Westwood Health and Rehabilitation
625 Ashland Street, Archdale, NC 27263 · For profit - Corporation · 68 certified beds · (336) 434-2902 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Feb 2026
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,642 in federal fines (most recent 2024-08-22)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (81%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 2 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 | 9.3% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.1% | 7.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 5.9% | 6.5% | better |
| 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 | 2.8% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.9% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 23.0% | 21.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.0% | 14.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 4.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.3% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.7% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.3% | 12.9% | 12.0% | 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.
48.4% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 96.3% 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 27 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 48.4%CMS range 38.1–61.4 | 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 | 10.8%CMS range 7.6–14.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 96.3% | 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 | 92.6% | 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 | 85.2% | 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 | 100.0% | 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 | not 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 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 | 2.9% | 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 | 0.0% | 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 | 6.5%CMS range 3.1–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 68 beds and averages 63.7 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 2.74 hrs/resident/day on weekends vs 3.39 on weekdays — 19% thinner on weekends. RN hours go from 0.39 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 81% 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
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.
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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 resident, staff, and transportation driver interviews, the facility failed to provide safe transportation for Resident #1 when she was being transported by a contracted van transport company from dialysis back to the facility on 5/25/24. Resident #1's wheelchair was not secured to the floor securement system per the manufacturer's instructions. When Driver #1 accelerated the vehicle, Resident #1's wheelchair tipped backward, and the resident hit the right back side of her head. Driver #1 pulled the transportation van over to the shoulder of the road and called 911. Emergency Medical Services (EMS) arrived, assessed the resident, and determined she needed to go to the hospital for evaluation for her complaints of head pain. The accident occurred post hemodialysis and Resident #1 was prescribed and received Plavix (anticoagulant medication). There was a high likelihood of a serious adverse outcome for Resident #1 due to the resident's wheelchair not being secured to 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 · E2026-05-21 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 staff, Pharmacy Consultant, and Medical Director interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration (Residents #4, #5, #6, #7, #8 and #9).The findings included: A. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease with dyskinesia (a movement disorder defined by involuntary and uncontrollable muscle movements). Review of the active physician orders included the following orders:- An order dated 1/15/25 for ropinirole (a medication used to improve muscle control and manage movement) 0.25 milligrams (mg). Give one tablet by mouth three times a day for Parkinson's disease.- An order dated 1/16/25 for Benztropine Mesylate (a medication used to reduce muscle stiffness, body spasms and tremors) 0.5 mg. Give one tablet by mouth in the afternoon for dyskinesia.- An order dated 1/6/25 for Sinemet (a 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.
- Potential for harm · E2026-05-21 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to ensure there was sufficient nursing staff in the facility on 5/16/26 from 1:00 PM to 5:00 PM to administer medications as ordered to the D and E halls for 6 of 32 residents reviewed for medication administration (Resident's #4, #5, #6, #7, #8 and #9).The findings included: This tag is cross referenced to: F658: Based on record reviews, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration. (Residents ##4, #5, #6, #7, #8 and #9). The facility's daily assignment sheet dated 5/16/26 revealed the following nursing staff were scheduled to work during the day shift (7:00 AM to 7:00 PM) for medication administration. Nurse #1 was assigned to work on the A and F halls from 7:00 AM to 7:00 PM), Nurse #2 was assigned to work on the B and C halls from 7:00 AM to 7:00 PM, Medication Aide (MA) #1 was assigned 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 · Ecited before2026-02-19 · 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 record review, observation and staff interviews, the facility failed to discard expired medications and date open multiple-dose medications in 2 of 3 medication carts (A and D medication carts) and 1 of 1 medication storage room observed.Findings included: a. On 2/15/26 at 12:35PM, the medication room was observed with the Director of Nursing (DON) and Nurse #2. There was one open undated vial of Apilsol Tuberculin Purified Protein Derivative (PPD) solution stored in the refrigerator (The manufacturer's storage instruction indicated once opened the solution should be discarded within 