Asheboro Rehabilitation and Healthcare Center
400 Vision Drive, Asheboro, NC 27203 · For profit - Limited Liability company · 100 certified beds · (336) 672-5450 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (59%) 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 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 held steady at 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 | 16.4% | 15.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.5% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 3.1% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 12.0% | 5.9% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.1% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.6% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 21.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.5% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 5.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.6% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.3% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.7% | 78.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.5% | 22.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.7% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.35 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.11 | 1.80 | 1.80 | worse |
‡ 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.
38.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.0% 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 32 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 38.3%CMS range 26.2–50.4 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.0%CMS range 9.8–19.3 | 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 | 75.0% | 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 | 65.6% | 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 | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 77.8% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 100 beds and averages 92.7 residents a day — about 93% occupied, or roughly 7 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.73 hrs/resident/day on weekends vs 3.32 on weekdays — 18% thinner on weekends. RN hours go from 0.39 to 0.25 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
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2023-04-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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, Nurse Practitioner (NP), Medical Director (MD) interviews and record review, the facility failed to have systems in place to identify a contracture which resulted in an avoidable wound where 3 fingernails on the resident's left hand punctured 2 areas into the palm of his contracted left hand requiring the need for wound care. The facility also failed to complete and document weekly assessments of the wound (Resident #70). This was for 1 of 2 residents reviewed providing care according to professional standards of practice. The findings included: 1. Resident #70 was admitted on [DATE] with a diagnosis of Parkinson's Disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #70 had severe cognitive impairment, was not coded for rejection of care, required extensive staff assistance with personal hygiene and he was coded for no limitation in range of motion to his upper extremities. Resident #70's care plan dated 5/2/22 last revised on 11/1/22 read he refused…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-13 · 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 staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of falls for 1 of 7 residents (Resident #97) reviewed for MDS accuracy.The findings included:Resident #97 was readmitted to the facility on [DATE] with diagnoses that included Dementia.A review of Resident #97's medical record revealed she had falls on 06/25/25 and 07/02/25 with no injuries. Resident #97 also had falls on 07/06/25 and 07/11/25 with minor injuries.A significant change Minimum Data Set (MDS) assessment, dated 07/29/25, indicated Resident #97's cognition was severely impaired and was coded for one fall with no injury since the last assessment (quarterly dated 06/24/25).An interview was conducted with the MDS Coordinator on 08/13/25 at 1:21 PM. The MDS Coordinator reviewed the MDS assessment dated [DATE] as well as Resident #97's medical record. The MDS Coordinator confirmed Resident #97 had 4 falls since the last assessment on 06/24/25 and should have been coded 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.
- Potential for harm · D2025-08-13 · tag F0644 — isolatedCoordinate 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 refer residents (Residents #2 and Resident #66) for a level II Preadmission Screening and Resident Review (PASRR) for newly diagnosed serious mental illness for 2 of 2 residents reviewed for PASRR.1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar type depression, dementia, anxiety disorder, and frontotemporal neurocognitive disorder. She was admitted with a level 1 PASRR as of 10/25/24 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Record review revealed Resident #2 was diagnosed on [DATE] with schizoaffective disorder. There was no evidence that a referral for level II PASRR screening was completed. Resident #2's annual Minimum Data Set, dated [DATE] indicated she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to follow a urology order to change the indwelling urinary catheter monthly for 1 of 2 residents reviewed for urinary catheters (Resident #47).The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (condition where urine flow is blocked or reversed) and neuromuscular dysfunction of the bladder (a condition where the nerves controlling bladder function are damaged). A review of Resident #47's medical record indicated he was admitted from the hospital on 5/16/25 and had been utilizing a urinary catheter while at home. A review of Resident #47's physician orders included the following: - An order dated 5/16/25 for indwelling catheter care- cleanse with soap and water every shift. - An order dated 5/16/25 to monitor the urinary catheter output every shift. - An order dated 5/20/25 to change the indwelling urinary catheter when occluded or leaking. - An order dated 5/21/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, Registered Dietitian (RD) and staff interviews, the facility