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Bethany Woods Nursing and Rehabilitation Center

33426 Old Salisbury Road, Albemarle, NC 28002 · For profit - Limited Liability company · 180 certified beds · (704) 983-1195 Medicare & Medicaid certified

Call the home — (704) 983-1195 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Apr 2026
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2026
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (59%) runs well above the national median (45%)
  • about 21% 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
929 N 2nd St · (980) 323-5625 · Call to confirm hours
Pharmacy
1420 US-52 N · (704) 550-9006 · Call to confirm hours
Grocery
Food Lion1.6 mi
2000 US-52 N · (704) 983-6170 · Call to confirm hours
Park
211 NE Connector · (704) 984-9560 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 3 to 4 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.2%15.6%15.4%better
Long-stay residents who lose too much weight4.3%7.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection1.9%2.3%2.0%typical
Long-stay residents with depressive symptoms0.0%5.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.2%3.5%3.3%typical
Long-stay residents whose ability to walk worsened5.8%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.4%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine89.8%94.1%95.3%typical
Long-stay residents with pressure ulcers4.4%5.5%4.7%typical
Long-stay residents with worsening bladder/bowel control5.2%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication2.2%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine53.3%78.1%79.4%worse
Short-stay residents rehospitalized after admission18.1%22.9%22.6%better
Short-stay residents with an outpatient ER visit14.3%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.621.781.67typical
Long-stay outpatient ER visits per 1,000 resident days0.961.801.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

51.2% 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 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.2%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
67.7%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 67.7% 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 31 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.2%CMS range 38.9–62.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.0–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.7%56.6%Oct 2024–Sep 2025CMS 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 discharge61.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.5%50.0%Oct 2024–Sep 2025CMS 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 identified95.6%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot 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 stay4.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 2.9–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 2022–Sep 2024CMS 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

0.48
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.20
RN hoursweekends
58.6%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 112.0 residents a day — about 62% occupied, or roughly 68 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below 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 3.15 hrs/resident/day on weekends vs 3.78 on weekdays — 17% thinner on weekends. RN hours go from 0.59 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above 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