30 days). b. On 2/15/26 at 2:38 PM, the medication cart for hall A was observed with Nurse #4. The following expired and undated medications were observed in the cart:- One bottle of Nitroglycerin 0.4 milligram (mg) tablet - expiration date 1/2026,- Two Humalog Insulin KwikPens opened and undated (The manufacturer's Insulin storage instruction indicated once opened, Humalog should be stored at room temperature and used within 28 days),- One Insulin Glargine Injection Pen opened and undated (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 · E2026-02-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 label and date food items and maintain food in sealed containers in the kitchen. Specifically, the facility did not label and date cups of orange juice in 1 of 1 walk-in cooler; did not seal and label a box of frozen biscuits with the date opened in 1 of 1 walk-in freezer; did not keep a small container of pimento cheese sealed in 1 of 1 reach-in refrigerator; and seal and label a box of rice with the date opened in the dry storage area. These practices had the potential to affect the safety and quality of food served to residents. The findings included:1. An observation on 2/15/26 at 10:05 AM revealed the following in the reach-in refrigerator: One small metal container of pimento cheese was loosely covered with plastic wrap, leaving it exposed to air. The date written on the wrap was obscured.The [NAME] was interviewed during the initial observation on 2/15/26 at 10:05 AM. She stated the pimento cheese was made the morning of 2/15/26. The cook did not respond when asked about the pimento cheese not being sealed.…
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 · D2026-02-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 reviews, observations, resident, and staff interviews, the facility failed to treat a resident in a dignified manner when there was a delay in answering a resident 's call light for 1 of 4 residents (Resident #21) reviewed for dignity.The findings included:Resident #21 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus, acute arterial ischemic stroke, multifocal, bipolar I disorder, current manic with psychotic features and Schizophrenia.Resident #21's admission care plan dated 01/23/26 did not have a focus area for behaviors.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21's cognition was intact. Resident #21 required moderate assistance by staff with oral hygiene, ambulating 10 feet, chair/bed to chair transfers, and personal hygiene, maximum assistance by staff with upper body dressing, bed mobility, and toileting transfers, and he was dependent on staff for toileting hygiene, and to shower/bathe self. A continuous…
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 · D2026-02-19 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, friend and staff and local Law Enforcement Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of resident's property. This affected 1 of 1 resident reviewed for misappropriation (Resident #19).The findings included: Resident #19 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #19 to be cognitively intact without behaviors. An initial allegation report was received by the State Agency from the facility's former Director of Nursing (DON) #2 on 8/29/25 at 4:15 PM. The report read that the facility initially became aware of the incident on 8/29/25 at 4:00 PM and alleged notification that Nurse #1 received a truck bed from Resident #19 with a BIMS of 12 (this score of 12 indicates the resident was cognitively intact). Resident's contact person notified staff that Nurse #1 was not supposed to receive the truck bed or any other of the items in her possession. Police were…
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 before2026-02-19 · 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 reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of accidents (Resident #11), and medications (Residents #49 and #21). This was for 3 of 24 residents whose MDS assessments were reviewed. The findings included: 1. Resident #11 was originally admitted to the facility on [DATE] with diagnoses that included history of a stroke and muscle weakness. A review of Resident #11's medical record revealed he had a fall on 12/13/25 with a minor injury of a skin tear to his right arm. The quarterly MDS assessment dated [DATE] indicated Resident #11 had severely impaired cognition. He was coded with one fall with no injury since the previous assessment. On 2/17/26 at 3:03 PM, an interview occurred with the MDS Consultant who had coded the 12/17/25 quarterly MDS assessment. She reviewed the MDS assessment dated [DATE] as well as Resident #11's medical record and confirmed Resident #11 had a fall on 12/13/25 that resulted in a skin tear to his…
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 · D2026-02-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, observation, Medical Wound Provider and staff interviews, the facility failed to assess a newly identified pressure ulcer that included the pressure ulcer stage, characteristics, and presence of pain and failed to complete pressure ulcer treatments as ordered 3 out of 5 days. This was for 1 of 5 (Resident #2) residents reviewed for pressure ulcer care.The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included recent left above the knee amputation and history of a stroke. An admission progress note dated 12/3/25, completed by Nurse #9, indicated Resident #2 had a surgical wound to the left thigh with 35 staples present. Her right foot was dry and cracked. Discoloration and scarring were present to the right leg, bruising was present to the right ankle, and her buttocks were free from any skin breakdown. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had moderately impaired cognition. She required maximum…