failed to ensure the enteral tube feed (a method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) formula was specified in the active physician's order for Resident #3. This failure had been ongoing since June 2025. In addition, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for Resident #11 and Resident #88 which had the potential for bacterial growth and contamination. The deficient practice affected 3 of 4 residents reviewed for enteral feeding management (Resident #3, Resident #11 and Resident #88).The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke and diabetes type 2. A review of Resident #3's physician orders included the following:- - An order dated 1/18/25 through 6/18/25 for Glucerna 1.5 calories via a pump at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-13 · 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 interviews, the facility failed to administer oxygen at the prescribed rate (Resident #88) and failed to secure two oxygen cylinders stored in a resident's room (Resident #12) for 2 of 3 residents reviewed for respiratory care (Resident #88 and #12).The findings included: Resident #88 was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 had impaired memory and severely impaired decision-making skills. She was coded with the use of oxygen. A review of Resident #88’s active physician orders included an order dated 5/27/25 for oxygen at 2 liters via nasal cannula as needed for shortness of breath. On 8/10/25 at 2:49 PM, Resident #88 was observed lying in bed with her eyes closed and oxygen flowing via a nasal cannula. The oxygen regulator on the concentrator was set at 1.5 liters flow when viewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-13 · 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 Nurse Practitioner (NP) and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when Nurse #1 failed to perform hand hygiene between residents during 2 of 3 medication administration observations and failed to perform hand hygiene before donning gloves and after glove removal during administration of eye drops. This deficient practice was for 1 of 5 staff members observed for infection control practices (Nurse #1).A review of the facility policy titled Medication Administration (not dated): Preparation instructions stated in part: Perform hand hygiene before preparing and administering medications. A review of the facility policy for administering eye drops (not dated) stated in part: perform hand hygiene, apply gloves, administer eye drops, remove gloves, and perform hand hygiene.A continuous observation was started on 08/13/25 at 8:11 AM and ended at 8:26 AM of Nurse #1 preparing and administering Resident #60 and Resident #48's medications. Nurse #1 was observed at the medication cart collecting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-06 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident # 82 was admitted on [DATE] with cumulative diagnoses of depression anxiety, dementia with behavioral disturbances, unspecified psychosis and affective mood disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had moderate cognitive impairment, exhibited no behaviors and was coded for the use of an antipsychotic and an antidepressant. Review of Resident #82 September 2024 Physician orders included the following order dated 4/23/24: Seroquel (antipsychotic) Extended Release 24 hour 50 milligrams give one tablet by mouth in the afternoon for dementia with mood/psychotic disturbances. Another order dated 8/1/24 read Sertraline (antidepressant) 50 milligrams give one tablet by mouth at bedtime for dementia with behaviors, depression and anxiety. Review of the medication administration records (MARs) from November 1, 2023 to September 2024 included an order that was not included on the monthly Physician orders that read: Is resident free from side effects of psychotherapeutic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-06 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Administrator, resident, Nurse Practitioner (NP) #1 and Consultant Pharmacist interviews, the facility failed to identify the targeted clinical behaviors and side effects to be monitored for the use of psychotropic medications for Resident's #82, #73 and #68. The facility also failed to complete a baseline abnormal involuntary movement scale (AIMS) with the initiation of a newly prescribed antipsychotic for Resident #145. This was for 4 of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident # 82 was admitted on [DATE] with cumulative diagnoses of depression anxiety, dementia with behavioral disturbances, unspecified psychosis and affective mood disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had moderate cognitive impairment, exhibited no behaviors and was coded for the use of an antipsychotic and an antidepressant. Review of Resident #82's comprehensive care included a care area initiated on 10/30/23 and revised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to revise a smoking care plan to reflect a resident's level of supervision needed for smoking for 1 of 3 residents (Resident #77) reviewed for smoking. The findings included: Resident #77 was originally admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction. Review of Resident #77's quarterly smoking assessment dated [DATE] revealed the resident was a safe smoker and did not require supervision. Review of Resident #77's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired and required extensive assistance for most activities of daily living (ADL). Review of Resident #77's care plan revised on 7/5/24 revealed the resident required supervision when smoking. An interview with the MDS coordinator on 9/4/24 at 9:28 am revealed Residents #77's care plan should have reflected the resident being an independent smoker and edited when the smoking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 review and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 1 resident reviewed for gastric feeding tube (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, history of a stroke, dysphagia (difficulty swallowing) and presence of a feeding tube. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 had severe cognitive impairment and received all nutrition and fluids via a feeding tube. Review of the active care plan, last reviewed 7/16/24, revealed Resident #45 required tube feeding for all nutrition and fluids. The active September 2024 physician orders included an order dated 6/20/24 for Guaifenesin Liquid 100 milligrams per 5 milliliters. Give 20 milliliters by mouth three times a day for cough/congestion. All other medications were written to be provided through the gastric feeding tube. The physician orders indicated…
