaluation conducted to assess the needs of individuals identified as having serious mental illness or intellectual disabilities, ensuring they received appropriate care and services in the nursing home) with no end date. A review of Resident #22's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to secure the indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #11).The findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses that included bladder rupture and urinary retention.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. She was coded as having an indwelling urinary catheter.A Physicians' Order dated 12/16/25 indicated Resident #11 had an indwelling urinary catheter for urinary retention.An observation was conducted on 12/17/25 at 10:22 AM of Nurse Aide #2 performing catheter care for Resident #11. The indwelling catheter tubing had no securement device to prevent pulling of the catheter tubing. There was no tension on the catheter tubing during observation.An interview was conducted with Nurse Aide #2 on 12/17/25 at 10:30 AM. NA #2 stated she was assigned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis for 1 of 2 sampled residents reviewed for dialysis (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease requiring dialysis.The resident's care plan, last updated on 10/21/24, documented chronic renal failure and the potential for complications related to hemodialysis. Interventions included:- Communicating with the dialysis center regarding medications, diet, and lab results.- Coordinating care with the dialysis center.- Monitoring the shunt site daily and as needed for signs of infection, pain, or bleeding.- Notifying the physician of absence of thrill or bruit.Review of a hospital note dated 11/18/25 revealed that Resident #6 was hospitalized on [DATE] for a critical procedure for patients requiring long-term dialysis access. The resident continued receiving hemodialysis.Upon readmission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0729 — isolatedVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure 1 of 6 nurse aides employed at the facility remained listed on the NC Nurse Aide Registry with an active Nurse Aide I certification (NA#1).The findings included:A review of Nurse Aide #1's employment record reported a hired date as [DATE]. The Nurse Aide Registry Verification form revealed the facility requested verification of Nurse Aide #1's certification on [DATE] and the NA's certification was current.During an interview with the Nurse Aide Registry Representative on [DATE] at 10:38 am, she stated NA #1's Nurse Aide I Registry expired on [DATE]. She stated NA #1's Nurse Aide registry was submitted and processed on [DATE].A review of NA #1's time sheet since [DATE] listed NA #1 worked the following dates:On [DATE] at 06:59 am to 07:01 pm as a Nurse AideOn [DATE] at 06:54 am to 07:01 pm as a Nurse AideOn [DATE] at 07:14 am to 07:04 pm as a Nurse AideOn [DATE] at 07:08 am to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, manufacturers' instructions, and staff and Pharmacy Consultant interviews, the facility failed to remove one (1) multi-dose insulin injector pen that was expired and 2 bottles of expired eye drops in 1 of 4 medication carts (East Annex Medication Cart #1) reviewed for medication storage and labeling.The findings included: The manufacturer's instructions for insulin lispro injector pen stated it should be discarded 28 days after opening. The manufacturer's instructions for latanoprost solution (eye drop used to treat glaucoma) stated once the bottle was opened it could be used for 6 weeks. The manufacturer's instructions for dorzol/timolol solution (eye drop used to treat glaucoma) stated once bottle was opened it should be discarded 28 days after opening. An observation of the East Annex medication cart #1 on 12/17/25 at 2:09 pm revealed one (1) insulin lispro injector pen that was open which had an opened date of 11/3/25, one (1) bottle of latanoprost solution 0.05 percent (%) which had an opened date of 10/29/25 with an expiration date handwritten on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-18 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to maintain 1 of 2 nourishment room refrigerators and freezer clean, and in a sanitary manner to prevent cross contamination by failing to clean up spills (South Unit refrigerator). The findings included:On 12/17/25 at 11:17 AM the South Unit nourishment refrigerator was observed with the South Unit Nurse. The clear refrigerator drawers were noted with small, dried food particles and there was a brown sticky substance spilled on the bottom shelf of the freezer section. The South Unit Nurse indicated during the observation she was not aware who was responsible for cleaning the refrigerator.A second observation of the South Unit nourishment room, on 12/18/25 at 10:36 AM revealed the refrigerator and freezer were in the same condition.In an interview on 12/18/25 at 10:25 AM Housekeeper #1 stated that she was assigned to clean the South Unit refrigerator once a week and had not looked at or cleaned the freezer that week. In an interview on 12/18/25 at 11:29 AM the Administrator stated the dietary department was responsible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-26 · tag F0727 — failed to provide required RN coverage — widespreadHave 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview the facility failed to designate a full-time Director of Nursing (DON) for the Skilled Nursing Facility (SNF) when the current DON went out on family medical leave. The findings included: During an interview with the Administrator on 9/23/24 at 9:53 AM, the Administrator explained that the Director of Nursing (DON) was out due to having surgery. She stated the DON had been available by phone when unable to physically be in the building due to these issues. The Administrator stated on 9/16/24 the DON had planned surgery and took medical leave at that time. The Administrator stated that the Staff Development Coordinator who was a registered nurse (RN) was the contact person for nursing-related questions. During an interview with the Staff Development Coordinator (SDC) on 9/24/24 at 2:48 PM, she stated she shared on call duty with the Wound nurse. The SDC reported staff would call her with nursing related questions after hours during her on call day. The Staff Development Coordinator stated she had not been informed that she was the DON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-26 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and Consultant Pharmacist interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for residents receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medication for 3 of 5 residents reviewed for unnecessary medications (Resident #7, Resident #62, and Resident #57). The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors. Resident #7 had an active physician order dated 4/20/24 for quetiapine fumarate oral tablet (an antipsychotic medication) 25 milligrams (mg) give one tablet by mouth one time a day for dementia with behaviors. Resident #7 had an active physician order dated 4/22/24 for quetiapine fumarate oral tablet 50 mg at bedtime for behaviors. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was not coded for behaviors.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-26 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and Medical Director interview, the facility failed to hold a blood pressure medication as ordered by the physician when the blood pressure was above the parameter for 1 of 1 resident reviewed for a significant medication error (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses which included hypertension, heart failure, and atrial fibrillation. A physician order dated 3/18/24 for midodrine (a medication used to treat low blood pressure) 5 milligram (mg) tablet by mouth three times a day for hypotension (low blood pressure). Hold for systolic blood pressure (SBP) greater than 120 millimeters of mercury (mmHg). Review of the Medication Administration Record for July 2024 revealed Resident #101 was administered midodrine 15 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 7/1/24 at 8:00 am SBP was 134 mmHg and was administered by Nurse #1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · E2024-09-26 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately document the administration of 14 doses of blood pressure medication in the medical record for 1 of 1 resident reviewed for a significant medication error (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses which included hypertension, heart failure, and atrial fibrillation. A physician order dated 3/18/24 for midodrine (a medication used to treat low blood pressure) 5 milligram (mg) tablet by mouth three times a day for hypotension (low blood pressure). Hold for systolic blood pressure (SBP) greater than 120 millimeters of mercury (mmHg). Review of the Medication Administration Record for July 2024 revealed Resident #101's midodrine was documented as administered 2 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 7/4/24 at 4:00 pm SBP was 132 mmHg and was documented as administered by Nurse #3. 7/10/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and resident interview, the facility failed to hold a care plan meeting or invite the resident to participate in the care planning process for 1 of 22 residents whose care plans were reviewed (Resident #62). The findings included: Resident #62 was admitted to the facility on [DATE]. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderate cognitive impairment. Resident #62 was coded for active participation in the assessment and goal setting. Review of Resident #62's electronic medical record revealed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-26 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of a pressure reducing surface for pressure ulcer (Resident #7) and the use of a continuous positive airway pressure (CPAP) machine (Resident #95) for 2 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #7 was admitted to the facility on [DATE]. Resident #7 had an active physician order dated 4/19/24 for a standard pressure ulcer redistribution mattress. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was coded for an unhealed, unstageable (due to coverage of the wound bed by slough and/or eschar) pressure ulcer. Resident # 7 was not coded for a pressure reducing surface for bed. An interview was conducted on 9/24/24 at 3:19 pm with MDS Nurse #2 who completed Resident #7's MDS quarterly assessment. MDS Nurse #2 confirmed Resident #7 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and resident interview, the facility failed to revise the care plan in the area of antipsychotic medication use (Resident #62) and risk for pain (Resident #101) for 2 of 22 residents reviewed for care plan revision. The findings included: 1. Resident #62 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, major depressive disorder, and cognitive communication deficit. Review of the Psychiatric Provider visit note dated 12/11/23 revealed Resident #62 was recommended to start olanzapine (an antipsychotic medication) 2.5 milligrams (mg) tablet at bedtime for mood instability related to dementia. Resident #62 had an active physician order dated 12/14/23 for olanzapine 2.5 mg at bedtime for mood instability related to dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderate cognitive impairment and was coded for rejection of care for 1-3 days during the 7-day look back period. Resident #62…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and Consultant Pharmacist interview, the Pharmacist failed to identify and report a medication irregularity when an Abnormal Involuntary Movement Scale (AIMS) assessment was not initiated for Olanzapine (antipsychotic medication used to regulate behaviors) or 1 of 4 residents reviewed for unnecessary medications (Resident #57). The findings included: Resident #57 was admitted on [DATE] with diagnoses that included anxiety disorder and dementia with behavioral disturbance. A review of the physician's orders revealed an order for Olanzapine 10 MG (milligrams) (an antipsychotic medication used to regulate behaviors)- Give 1 tablet by mouth at bedtime for mood instability and hallucinations dated 1/17/23. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact and was not coded for behaviors. Resident #57 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with resident, Speech Language Pathologist, Registered Dietitian, and staff, the facility failed to honor food preferences for 1 of 4 residents reviewed for preferences (Resident #66). The findings included: Resident #66 was readmitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, failure to thrive, diabetes, and dysphagia. An admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #66 with adequate hearing/vision, understood, understands, clear speech, severely impaired cognition. A diet order for Resident #66 dated 9/15/23 recorded a regular diet with mechanical soft ground meat texture on a sectioned plate with thin liquids, and double portions. Review of Diet Order and Communication form dated 9/15/24 for Resident #66 revealed a new diet order that included mechanically altered level 2, thin liquids, and double portions on a sectioned plate. A Nutritional Review dated 9/20/24, completed by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-10 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff and pharmacy interviews, the facility failed to complete the shift change inventory sheet consistently and accurately for 4 of 7 medication carts reviewed. Findings included: Review of the policy for Narcotic Reconciliation Protocol provided by the facility dated 5/30/23 stated in part: - The Director of Nursing or Nurse Manager shall reconcile narcotics monthly on or before the 15th of each month. - The reconciliation audit will include review of each narcotic book for shift count, narcotic count, narcotic page count and that the narcotics are stored with a double lock and key system. - Narcotic Management includes: o Assuring the Narcotic Shift Count is performed. 1 a. Review of the [NAME] Annex #1 medication cart with Nurse #3 revealed the Shift Change Controlled Substance Inventory Count sheet from 7/17/23 7:00 AM - 8/9/23 7:00 AM were missing the following entries: - 7 of 90 controlled substance card counts were not completed - 3 of 45 nurse signatures for coming on duty were missing - 3 of 45 nurse's signatures for going off duty were missing An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-10 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to secure medication storage cabinets in an unlocked room, remove expired medications from storage cabinets and refrigerator, failed to monitor temperatures of a refrigerator storing medication, and failed to secure a medication cart for 2 of 9 storage areas reviewed (Training Room and [NAME] Hall medication cart). Findings included: 1. Facility documentation noted two medication storage areas, one on the east annex hall and one on the west hall. The Training Room, used as a conference room, was granted to the state agency for use while on site. It was observed on 8/7/23 at 10:15 AM with a bank of cabinets on the walls on the right side of the room. There were 10 cabinet doors, 4 were observed with engaged padlocks and the remaining six without locks. A small refrigerator was observed to the left against the back wall. Daily Training Room remained unlocked while the state agency was on site, On 8/8/23 at 3:21 PM The Assistant Director of Nursing (ADON) was observed in the Training Room and retrieved an item from a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-10 