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 · D2026-02-19 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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, observation, and interviews with staff and Medical Director, the facility failed to provide behavioral healthcare services to a resident with diagnosed mental health disorders and behavioral symptoms for 1 of 1 resident (Resident #21) reviewed for behavioral and emotional needs.The findings included:A review of Resident #21's hospital Discharge summary dated [DATE] revealed he was admitted on [DATE] and discharged on 01/23/26 with discharge diagnosis that included bipolar I disorder-manic. His hospital course included psychiatry was consulted for Extrapyramidal Symptoms (EPS) (involuntary movements such as tremors, rigidity, and restlessness) agitation, and acute mania. Resident #21's discharge summary also included the following:Follow up appointments: Please make sure to follow up with Psychiatric appointments and medication management. Resident #21 was admitted to the facility on [DATE] with diagnosis that included bipolar I disorder, current manic with psychotic features and…
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 · D2026-02-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record review, Medical Director and staff interviews, the facility failed to hold a blood pressure medication as ordered by the physician for 1 of 6 residents whose medications were reviewed (Resident #49) for unnecessary medication.The findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included hypertension and heart failure. Review of Resident #49's physician orders included an order dated 9/6/24 for Metoprolol Tartrate (a medication for high blood pressure) 25 milligrams (mg). Give 12.5 mg by mouth every 12 hours. Hold if systolic blood pressure (SBP-the top number in the blood pressure reading) is less than 110. The January 2026 Medication Administration Record (MAR) was reviewed and revealed Resident #49 had received Metoprolol Tartrate, despite the SBP being below 110 on the following dates:1/3/26 for 9:00 PM dose, SBP was 109 administered by Nurse #5.1/9/26 for 9:00 PM dose, SBP was 109 administered by Medication Aide (MA) #1.1/10/26 for 9:00 PM dose, SBP…
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 18 citations
- Potential for harm · D2025-11-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect a resident's right to be free from resident to resident sexual abuse when Medication Aide #2 observed Resident #1, a male resident, fondle a severely cognitively impaired female resident (Resident #2) when he lifted both of Resident #2's breasts out of the neckline of her V-neck shirt and caressed them with both hands and when Medication Aide #1 observed Resident #1 holding the hand of Resident #2 and rubbing her hand over his pants in his crotch area. Resident #2 did not have the cognitive capacity to consent to this intimate sexual contact. This deficient practice affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2).The findings included:A. Resident #1 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, diabetes mellitus, coronary artery disease, cognitive communication deficit and a history of a cerebral infarction (a condition where blood flow to 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 · Ecited before2024-11-21 · 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, record review, and staff interviews, the facility failed to date opened vials of insulin and insulin pens stored 2 of 2 medication carts (B and C hall cart, and D and E hall cart) the facility failed to keep a medication refrigerated per manufacturer guidelines in 1 of 2 medication carts (B and C hall cart), and also failed to discard expired medications in 1 of 1 medication storage room. The findings included: a. An observation was conducted on 11/19/24 at 11:19 AM of the D and E hall cart with Nurse #1. The observation revealed 5 Lispro insulin pens were opened and undated, 2 of the 5 Lispro insulin pens were not labeled with resident names, 1 Lantus insulin pen was opened and undated, 1 Basaglar insulin pen was opened and undated. Nurse #1 verbalized that all opened medications should have been dated with the date they were opened. The medications were given to Nurse #3 to be discarded. Per the manufacturer's instructions, insulin should be discarded after 28 days of opening, b. An observation was conducted on 11/19/24 at 2:14 PM of the B and C hall cart…
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 · D2024-11-21 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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, observation, and staff interviews, the facility failed to honor a resident's request for his hair to be trimmed to his preferred length by not coordinating a hair cut despite staff's knowledge of the resident's preference. This deficient practice affected 1 of 2 residents reviewed for choices (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. Review of Resident #48's admission Minimum Dat Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #48's care plan revealed the resident had an activity of daily living (ADL) self-care performance due to weakness and cognitive loss. The goal was for Resident #48 to improve the current level of function in (ADL) through the next 90 days. Interventions included Resident #48 would be able to provide personal hygiene and oral care with supervision. An observation and interview conducted with Resident #48 on 11/17/24 at 12:10 PM…
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 before2024-11-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 as part of basic hygiene services for residents whose payor source was Medicaid. This was for 2 of 6 residents reviewed for Activities of Daily Living (ADL) (Residents #16 and #26). The findings included: 1. Resident #16 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was cognitively intact. During an interview and observation with Resident #16 on 11/17/24 at 11:45 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 his hair cut about six to eight weeks ago by someone he paid to come cut his hair and that he had asked staff several times about getting his hair cut. Resident #16 was unable to recall the staff that he talked to about getting his hair cut. Resident #16's hair touched his collar in the back and was long around the ears. On 11/19/24…