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 15 citations
- Potential for harm · Ecited before2023-04-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents (Rooms #104, #111, #206, #207, #302, #308, #310, #312, #316, #404, #405, #407 and #408). This was for 13 of 16 resident rooms reviewed for comfortable, clean, and homelike environment. The findings included: 1. On 4/17/23 from 10:30 AM to 12:00 PM the following was observed: - room [ROOM NUMBER] PTAC vent had a large amount of grey dust particles and thick yellow material throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had a thick amount of white substance throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had scattered particles of potato chip and a thick white material throughout the vent area. The room was occupied and the PTAC was running at the time of the observation. - room [ROOM NUMBER] PTAC vent had a large…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-20 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 observations, staff interviews and record review, the facility failed to provide scheduled showers for a resident requiring total staff assistance with bathing/showering. This was for 1 (Resident #70) of 3 residents reviewed for activities of daily living. The findings included: Resident #70 was admitted on [DATE] with a diagnosis of Parkinson's Disease. Resident #70's care plan dated 5/2/22 last revised on 11/1/22 read he refused his colostomy bag changes and eating. The care plan also read he refused care but there no documentation stating what care he refused. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #70 was coded with severe cognitive impairment, exhibiting no behaviors and he required total staff assistance with bathing. An observation was completed on 4/17/23 at 11:11 AM. Resident #70 was in bed wearing a facility gown and an odor was noted. Also observed was his hair and facial hair appeared unkept. An interview was completed with Nursing Assistant (NA) #9 who was in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, and resident and staff interviews, the facility failed to implement their smoking policy for conducting quarterly smoking assessments, ensuring a resident assessed as an unsafe smoker was supervised, smoking materials were secured, and cigarette butts were disposed of safely for 1 of 3 residents (Resident #69) reviewed for accidents. Findings included: Review of the facility smoking policy read in part, supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. It further read in part, Smoking materials for supervised smokers will be required to be locked at the nurse's station. No residents will be allowed to maintain their own lighter or matches. Residents will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. The resident should properly dispose of ashes or butts. Resident #69 was admitted 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 · E2023-04-20 · 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 discard opened food items ready for use by the labeled discard date in 1 of 1 walk-in refrigerators and failed to label, and date opened food left in 1 of 2 nourishment room refrigerators (station 1 reach-in refrigerator). This practice had the potential to affect foods served to residents. The findings included: 1. a. During the initial tour of the main kitchen with the Dietary Manager (DM) on 04/17/23 at 10:06 AM revealed the following items were observed in the walk-in refrigerator available for use. - One square shaped container with approximately 30 slices of bologna with a label on top of the container that read opened on 04/07/23 and a discard date of 04/11/23. - One square shaped container 1/4-1/2 full of turkey with a label on top of the container that read opened on 04/07/23 and a discard date of 04/11/23. - One square shaped container 1/2 full of shredded cheese with a label on top of the container that read opened on 04/09/23 and a discard date of 04/16/23. b. On 04/17/23 at 10:30 AM in station 1 ' s…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-20 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record 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 the annual recertification and complaint survey completed on 4/28/2022. This was for 3 deficiencies that were cited in the areas of clean homelike environment, accuracy of assessments, and providing activities of daily living care for dependent residents. 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. F677- Based on observations, staff interviews and record review, the facility failed to provide scheduled showers for a resident requiring total staff assistance with bathing/showering. This was for 1 (Resident #70) of 3 residents reviewed for activities of daily living. During the facility's recertification survey of record on 4/28/2022, the facility failed to trim and clean…
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 · D2023-04-20 · tag F0554 — isolatedAllow 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 observations, record review and staff and resident interviews, the facility failed to assess the self-administration of medications for 2 of 2 residents (Resident #5 and Resident #47) reviewed for self-administration. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was intact. Resident #5 had a physician's order dated 02/27/23 for Albuterol Sulfate HFA inhaler 2 puff inhale orally every 4 hours as needed for shortness of breath. Resident #5 was observed on 04/17/23 at 12:15 PM to have the Albuterol Sulfate inhaler on his overbed table. When interviewed, Resident #5 stated he had been using the inhaler since his admission. He stated the facility had always left the inhaler with him, so he did not have to ask every 4 hours to use it. Review of Resident #5's medical…
