Givens Health Center
600 Barrett Lane, Asheville, NC 28803 · Non profit - Corporation · 70 certified beds · (828) 771-2900 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 4 to 5 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 | 28.3% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 7.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.3% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.4% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.2% | 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 | 9.6% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 37.6% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.3% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.9% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 5.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 27.2% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.6% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 74.4% | 78.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.9% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.7% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.76 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.9% 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 114 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 59.6%CMS range 51.6–65.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.9–13.8 | 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 | 71.9% | 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 | 57.9% | 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 | 64.0% | 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 | 69.3% | 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 | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 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 3.6–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 70 beds and averages 54.7 residents a day — about 78% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.30 hrs/resident/day on weekends vs 5.65 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.29 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · Dcited before2026-03-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the fall history on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accidents (Resident #4).Findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, and dementia. Review of the nurse's progress note dated 08/22/2025, a fall event record dated 09/06/2025, and the nurse's progress note dated 09/26/2025 revealed Resident #4 had three unwitnessed falls in her room where she was found sitting on floor. The notes and fall record revealed after each fall the nurse assessed Resident #4 and Resident #4 had no injury. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had no falls since the prior assessment. During an interview of 03/18/2026 at 2:29 PM, the MDS Coordinator confirmed she completed Resident #4's fall history on the annual MDS dated [DATE]. She explained she reviewed the resident's fall event history…
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 · E2025-02-06 · 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 ensure 5 of 36 dishes ready for use on the tray line were free from dried scattered crumb like particles, provide expiration dates for 4 of 4 frozen boxes of pureed foods, label and date one stainless steel container of gravy and four cookie sheets of bacon that was located in 1 of 5 reach in coolers, and ensure 1 of 4 dietary staff restrained hair during food preparation. These practices had the potential to affect food served to residents. Findings included: 1. During the initial tour of the kitchen on 02/03/2025 at 11:12 AM the following areas of concern were observed. Two white scoop bowls with a yellow/orange substance on the bottom and side of each bowl and three divided plates with yellow/orange dried scattered crumb like particles. The dishes were observed on the tray line, ready to be used. On 2/5/25 at 11:05 AM Dietary Assistant #2 was interviewed. She explained she was one of three people who checked the dishes for cleanliness. Dietary Assistant #2 revealed the person who pulled the dishes out of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · 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, observation, staff and physician interviews, the facility failed to ensure residents had pain patches removed at bedtime as ordered for 2 of 29 residents reviewed for medication errors (Residents #45 and #31). Findings included: 1. Resident #45 was admitted on [DATE] with multiple diagnoses including wedge compression fracture of the thoracic vertebrae numbers 11-12 (lower end of the middle section of the spine) and low back pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was severely cognitively impaired and was documented as requiring pain management. The physician order dated 1/23/25 read apply one Lidoderm (local anesthetic pain patch that contains lidocaine) 5% topical patch to T12 spine area every morning, remove Lidoderm patch each night at bedtime. A Medication Administration observation of Medication Aide (MA) #1 on 02/05/25 at 8:15 AM revealed a lidocaine patch was left in place on Resident #45's lower back dated 2/4/25. During an interview on…
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 before2025-02-06 · 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 observation, record review, and staff and physician interviews the facility failed to ensure a resident was provided supplemental oxygen per physician's orders for 1 of 2 residents (Resident #43) reviewed for oxygen. findings included: Resident #43 was admitted to the facility on [DATE] with multiple diagnoses that included acute respiratory failure with hypoxia (an absence of enough oxygen to sustain bodily functions). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was severely cognitively impaired and was documented as requiring supplemental oxygen. The physician's order dated 10/29/24 read to administer oxygen at 2 to 3 liters per minute via nasal canula. An observation of Resident #43 occurred on 02/04/25 at 9:00 AM. Resident #43 was observed in the sitting area on the 300 hall watching television. The resident's nasal canula was in place in the resident's nostrils and the tubing was connected to a portable oxygen tank secured to the back of Resident #43's wheelchair. While…