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 before2024-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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, observations, resident and staff interviews the facility failed to implement interventions to prevent further falls for Resident #6. This was for 1 of 3 residents reviewed for accidents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnosis that included unsteadiness on feet, orthostatic hypotension, osteoporosis, and dementia. Resident #6's care plan, last revised 08/20/24, indicated she was risk for falls related to cognitive loss, history of falls, weakness, incontinence, and use of psychotropic medication. Resident #6 also had poor safety awareness and required frequent cueing of safety. She had an unsteady gait and continued to transfer/ambulate without assistance due to cognitive loss. The interventions included the following: · Undated intervention: Ensure that the Resident #6 was wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheel chair · Fall on 3/17/24: Assist resident with toileting if will allow. ·…
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 · D2024-11-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, Nurse Practitioner, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 29 opportunities, resulting in a medication error rate of 6.9% for 2 of 3 residents (Resident #5 and Resident #16) during the medication administration observation. The findings included: a. Resident #16 was admitted to the facility on [DATE] with a diagnosis of retention of urine. A review of Resident #16's active Physician's orders included a current order for Macrobid (antibiotic) capsules 100 milligrams initiated on 11/4/24, one capsule one time daily for long term urinary tract infection prophylaxis. On 11/19/24 at 8:25 AM, the Unit Manager, who was working as a floor nurse, was observed as she prepared 11 of 12 medications for Resident #16. It was noted the Unit Manager had pulled the card containing the ordered Macrobid out of the medication cart, but instead of dispensing the medication in the cup with the others,…
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 · D2024-11-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interviews, the facility failed to disinfect a glucometer (used to check a resident's blood glucose level) after using per manufacturer's guidelines for 1 of 1 resident (Resident #29). The glucometer was individually assigned to Resident #29 and stored in the medication cart. The findings included: Review of facility policy titled Blood Glucose Monitoring and Disinfecting revised date 4/20/22 read in part; clean and disinfect the meter with disinfecting wipes (per manufacture guidelines), place meter in resident specific bag for storage. Review of the glucometer manufacturer's guidelines stated to disinfect, the meter's surface should be thoroughly wet with a Sani cloth wipe and allowed to remain wet for a full 2 minutes. Let air dry. A continuous observation was made on 11/19/24 from 1:04 PM to 1:10 PM. Nurse #1 opened the medication cart and removed the glucometer labeled for Resident #29. She then entered Resident #29's room prepared to check her blood glucose level. She cleaned Resident #29's finger on her left hand with an alcohol…
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 before2023-08-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, resident and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #24 and #44). This was for 2 of 6 residents reviewed for activities of daily living (ADL). The findings included: 1) Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, muscle weakness and lack of coordination. A significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #24 had severe cognitive impairment and required extensive assistance with personal hygiene tasks. A review of Resident #24's active care plan, last reviewed 8/8/23, revealed a focus area for having an ADL self-care performance deficit related to limited functional abilities and cognitive deficits. A review of Resident #24's nursing progress notes from 2/1/23 until 8/14/23 revealed no refusals of nail care documented. On 8/13/23 at 12:00 PM, Resident #24 was observed lying in bed. He was noted to have a dark brown…
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 · D2023-08-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 record reviews, observations and staff and resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #31). The findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, and heart failure. A review of the physician orders for Resident #31 included an order dated 11/07/22 for continuous oxygen at 2 liters per minute by nasal cannula every shift related to acute and chronic respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31's cognition was intact. He was coded with the use of oxygen. Resident #31's care plan dated 07/25/23 indicated a focus area of Resident #31 had oxygen therapy related to ineffective gas exchange and respiratory failure. The goal indicated Resident #31 would have no signs or symptoms of poor oxygen absorption through the review…
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 · D2023-08-16 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 reviews, observations, resident 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 an annual recertification and complaint survey completed on 04/12/22. This was for two deficiencies that was cited in the areas of Activities of Daily Living Care Provided for Dependent Residents and Respiratory/Tracheostomy Care and Suctioning. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This citation is cross referenced to: 1. F677 - Based on record reviews, observations, resident and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #24 and #44). This was for 2 of 6 residents reviewed for dependency on staff for Activities of Daily Living (ADLs). During the facility's recertification survey of 04/12/22 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.