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 before2023-04-20 · 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 feeding tube (Resident #89) and bowel continence (Resident #70). This was for 2 of 23 resident records reviewed. The findings included: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (presence of a feeding tube-PEG tube). A review of Resident #89's physician orders revealed an order dated 2/18/22 to flush PEG tube with 250 milliliters (ml) of water twice a day. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #89 was cognitively intact. It did not include the presence of a feeding tube nor the amount of water received via the feeding tube during the seven day look back period. Resident #89's active care plan, last reviewed 3/13/23, included a focus area for a feeding tube present to meet nutritional needs due to history of a stroke and dysphagia. Tube…
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 · D2023-04-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to develop a comprehensive care plan in the area of contractures. This was for 1 (Resident #70) of 23 residents reviewed for care planning. The findings included: Resident #70 was admitted on [DATE] with a diagnosis of Parkinson's Disease and a contracture to his left hand. Resident #70's care plan dated initiated 4/12/22 and last revised on 3/1/23 did not include a comprehensive care plan related to his left-hand contracture. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #70 had severe cognitive impairment and coded for impairment to one side of his upper extremities. The MDS Nurse was interviewed on 4/20/23 at 10:40 AM. She stated she should have developed a care plan for Resident #70's left hand contracture and stated it was an oversight. The Administrator was interviewed on 4/20/23 at 11:45 AM. She also stated Resident #70's left hand contracture should have been care planned with appropriate interventions.
- Potential for harm · D2023-04-20 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included a history of a traumatic brain injury and contracture to the right wrist and hand. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 was severely cognitively impaired and displayed no rejection of care. She was coded with limited range of motion to one upper extremity. A review of Resident #55's active orders revealed a physician's order for right elbow support and hand therapy carrot as tolerated and to check each shift. The orders was dated 1/4/2023 An OT Discharge summary dated [DATE] indicated Resident #55 received OT therapy from 1/11/2023 through 1/24/2023 for a right elbow and wrist contracture. Upon discharge, the OT recommendation was for Resident #55 to wear the right elbow support and therapy carrot as tolerated to reduce risk for contracture and skin integrity problems. The care plan, last reviewed 4/17/2023, included a focus area for risk for alterations in functional mobility related…
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 before2023-04-20 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 staff interviews, the facility failed to ensure a bottle of tube feeding formula was dated when opened for use (Resident #200). This 1 of 4 residents reviewed with feeding tubes. The findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses that included dysphagia and gastrostomy (G-tube) status. Review of a physician order dated 4/1/23 read: Tube feed formula 1.5 CALORIES- Administer continuous via pump 70 milliliters (ml) per hour 20 hours per day. Downtime 2:00 AM until 6:00 AM. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #200 was severely impaired for daily decision making and required total assistance for all Activities of Daily Living (ADLs). The MDS further revealed that Resident #200 had a feeding tube and 51% or more of daily calories and 501 ml or more of daily fluid intake came from the feeding tube. An observation of Resident #200 was made on 4/17/23 at 12:12 PM as she was resting in a gerichair.…
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 · D2023-04-20 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 review, staff and Nurse Practitioner interviews, the facility failed to provide a dressing change to a Central venous catheter (CVC) line (a thin, flexible tube (catheter) that is placed into a large vein above the heart) as ordered. This was for 1 of 1 (Resident #14) resident reviewed for infections. The findings included: Resident #14 was originally admitted to the facility on [DATE]. She had a recent hospitalization from 03/28/23 through 04/03/23. She was readmitted to the facility on [DATE] with a diagnosis of urosepsis. Resident #14 ' s quarterly Minimum Data Set, dated [DATE] indicated her cognition was undetermined due to her persistent vegetative state/no discernible consciousness. Review of Resident #14's hospital Discharge summary dated [DATE] revealed she was to continue to receive Intravenous (IV) antibiotic for another 2 doses. Discharge paperwork indicated a CVC was placed to her left subclavian vein on 03/31/23. Review of Resident #14's readmission Physician orders…
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 before2023-04-20 · 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 observations, staff, Nurse Practitioner (NP) and Medical Director interviews and record review, the facility failed to obtain Physician orders for continuous oxygen (Resident #38) and failed to provide oxygen as ordered (Resident #37). This was for 2 of 6 residents reviewed for respiratory care. The finding included: 1. Resident #38 was admitted on [DATE] with diagnoses of Congestive Heart Failure (CHF), Aortic Stenosis, Chronic Obstructive Pulmonary Disease (COPD) and Atrial Fibrillation. Review of Resident #38's comprehensive care plan dated 3/2/23 read she was at risk for respiratory complications related to COPD, asthma and allergic rhinitis. The admission Minimum Data Set, dated [DATE] indicated Resident #38 was cognitively intact, exhibited no behaviors and was not coded for the use of oxygen. Review of Resident #38's cumulative Physician orders from 3/1/23 to 4/18/23 did not include any orders for the use of oxygen. Review of a nursing note dated 4/2/23 at 4:20 AM documented by Nurse #2 indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-08-13 · tag F0732 — widespreadPost nurse staffing information every day.