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 · D2025-02-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and physician interviews, the facility failed to ensure accurate documentation in the medical record for 2 of 29 residents (Residents #45 and #31) reviewed for accurate medical records. Findings included: 1. Resident #45 was admitted on [DATE]. The physician's order dated 1/23/25 read apply one Lidoderm (local anesthetic pain patch that contains lidocaine) 5% topical patch to T12 spine area every morning, remove Lidoderm patch each night at bedtime. A review of Resident #45's Medication Administration Record (MAR) for the month of February 2025 revealed Nurse #1 had documented the removal of the Lidocaine pain patch from Resident #45's lower back at 8:00 PM on 02/04/25. A medication pass observation of Medication Aide (MA) #1 on 02/05/25 at 8:15 AM revealed a lidocaine patch was left in place on Resident #45's lower back dated 2/4/25. During an interview on 02/05/25 at 09:00 AM with MA #1, the MA verbalized that the overnight nurse must have forgotten to remove the pain…
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 · D2025-02-06 · 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 record review, observation, and staff and physician interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a urinary catheter for when Nursing Assistant (NA) #1 emptied the resident's urinary catheter bag without wearing a gown for 1 of 2 staff (NA #1) observed for infection control practices. Findings included: The facility's policy titled Enhanced Barrier Precautions revised on 6/2024 states EBP refers to an infection control intervention designed to reduce transmission of multi-drug organisms that employs targeted gown, and gloves use during high contact resident care activities. Observation of Resident #43's door on 02/02/25 at 12:15 PM revealed signage for Enhanced Barrier Precautions. The signage indicated that staff who are performing direct care to Resident #43 required a gown and gloves to be worn. Further observation revealed a caddy outside of Resident #43's door that contained Personal Protective Equipment (PPE) such as gowns and gloves. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · 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 observation, record review, family and staff interviews the facility failed to honor a resident's choice to have a beard for 1 of 2 residents (Resident #10) reviewed for choices. The finding included: Resident #10 was admitted to the facility 11/02/22. A significant change Minimum Data Set assessment dated [DATE] indicated that Resident #10 had severe cognitive impairment. On 12/18/23 at 3:39 PM an interview was conducted with Resident #10's family member and an observation were made of Resident #10 during the interview. Resident #10 was sitting in a semi reclined position sleeping. He was neatly groomed with a light growth of a gray beard and mustache. The family member explained that the Resident was always very particular about his facial hair and kept his beard and mustache neatly groomed for the past 30 years or more. She indicated if Resident #10 understood that his beard had been shaved off, he would have been disappointed. She continued to explain that a while back she came in to find that…
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 · D2023-12-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure the code status information was accurate throughout the medical record for 2 of 2 residents reviewed for advanced directives (Resident #47 and Resident #53). The findings included: 1. Resident #47 was admitted to the facility on [DATE]. A review of the code status notebook maintained at the nursing station on [DATE] at 11:05 AM revealed a yellow golden rod code status of Do Not Resuscitate (DNR) dated [DATE]. Resident #47's quarterly Minimum Data Set assessment dated [DATE] revealed his cognition was severely impaired. A review of Resident #47's medical record on [DATE] at 11:05 AM revealed an advanced directive status of Cardiopulmonary Resuscitation (CPR). On [DATE] at 11:30 AM an interview was conducted with Nurse #1 who explained the residents' code status was maintained in their electronic medical record under their picture on their profile screen. The Nurse also stated their code status was also maintained in the code status notebook…
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 · D2023-12-21 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A services for 1 of 3 residents reviewed for Beneficiary Notification (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE]. Review of the beneficiary notifications for Resident #10 revealed a Notice of Medicare Non-Coverage (NOMNC) was signed by Responsible Party (RP) on 11/06/23. The NOMNC showed the facility initiated Resident #10 be discharged from skilled rehab therapy on 11/09/23 due to no further progress. The facility was unable to provide evidence a SNF-ABN was provided to Resident #10 or the RP. Review of the beneficiary notification of residents discharged within the last six months revealed Resident #10 was discharged from Medicare Part A on 11/09/23 with remaining benefit days. Resident #10 remained as a resident in the facility. During an interview on 12/19/23 at 12:24 PM 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 · D2023-12-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change had occurred for 2 of 9 sampled residents reviewed for hospice and resident assessments (Residents #28 and #47). Findings included: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses that included other neurological conditions and malnutrition. Review of Resident #36's electronic medical record revealed a significant change MDS assessment with an Assessment Reference Date (ARD) of 11/09/23. The MDS assessment was signed as completed on 12/14/23 which was 36 days after the facility determined Resident #28 had a significant change in status. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #28's significant change MDS assessment dated [DATE] was late and not completed within 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.