9
deficiencies at the latest standard inspection (2026-04-02)
3
at the previous standard inspection (2024-12-19)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · E2026-04-02 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, and interviews with the police detective, pharmacy consultant, physician and staff, the facility failed to protect the residents' right to be free from misappropriation of multiple non-narcotic medications when Nurse #1 was found with a bag of prescribed medications during a traffic stop. This deficient practice affected 16 of 16 residents reviewed for misappropriation (Residents #2, #10, #31, #37, #60, #68, #78, #86, #88, #121, #122, #123, #124, #125, #126, and #127).The findings included: A review of the facility's policy entitled Abuse, Neglect, Misappropriation and Exploitation dated August 2019 read in part . The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without consent. A review of sheriff's office incident sheet dated 9/4/25 read that on 9/4/25 at 3:08 PM, a traffic stop was conducted with Nurse #1 due to a vehicle…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-02 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    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 and staff interviews, the facility failed to secure medications left on top of and in an unattended unlocked medication cart (400 hall medication cart) and failed to remove one (1) bottle of expired eye drops, label an Ozempic insulin pen with the name of the specific resident for whom it was prescribed and the date it was opened, and stored an unopened insulin pen in the medication cart (800 hall medication cart). This was for 2 of 3 medication carts observed for medication storage (400 hall and 800 hall medication cart). The findings included: 1. A continuous observation of an unattended medication cart on the 400 hall was made on 4/2/26 from 12:35 PM until 12:38 PM. The medication cart was observed to be unlocked (a red dot is visible on the lock mechanism when in the unlocked position), the narcotic medication drawer was pulled out and open, allowing the medications in the narcotic drawer to be exposed. In addition, a cup of crushed white pills and a small white bottle of 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 resident and staff interviews, the facility failed to ensure that residents were treated in a dignified and respectful manner. This was evidenced by staff arguing with a resident and using profanity in the resident's presence for 1 of 4 residents reviewed for dignity (Resident #7).Findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses that included unspecified mood affective disorder and anxiety disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #7 was cognitively intact.Resident #7's active care plan, last reviewed on 3/2/26, indicated that he exhibits problematic behaviors related to ineffective coping, including verbal aggression and expressions of anger. These behaviors include use of profanity towards others, making threats toward staff, and making false accusations regarding his care. Interventions included avoid arguments with the resident.A review of the investigation report dated 3/23/26, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 reviews, resident and staff interviews, the facility failed to ensure a resident's call light system was placed within reach and accessible for 1 of 8 residents reviewed for accommodation of needs (Resident #7).The findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses including quadriplegia, diabetes mellitus, stage 3 chronic kidney disease.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #7 was cognitively intact, had impaired function in both upper and lower extremities, and was dependent on staff for all activities of daily living (ADL).Review of the active care plan, last reviewed 3/2/26, identified the resident required staff assistance for all ADL due to quadriplegia and utilized a mouth blowing call system device to summon assistance. The care plan also indicated the resident exhibited problematic manner behaviors, including calling 911 when not receiving timely attention. Interventions included responding promptly 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident and staff interviews, the facility failed to provide personal privacy during incontinence care when Nurse Aide (NA) #1 captured a picture of Resident #42 with her cellphone while in the room during care. Resident #42 was partially clothed and uncovered in the photo. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident # 42).The findings included:Resident #42 was admitted to the facility on [DATE] with diagnoses including diabetes type II, congestive heart failure, and peripheral vascular disease with a right below the knee amputation (BKA). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 was cognitively intact, frequently incontinent, and dependent on assistance for activities of daily living (ADL).The Director of Nursing (DON) interview was conducted on 04/02/26 at 9:11 AM. The DON stated they received a call from an anonymous caller on 1/16/26 stating he had a screenshot of a resident from…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 reviews, and resident, staff, and Medical Director interviews, the facility failed to ensure oxygen was delivered at the prescribed rate. This deficient practice occurred for 1 of 4 residents reviewed for respiratory care (Resident #11).Findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure and COPD (chronic obstructive pulmonary disease).The care plan dated 12/31/25 revealed Resident #11 had an intervention for oxygen therapy as ordered related to COPD.A review of the electronic medical record for Resident #11 revealed a physician order dated 1/22/26 for oxygen therapy at 3 liters per minute (LPM) via nasal cannula continuously to keep oxygen saturation levels above 90%.