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 nurse staffing data was posted daily for 1 of 4 days of the survey conducted 8/10/25 through 8/13/25 (8/10/25).Findings included: During the initial tour of the facility on 8/10/25 at 10:00 AM, the posting of the daily staffing data was dated 8/8/25. An interview was conducted with Nurse Aide #3 on 8/10/25 at 3:40 PM who stated she was filling in for the scheduler who was currently on vacation. She indicated the scheduler did not work on the weekends, and it was up to the nursing staff to post the daily schedule on the weekends. On 8/10/25 Nurse #4 entered the facility from her reported break at 10:00 AM and stated, I am an agency nurse, and this is my first day working. I don't know anything, and I can't help you. The Director of Nursing was interviewed on 8/10/25 at 3:36 PM who stated the scheduler was responsible for posting daily staffing when she worked, but the hall nurse was responsible for the daily posting on the weekend. The Administrator was interviewed on 8/13/25 at 12:50 PM who stated 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 · Bcited before2025-08-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 maintain a clean toilet seat and an environment that was free of urine odor in residents' rooms. This deficient practice affected 1 of 4 residents reviewed for a safe, clean, comfortable, homelike environment (Resident #62). The findings included: An initial observation completed on 8/10/25 at 10:50 AM revealed Resident #62’s bathroom had yellow staining on the left front of the toilet seat. In addition, the trash can in the bathroom had 2 soiled adult undergarments rolled up inside, and the resident’s room and bathroom smelled strongly of urine. During subsequent observations on 8/11/25 at 1:18 PM and 8/12/25 at 2:40 PM Resident #62’s room and bathroom continued to have strong urine odors, and the yellow staining on the toilet seat remained. Wetness was noted on the floor surrounding the front of the toilet and seeping towards the doorway during the observation on 8/12/25. Resident #62 resided in his room during all observations, and he did not have a roommate during the survey. An interview and observation 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.
- No harm found · Bcited before2024-09-06 · 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 2a. Resident #36 was admitted to the facility on [DATE] with diagnosis that included major depressive disorder and schizophrenia. Review of Resident #36's physician orders included an order initiated on 11/6/23 for an antipsychotic medication to be given two times daily. A review of the July 2024 Medication Administration Record revealed Resident #36 was administered antipsychotic medication daily. An annual Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #36's cognition was cognitively impaired. The medications section was coded that she did not receive antipsychotic medication during the 7 -day look back period. On 9/5/24 at 3:28 PM, an interview occurred with the MDS nurse. She explained she had completed the medication section of the MDS and did not code the antipsychotic medication usage section correctly and that it was an oversight. b. A review of the PASRR Level II determination notice dated 3/1/24 indicated Resident #36 was approved for a Level II PASRR. A review of the Resident 36's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to YAD HEALTHCARE — 13 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 | 2 of 5 | 1.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.2 | +0.8 vs chain |
| Staffing | 1 of 5 | 1.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 2.8 | +0.2 vs chain |
The other 12 homes this chain runs (chain average 1.7★, 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 | Share | Since |
|---|---|---|---|---|
| ASHEBORO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2023 |
| ALTER, TZVI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 93% | since 08/01/2023 |
| BRAUN, JOSEPH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 08/01/2023 |
| ZARIF, AMIR | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2023 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
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 $96K 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 345277. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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.