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, staff interviews, and pharmacy interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 12/17/20 complaint investigation survey and 2/4/22 recertification survey. The facility had deficiencies previously cited in the areas of pharmacy services/procedures/pharmacist/records (F755) and label/store drugs and biologicals (F761). F761 was cited on 12/17/20 during a complaint investigation survey and on 2/4/22 during a recertification survey and F755 was cited on 2/4/2022 during a recertification survey. These deficiencies were cited again during the facility's current recertification and complaint investigation survey of 8/10/23. The continued failure of the facility during 3 federal surveys shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: The tag is cross referenced to: 1. F755: Based on record review, staff and pharmacy interviews, the facility failed to complete…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-10 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations upon admittance into the facility (Resident #66, Resident #80, Resident #94) and offer annual influenza vaccine (Resident #66) for 3 of 5 residents reviewed for immunizations. The findings included: The facility policy for Pneumococcal Vaccine dated 2/2/2022 read in part It is the policy of the facility that all residents be provided the opportunity and encouraged to receive pneumococcal vaccinations. Upon admission, obtain consent and acknowledgement for administering the pneumococcal vaccination from resident and/or resident's representative party. If vaccination was previously obtained within the past 5 years, it will be recorded on the immunization record. The facility policy for Influenza Vaccine dated 2/2/2022 read in part All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually. It…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-12-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to ensure accurate daily staff nursing postings for 13 of 30 days reviewed for accurate nurse staffing information (11/17/25, 11/18/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/27/25, 11/29/25, 11/30/25, 12/2/25, 12/11/25, 12/12/25 and 12/13/25).The findings included:The daily staff nursing postings from 11/15/25 through 12/15/25 did not include the resident census on 11/17/25, 11/18/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/27/25, 11/29/25, 11/30/25, 12/2/25, 12/11/25, 12/12/25 and 12/13/25.An interview conducted with the Director of Nursing (DON) on 12/18/25 at 12:11 PM revealed she was responsible for updating the daily nurse staffing information postings. The DON stated the daily nurse staffing posting was usually filled out the previous evening and updated with the current daily census after the morning clinical meeting. The DON stated that Unit Manager #2 was responsible for updating the census on the weekends and the daily nurse staffing postings had been overlooked by the Unit Manager on the days it was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-12-18 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to develop a person-centered care plan in the areas of antipsychotic medication use (Resident #8), and preferred activities (Resident #109) for 2 of 32 residents whose care plans were reviewed.The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with psychotic disturbance. Review of Resident #8's December 2025 physician's orders revealed a medication order dated 07/22/25 for olanzapine (antipsychotic medication) 5 milligrams (mg) one (1) tablet every 12 hours for psychotic disorder. Review of Resident #8's current comprehensive care plan last reviewed on 10/24/25 did not reveal a care plan focus area related to receiving an antipsychotic medication. Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and was coded for antipsychotic medication use. Review of Resident #8's December 2025 medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-09-26 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a care plan that addressed dementia care for 1 of 3 residents reviewed for comprehensive care plans (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Dementia and Insomnia. Review of Resident #39's care plan updated on 8/7/2024 revealed a focus area for dementia was not reflected in the care plan. A review of Resident #39's Nursing progress note dated 9/21/2024 at 11:18 P.M. revealed the resident refused the previous shift nurse to complete wound care. In an interview with Nurse #12 on 9/25/2024 at 12:03 P.M. she revealed Resident #39 had behaviors which included refusing wound care and medications or forcing his way to the smoking area outside smoking times. During an interview with MDS Nurse #2 on 9/24/2024 at 12:10 P.M. she revealed it was her responsibility to ensure the diagnosis of Dementia was care planned. She further revealed the error of not updating the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AUGUST HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 5 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| EL KHOURY, SEMAAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| PRICE, SHANEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345359. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.