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was cognitively intact and was receiving oxygen therapy.An observation of Resident #11 was conducted on 3/30/26 at 2:20 PM. It was noted the oxygen concentrator…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 2 of 3 residents observed for medication administration (Resident #129 and Resident #110).The findings includeda. Resident #129 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation and cardiomyopathy.A review of Resident #129's active physician's orders included a current order for March 2026 of metoprolol succinate 25 milligrams (mg) by mouth once daily. Hold for systolic blood pressure less than 110 or heart rate less than 60.On 4/1/26 at 9:00 AM Nurse #3 was observed as she obtained Resident #129's blood pressure and heart rate. Resident #129's blood pressure was noted as 110/64 and heart rate was 79. Nurse #3 stated she was going to hold Resident #129's metoprolol succinate since her systolic (top number) blood pressure was so close to the hold…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-19 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, observations and interviews with residents and staff, the facility failed to provide routine hair trimming. This was for 4 of 6 residents reviewed for activities of daily living (ADL) (Residents #36, # 50, #53, and #77). The findings included: 1. Resident #36 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact. During an interview and observation with Resident #36 on 12/18/24 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it. He explained he had not been able to get his hair cut in four months since the facility no longer had anyone available to provide this service. Resident #36 was unable to recall the staff that he talked to about getting his hair cut. Resident #36's hair was long on the sides and was long around the ears. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-19 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 reviews, and Nurse Practitioner, Medical Director, family member, and staff interviews, the facility failed to prevent significant medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included Eliquis (used to prevent blood from clotting), buspirone (used to treat anxiety disorders), gabapentin (used to treat epilepsy), isosorbide (used to treat high blood pressure), metoprolol (used to treat high blood pressure), spironolactone (used to treat high blood pressure), citalopram (used to treat depression). In addtion Resident #4 was administered medications prescribed to Resident #191 which included Aricept (used to treat dementia), Lexapro (used to treat depression) and Tramadol (used to treat pain). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #4). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 Nurse Practitioner (NP), Medical Director, family member, and staff interviews, the facility failed to prevent medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included fish oil (used to promote health by reducing triglycerides) and famotidine (decreases stomach acid and used to treat heart burn and gastroesophageal reflux disease). The facility also failed to prevent medication errors when medications were not administered as ordered by the physician (Resident #55). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #55). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. Resident #240 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #240 had orders for: - Famotidine 20 milligrams (mg) by mouth one time a day related to gastroesophageal reflux disease. -Fish Oil…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2023-09-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 observation and staff interview, the facility failed to maintain a clean floor and walls in the dry food storage room for 1 of 2 dry food storage rooms observed (the emergency dry food storage area). Findings included: On 08/28/23 at 9:34 am an initial observation of the kitchen, including the emergency dry food storage room was conducted. The dry food storage room floor and walls had black soiling all over them (entire floor and wall without shelves) as well as the front of the ice machine. The inside of the ice machine was clean and had ice. Concurrent interview with the Dietary Manager was conducted. He stated the floor had not been cleaned in a couple of days and the black was soil not aging of the floor tile and the front of the ice machine had splatter. The Dietary Manager stated that a couple of weeks ago the Maintenance staff had serviced the ice machine and caused the splatter which had not been cleaned. On 8/31/23 at 1:40 pm the Administrator was interviewed. The Administrator stated she was not aware the emergency dry food storage room floor and walls were dirty…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-01 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey conducted on 2/3/2022. This was for 5 deficiencies in the areas of resident rights, safe/clean/comfortable homelike environment, accuracy of assessments, care plans, and services to meet professional standards, previously cited on 2/3/2022 and recited on the current recertification and complaint survey of 8/31/23. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F550- Based on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder. The findings included: Resident #87 was admitted [DATE]. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required supervision and set up only during the assessment period. Resident # 87's comprehensive care plan was last revised 8/3/2023 and included a focus for nutritional status due to inadequate intake. On 8/28/2023 at 12:37 PM Resident #87 was observed in the dining area. The Occupational Therapy Assistant (OTA) provided Resident #87 with assistance eating and drinking. On 8/29/2023 at 12:45 PM Resident #87 was observed in the dining area. OTA provided Resident #87 with…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 assess Residebt #22 for self administration of medication for 1 of 1 resident observed to self-administer medication. Findings included: Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's current physician orders did not include an order for the resident to self-administer medications. The annual Minimum Data Set, dated [DATE] documented Resident #22 had a moderately impaired cognition. The resident's active diagnoses were hypertension, arthritis, and osteoporosis. Resident #22's care plan dated 7/1/23 revealed the resident was not care planned to self-administer medications. On 08/28/23 at 9:55 am entry to Resident #22's room (room [ROOM NUMBER]), it was observed that the resident was holding a medication cup with 3 pills. The resident was taking a pill independently during entry into the room. Nurse #1 was not present. The remaining pills were red and orange in color. The 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 interviews with staff, the facility failed to request a level II Preadmission Screening and Resident Review (PASRR) for a resident (Resident #81) newly diagnosed mental illness for 1of 1 residents reviewed for PASRR. The findings included: Resident #81 was admitted from another facility on 6/7/22 with diagnoses of Diabetes, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. He was admitted with a level 1 PASRR as of 6/1/20 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Resident #81 was seen by Psychiatry on 12/14/22 due to anger, aggression and mood instability. Resident #81 was newly diagnosed with Borderline Personality Disorder, Bipolar Disorder and Narcissistic Personality Disorder. Resident #81's annual Minimum Data Set, dated [DATE] indicated he was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan. Findings included: 1. Resident #32 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. A review of Resident #32's electronic medical records from 6/1/23 to 8/31/23 documented the resident refused care, including incontinence care when needed at least once a week. Resident #32's care plan dated 7/26/23 documented she was totally dependent of 2 staff for bathing and was incontinent of bowel and bladder. There was no mention of care refusal. Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition. The resident had feelings of being down and refused care 3 to 5 times a week. No other behaviors were coded. The resident was dependent for bathing and required assistance of…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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, resident and staff interviews and record review, the facility failed to provide assistance with eating to maintain a resident's ability to feed himself for 1 of 1 residents (Resident #87) reviewed for activities of daily living (ADL). The findings included: Resident #87 was admitted [DATE] with diagnoses that included dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident required supervision and set up only during the assessment period. Resident # 87's care plan was last revised 8/3/2023 and included a focus for activities of daily living and personal care deficit. Interventions included provide supervision with minimal set up or assistance with cutting food, verbal cues and/or assist to complete meals as needed. Resident #87's medical record also contained an Occupational Therapy (OT) Plan of Care dated 8/4/2023. The OT care plan indicated the resident's current level of function required total assist for completion of meals. On 8/28/2023 at 12:37…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-02 · tag F0732 — widespread
    Post 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 post accurate daily staffing information as compared to the daily staffing schedules for licensed and unlicensed nursing staff for 19 out of 30 days (3/1/26, 3/2/26, 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/12/26, 3/13/26, 3/14/26, 3/17/26, 3/19/26, 3/20/26, 3/21/26, 3/24/26, 3/26/26, 3/27/26, and 3/28/26). The findings included: A review of the facility's daily posting for nursing staff for the past 30 days (3/1/26 to 3/30/26) as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 3/1/26 indicated that 12 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM, 5 Licensed Practical Nurses (LPNs) worked 11:00 PM to 7:00 AM and one Medication Aide (MA) worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/1/26 documented that 14 NAs worked 7:00 AM to 3:00 PM, 6 LPNs worked 11:00 PM to 7:00 AM and no MA worked 11:00 PM to 7:00 AM. b. The nursing schedule for 3/2/26 indicated that 4 Registered Nurses…