Show the remaining 9 citations
- Potential for harm · Dcited before2023-12-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set Assessments (MDS) in the areas of Preadmission Screening and Resident Review (PASRR) and hospice for 2 of 4 residents reviewed for PASRR and hospice (Residents #6 and #18). Findings included: 1. A PASRR Level II Determination Notification letter dated 05/17/22 for Resident #6 had an expiration date of 06/16/22. It was noted nursing facility placement was appropriate for a limited nursing facility stay lasting no more than 30 calendar days. Resident #6 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation and depression. The annual MDS assessment dated [DATE] indicated Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 12/18/23 revealed…
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 · D2023-12-21 · 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 staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 2 sampled residents reviewed for PASRR (Resident #6). Findings included: A PASRR Level II Determination Notification letter dated 05/17/22 for Resident #6 had an expiration date of 06/16/22. It was noted nursing facility placement was appropriate for a limited nursing facility stay lasting no more than 30 calendar days. Resident #6 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation and depression. The annual MDS assessment dated [DATE] indicated Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 12/18/23 revealed Resident #6 had a 30-day [NAME] II PASRR effective 05/17/22…
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 · D2023-12-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 refer residents who were admitted with mental health disorders for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination of specialized services for 1 of 2 residents reviewed for PASRR (Residents #57). The findings included: A PASRR Determination Notification letter dated 07/31/23 revealed Resident #57 had a Level I PASRR with no expiration date. Resident #57 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, delusional disorder, and bi-polar disorder. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #57 received antipsychotics on a routine basis during the MDS assessment period. The psychotropic drug use Care Area Assessment (CAA) associated with the admission MDS…
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 · D2023-12-21 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 sampled residents whose closed records were reviewed (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses that included acute (severe and sudden onset) nondisplaced (bone cracks or breaks but maintains proper alignment) S2/S3 (referring to a sacrum fracture), severed L4-5 (referring to lumbar fracture), and severe, chronic L5 compression (type of fracture or break in the bones that make up the spine) fracture. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #65 had intact cognition. She required supervision with eating and locomotion off the unit and extensive staff assistance with all other activities of daily living (ADL). She received scheduled and as needed pain medication and reported a pain level of 09 out of 10 (numerical pain rating scale with 10 being the worst possible pain)…
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 before2023-12-21 · 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 2. Resident #48 was admitted to the facility on [DATE]. Resident #48's diagnoses included dementia and chronic obstructive pulmonary disease (COPD). Review of the active physician orders included Resident #48 received continuous oxygen at a rate of 2 liters per minute (LPM) as needed and continuous oxygen at 2 LPM twice daily when working with therapy for hypoxia (low levels of oxygen in the body's tissues). During an observation made on 12/19/23 at 9:24 AM, Resident #48 was sitting in his room in his wheelchair wearing oxygen via nasal cannula set at 2 liters per minute. There was no warning sign posted on the outside of the entry door to indicate oxygen was in use in the room of Resident #48. During an interview on 12/20/23 at 11:25 AM Nurse #1 explained she occasionally was the assigned nurse for Resident #48. She revealed the person who initiates oxygen should post the oxygen in use signs on the resident's door. During an interview on 12/20/23 at 11:33 AM Nurse Supervisor #1 explained the setup for oxygen…
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 · D2023-12-21 · 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 observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 04/09/21 and 08/26/22. This was for a repeat deficiency for failure to provide beneficiary notice originally cited on 04/09/21 and subsequently recited on the annual recertification survey conducted on 12/21/23. The repeat deficiency for failure to develop and implement a comprehensive care plan was originally cited during the recertification and complaint survey conducted on 08/26/22 and subsequently recited on the annual recertification survey conducted on 12/21/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: The tags were cross referenced to: F582- Based on record review and interviews with staff the facility failed to provide a Skilled Nursing Facility Advanced…
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 · D2023-12-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident and staff the facility failed to offer and administer the influenza vaccine for 1 of 5 residents reviewed for immunizations (Resident #5). Findings included: Review of the facility's policy for resident immunizations revised 11/2017 read in part, The Director of Nursing (DON) will be responsible for ensuring residents receive immunizations. On admission the facility will request information on previous immunizations and the Medical Records Coordinator and will notify the DON or designee of the history. Prior to immunization, the resident or their legal representative will be provided information and education regarding the benefits and potential side effects of the influenza immunization. Receipt of education and refusal of vaccination will be documented in the medical record. All residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident was already immunized. If immunization is…
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 · B2023-12-21 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 1 of 9 residents reviewed for resident assessments (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's electronic health record revealed an annual MDS assessment with an ARD of 08/10/23 was marked as completed on 09/08/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #2's annual MDS assessment dated [DATE] was late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-12-21 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the observation period) for 7 of 9 residents reviewed for resident assessments (Residents #2, #6, #16, #20, #28, #48, and #52). Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Electronic Health Record (EHR) on 12/19/23 at 3:55 PM revealed the following: a. A quarterly MDS assessment with an ARD of 08/10/23 was marked as complete on 09/08/23. b. A quarterly MDS assessment with an ARD of 11/10/23 with no date of completion. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator explained Resident #2's quarterly MDS assessment dated [DATE] was completed late and the MDS assessment dated [DATE] had not yet been done. She confirmed both assessments were not…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PARTIN, KENNETH | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 07/01/1983 |
| COWAN, JOHN | Individual | CORPORATE DIRECTOR | since 07/01/2009 |
| SHEPHERD, ROBERT | Individual | CORPORATE DIRECTOR | since 07/01/2009 |
| SUDDERTH, ROBIN | Individual | CORPORATE DIRECTOR | since 10/26/2012 |
| SMITH, PATRICIA | Individual | CORPORATE OFFICER | since 10/26/2012 |
| SQUIRES, ALLEN | Individual | CORPORATE OFFICER | since 08/01/1995 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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 345328. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.