- No harm found · C2026-02-19 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and staff interviews, the facility failed to post the most recent survey of the facility in the survey results notebook. This occurred for 2 of 4 days of the survey (2/15/26 and 2/17/26).Findings included: According to the iQIES database system, the facility's most recent survey was a complaint investigation survey completed on 11/7/25. During tours of the facility on 2/15/26 at 9:45 AM and 2/17/26 at 9:00 AM, the facility's survey results were observed in a notebook placed on a low table in the front lobby. The notebook contained survey results from a recertification survey completed on 8/16/23. The following surveys were not included in the survey results notebook:A compliant investigation survey dated 1/30/24.A focused infection control survey dated 4/8/24.A complaint investigation survey dated 8/22/24.A recertification survey dated 11/21/24.A complaint investigation survey dated 12/30/24.A complaint investigation survey dated 1/15/25.A complaint investigation survey dated 7/15/25.A complaint investigation survey dated 11/7/25. In 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.
- No harm found · C2026-02-19 · 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 post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 22 out of 46 days (1/6/26, 1/7/26, 1/10/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/24/26, 1/25/26, 1/28/26, 1/30/26, 1/31/26, 2/1/26, 2/2/26, and 2/3/26). The findings included: A review of the facility's daily posting for nursing staff for 1/1/26-2/15/26 as compared to the daily staffing schedule revealed an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 1/6/26 indicated that 6 Nurse Aides (NAs) worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 1/6/26 documented that 5 NAs worked 7:00 AM to 3:00 PM. b. The nursing schedule for 1/7/26 indicated that 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 1/7/26 documented that 7 NAs worked from 3:00 PM to 11:00 PM. c. The nursing schedule for 1/10/26 indicated that 2 Medication Aides (MAs)…
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 · B2026-02-19 · tag F0698 — failed to provide proper dialysis care — patternProvide 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 maintain evidence of ongoing communication with the dialysis treatment center in the medical record for 1 of 2 residents reviewed for dialysis (Resident #65). The findings included:Resident #65 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter waste and water from the blood). Resident # 65 was discharged on 12/19/25.Resident #65 had a physician order dated 12/4/25 for hemodialysis on Tuesday, Thursday, and Saturday.A review of Resident #65's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was not coded as receiving dialysis (not coded in error).A Review of Resident #65's electronic medical record revealed no completed dialysis communication forms. The facility was unable to locate any dialysis communication forms for Resident #65.A review of Resident #65 progress notes…
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 · C2024-11-21 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide the resident and their Responsible Party (RP) a written notification of the bed hold policy upon a resident's transfer to the hospital for 2 of 2 residents (Resident #37 and & 30) reviewed for hospitalization. This practice had the potential to impact 54 of 54 residents at the facility. Findings included: 1.Resident #37 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #37 was cognitively impaired. The discharge assessment dated [DATE] revealed Resident #37 was discharged to the hospital on [DATE] and was readmitted on [DATE]. Review of the nursing progress notes revealed there was no documentation that Resident #37 received written notice of the bed hold policy when she was sent to the hospital. An interview was conducted with the social worker on 11/19/24 at 11:48 am and she indicated that she did not send the bed hold policy to the resident, resident representative…
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 · B2024-11-21 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 staff interviews, the facility failed to provide the resident and/or the Responsible Party with a written notification of the reason for a hospital transfer for 2 of 2 residents reviewed for hospitalization (Residents #37 & #30). The findings included: 1.Resident #37 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively impaired. The discharge MDS assessment dated [DATE] revealed Resident #37 was discharged to the hospital on [DATE] and was readmitted on [DATE]. Review of the nursing progress notes revealed there was no documentation that Resident #37 received written notice of discharge or transfer when she was sent to the hospital. An interview was conducted with the Social Worker on 11/19/24 at 11:48 am and she indicated that she did not send a transfer/discharge notice to the resident and/or the responsible party (RP) when Resident #37 was sent to the hospital on [DATE]. She further…