    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.

    Nursing and Physician Services Deficiencies · No revisit needed
  • No harm found · Bcited before2026-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to ensure resident rooms were maintained in good repair for 7 of 19 resident rooms reviewed for clean, comfortable and homelike environment (Residents #3, # 8, #31, #37, #63, #65, and #72). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit (Resident #3) was kept clean for 1 of 19 resident rooms observed. This deficient practice affected 3 of 8 facility hallways. The findings included: 1 a. On 3/30/26 at 10:31 AM, observation of Resident #63's room revealed scattered areas of damage to the wall behind the head of the bed, with sheetrock exposed. b. On 3/30/26 at 10:44 AM, observation of Resident #31's room showed scattered areas of wall damage behind the head of the bed that extended to the left side of the room on the same wall, with exposed sheetrock. c. On 3/30/26 at 10:56 AM, observation of Resident #37's room revealed multiple scattered areas of wall damage on the left side of the bed, with sheetrock exposed. In an interview with the Maintenance Director on 4/2/26 at 12:30 PM, he…

    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.

    Resident Rights Deficiencies · No revisit needed
  • No harm found · Bcited before2023-09-01 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to have a Packaged Terminal Air Conditioner (PTAC) unit in good repair (room [ROOM NUMBER]). This was for 1 of 6 rooms reviewed for comfortable, clean, and homelike environment. The findings included: On 8/28/23 at 12:30 PM, an observation of room [ROOM NUMBER] revealed the PTAC unit to have two broken vents and two missing sections of vent slats. Observations were conducted with the Maintenance Director on 8/31/23 at 8:50 AM. He observed the broken vent slats as well as the two sections of missing vents and indicated he was not aware of the damage to the PTAC unit. He acknowledged the area did require attention and would be repaired. The Administrator was interviewed on 8/31/23 at 1:45 PM and stated it was important for the environment to be well repaired and homelike.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2023-09-01 · tag F0641 — pattern
    Ensure 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 reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications (Resident #13 and Resident #42 ) for 2 of 22 residents reviewed. The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A review of Resident #13's physician orders included an order for Humalog Solution (insulin to treat diabetes) 100 units per milliliter (ml). Inject as per sliding scale subcutaneously with meals. If blood glucose levels measure: 0-200= then administer 0 units; 201-250= 1 unit; 251-300= 2 units; 301-350= 3 units; 351-400= 4 units. a. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 had received 7 days of an insulin injection. A review of the May 2023 Medication Administration Record (MAR) indicated Resident #13 received Humalog Solution as per sliding scale five days during the 7-day look back period for the 5/12/23 MDS assessment (5/6/23, 5/9/23,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Bcited before2023-09-01 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, observation, and staff interviews, the facility failed to clarify a consultation note and discontinue an order to flush an abscess drain (Resident #25). This was for 1 of 1 resident reviewed for well-being. The findings included: Resident #25 was originally admitted to the facility on [DATE]. He was recently readmitted from the hospital on 8/2/23 with a diagnosis of a liver abscess with a drain present. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 had severely impaired decision-making skills and was coded with surgical wounds. A review of Resident #25's active physician orders included an order dated 8/9/23 to use 5 milliliters (ml) of sterile saline solution via irrigation twice a day for the abscess tube for six weeks. Keep the drain to gravity drainage. Review of a Report of Consultation from a radiology specialist, dated 8/10/23, indicated the abscess had resolved and the drain was removed. Resident #25's August 2023 Medication Administration…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 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 →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 52.9+0.1 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 4 of 53.3+0.7 vs chain
The other 39 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Ayden Court Nursing and Rehabilitation CenterAyden, NC 1 of 5Greendale Forest Nursing and Rehabilitation CenterSnow Hill, NC 1 of 5River Trace Nursing and Rehabilitation CenterWashington, NC 1 of 5Somerwoods Rehabilitation and Healthcare CenterSomerset, KY 1 of 5University Place Nursing and Rehabilitation CenterCharlotte, NC 2 of 5Cherry Point Bay Nursing and Rehabilitation CenterHavelock, NC 2 of 5Clear Creek Nursing & Rehabilitation CenterMint Hill, NC 2 of 5Graham Healthcare and Rehabilitation CenterRobbinsville, NC 2 of 5Greenwood Rehabilitation and Healthcare CenterBowling Green, KY 2 of 5Macon Valley Nursing and Rehabilitation CenterFranklin, NC 2 of 5Magnolia Lane Nursing and Rehabilitation CenterMorganton, NC 2 of 5Northchase Nursing and Rehabilitation CenterWilmington, NC 2 of 5Tower Nursing and Rehabilitation CenterRaleigh, NC 2 of 5Westwood Hills Nursing and Rehabilitation CenterWilkesboro, NC 2 of 5Willow Creek Nursing and Rehabilitation CenterGoldsboro, NC 3 of 5Franklin Oaks Nursing and Rehabilitation CenterLouisburg, NC 3 of 5Greenhaven Health and Rehabilitation CenterGreensboro, NC 3 of 5Harmony Hall Nursing and Rehabilitation CenterKinston, NC 3 of 5Pine Ridge Health and Rehabilitation CenterThomasville, NC 3 of 5Piney Grove Nursing and Rehabilitation CenterKernersville, NC 3 of 5Premier Nursing and Rehabilitation CenterJacksonville, NC 3 of 5Richmond Pines Healthcare and Rehabilitation CenteHamlet, NC 3 of 5Riverpoint Crest Nursing and Rehabilitation CenterNew Bern, NC 3 of 5Smoky Mountain Health and Rehabilitation CenterWaynesville, NC 3 of 5Springbrook Nursing and Rehabilitation CenterClayton, NC 4 of 5Barbour Court Nursing and Rehabilitation CenterSmithfield, NC 4 of 5Carolina Rivers Nursing and Rehabilitation CenterJacksonville, NC 4 of 5Chowan River Nursing and Rehabilitation CenterEdenton, NC 4 of 5Croatan Ridge Nursing and Rehabilitation CenterNewport, NC 4 of 5Kerr Lake Nursing and Rehabilitation CenterHenderson, NC 4 of 5Lake Park Nursing and Rehabilitation CenterIndian Trail, NC 4 of 5Lake Way Rehabilitation and Healthcare CenterBenton, KY 4 of 5Northampton Nursing and Rehabilitation CenterJackson, NC 4 of 5Wayland Nursing And Rehabilitation CenterKeysville, VA 4 of 5Wilson Pines Nursing and Rehabilitation CenterWilson, NC 5 of 5Grantsbrook Nursing and Rehabilitation CenterGrantsboro, NC 5 of 5Harnett Woods Nursing and Rehabilitation CenterDunn, NC 5 of 5Jacob's Creek Nursing and Rehabilitation CenterMadison, NC 5 of 5Maple Grove Health and Rehabilitation CenterGreensboro, NC

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 / managerTypeRoleSince
HILL, RAYMONDIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2011
HILL, ROBERTIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2011
HILL, STEPHENIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2011
LARMAND, KERRIANNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
SALTZMAN, LEONARDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/01/2017
BOICE, GALEIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 02/18/2026
JOHNSON, DIANNEIndividualCORPORATE OFFICERsince 01/01/2011
PRINCIPLE IT SERVICES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2011
PRINCIPLE LONG TERM CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2011

CMS files one row per role, so the 19 rows in the source record cover these 9 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.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$11.6M
Net patient revenuemost recent cost report
-15.8%
Operating marginrevenue minus expenses
$2.8M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 6%Other / private 17%

About 77% 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 $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$357per resident / day
operating cost
$10,843per month
≈ monthly operating cost
$308per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

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 345146. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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.

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