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 · Bcited before2024-11-21 · 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 reviews, and staff interviews, the facility failed to have complete and accurate documentation for wound care (Residents #30, #55 and #56). This was for 3 of 35 resident records reviewed. The findings included: 1. Resident #30 was originally admitted to the facility on [DATE] with diagnoses of surgical aftercare for right below the knee amputation, and diabetes type 2. Resident #30 was seen in the hospital 4/22/24 to 5/1/24 for wound healing complication to the right below the knee amputation site. She underwent a revision to an above the knee amputation and returned to the facility for surgical wound care. Resident #30 required another hospitalization from 6/3/24 to 6/8/24 for altered mental status. Resident #30's physician orders revealed the following: - An order dated 6/10/24 to clean the wound to the left forearm with wound cleanser, apply Xeroform gauze (a sterile, medicated, non-adhering protective dressing) and a dry dressing daily. - An order dated 6/10/24 to cleanse the surgical…
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 · Bcited before2024-01-30 · 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 reviews, staff and Physician interviews, the facility failed to maintain complete and accurate medical records in the area of hospital readmission and medication changes for 1 (Resident #1) of 14 medical records reviewed. The findings included: Resident #1 admitted on [DATE] with diagnoses of a history of a Cerebral Vascular Accident (CVA), Diabetes Mellitus (DM) encephalopathy, schizophrenia, Parkinson's Disease and a history of urinary tract infections (UTIs). Review of Resident #1's September 2023 Physician orders included orders for Levemir insulin, Insulin Glargine and Humalog sliding scale insulin along with orders for oral anti-glycemic medications (Metformin and Januvia) and blood sugar checks three times daily. Review of a nursing note dated 9/29/23 read she was discharged to the hospital for an altered mental status. Review of Resident #1's hospital Discharge summary dated [DATE] read was discharged back to the facility with orders to continue all of her medications and blood sugar…
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 · Bcited before2023-08-16 · tag F0641 — patternEnsure 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 2) Resident #36 was admitted to the facility 04/13/23 with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and Gastroesophageal Reflux Disease. Resident #36's care plan dated 05/16/23 indicated a focus area of Resident #36 had a Percutaneous Endoscopic Gastrostomy (PEG) tube due to dysphagia from a stroke. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was not coded as having a feeding tube. On 8/15/23 at 2:45 PM, an interview occurred with the Dietary Manager. She verified she had completed the nutritional section for Resident #36's 07/28/23 MDS assessment. She stated she knew Resident #36 had a feeding tube, and she should have marked Resident #36's MDS as having a feeding tube. She stated the incorrect coding was due to human error. During an interview with the Director of Nursing and Administrator on 8/16/23 at 9:34 AM, they indicated the Dietary Manager was still learning the MDS coding process but would expect 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.
“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
$15,642 in federal fines across 1 penalty.
- $15,642 — penalty dated 2024-08-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to AVARDIS HEALTH — 38 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 | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 3.2 | +0.8 vs chain |
The other 37 homes this chain runs (chain average 2.0★, 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 |
|---|---|---|---|
| ARCHDALE PARENTCO LLC | Organization | DIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| NCOP HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| NU C II IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| NU C IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| RANDOLPH HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| SNF CARE CENTERS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| ZENITH HOLDCO II LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| ZENITH HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2025 |
| FC ENCORE ARCHDALE LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 05/01/2025 |
| HOBACK, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| SEMONES, BRANDI | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| SNF MGR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/19/2025 |
| BERNARDINI, HOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| FREEMAN, EVELYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| JONES, TEQUILLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| JOSEPH, DAWSON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 16 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.
10 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.
This home reported $387K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 345450. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.