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Currituck Health & Rehab Center

3907 Caratoke Highway, Barco, NC 27917 · For profit - Limited Liability company · 100 certified beds · (252) 457-0500 Medicare & Medicaid certified

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Flagged for abuse3 immediate-jeopardy citations2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$120,975 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $120,975 in federal fines (most recent 2024-08-30)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (57%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 Plank Bridge Rd Unit B · (252) 331-1829 · Call to confirm hours
Pharmacy
532A Caratoke Hwy · (252) 232-0278 · Call to confirm hours
Grocery
112 Maple Rd · (252) 267-3332 · Call to confirm hours
Park
130 Community Way · (252) 232-3007 · Typically dawn to dusk
Place of worship
4134 Caratoke Hwy · (252) 453-2773

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 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.4%15.6%15.4%better
Long-stay residents who lose too much weight6.3%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection3.5%2.3%2.0%worse
Long-stay residents with depressive symptoms9.4%5.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.2%3.5%3.3%better
Long-stay residents whose ability to walk worsened18.3%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.5%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine98.4%94.1%95.3%typical
Long-stay residents with pressure ulcers3.7%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control21.5%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table8.8%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication2.2%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine32.4%78.1%79.4%worse
Short-stay residents rehospitalized after admission26.7%22.9%22.6%worse
Short-stay residents with an outpatient ER visit10.6%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.521.781.67typical
Long-stay outpatient ER visits per 1,000 resident days1.111.801.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 210 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.5%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
35.9%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 35.9% 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 78 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.5%CMS range 42.6–56.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.6–13.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge35.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge34.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.3–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.26
Total nurse hours/ resident / day
0.33
RN hoursweekends
57.0%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 79.5 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.85 hrs/resident/day on weekends vs 3.43 on weekdays — 17% thinner on weekends. RN hours go from 0.37 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

4
deficiencies at the latest standard inspection (2025-12-04)
15
at the previous standard inspection (2024-08-30)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 15 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2024-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 observation, record review, and interviews with Division of Health Service Regulation (DHSR) Life Safety Surveyor, resident, physician and staff, the facility failed to provide the necessary supervision to ensure residents were safe while smoking when Resident #31 was found smoking in the presence of a supplemental oxygen device, to implement their smoking policy and effective interventions to address the resident's repeated non-compliance with safe smoking practices both inside and outside of the facility, and to monitor the resident to prevent further incidents of unsafe smoking. Resident #31 was assessed on admission as a non-smoker at the facility. On 1/31/24 Resident #31 was observed smoking outside in the designated smoking area and he had smoking materials in his possession in violation of the smoking policy. On 6/27/24 Resident #31 was observed smoking outside in a non-designated smoking area with his portable oxygen tank on his wheelchair. On 7/9/24 Resident #31 was observed lying in bed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-08-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, physician and laboratory customer service staff, the facility failed to notify the physician when Resident #6 experienced a change of condition. Resident #6 received a positive result from a urinalysis (UA) and culture and sensitivity (C&S), which indicated the resident had a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL, an enzyme produced by some bacteria that makes them resistant to many antibiotics) in her urine and failed to notify the physician of the C&S results after the report was received from the facility. These deficient practices affected 1 of 4 residents reviewed for a experiencing a change of condition related to a UTI (Resident #6). Resident #6 was sent to the emergency department on 6/22/24 after being found with seizure-like symptoms, requiring hospital admission for acute metabolic encephalopathy (an alteration in consciousness caused by large-scale brain dysfunction from impaired cerebral metabolism) caused by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-08-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed protect a resident's right to be free from abuse when a moderately cognitively impaired resident (Resident #29) punched severely cognitively impaired resident (Resident #231) in the face. Resident #231 was prescribed and received a blood thinner daily. Resident #231 sustained bruising and swelling to the left side of his face. Resident #231 stated he was scared and did not want to be near Resident #29. Resident #29 and Resident #231 were immediately separated. Resident #29 was moved to another room by himself. Resident #231 requested to be sent to emergency room for evaluation and did not return to the facility. Resident #231 transferred from the hospital to a different facility. Resident #231's family member stated Resident #231 had never emotionally recovered from the incident and still does not want to be in a room with someone else. This deficient practice affected 1 of 3 residents reviewed for abuse. The findings included: Resident #231 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-08-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 interviews with staff and the physician, the facility failed to ensure Resident #6 received necessary care and services for a urinary tract infection (UTI) when she experienced signs and symptoms of a change in condition. The facility failed to follow up on results of urinalysis, failed to effectively respond to a positive urinalysis (UA) report, failed to follow up on results of urine culture and sensitivity, effectively respond to urine culture and sensitivity results (C&S), and administer an antibiotic that was sensitive to the microorganism listed on the C&S report. These deficient practices affected 1 of 4 residents reviewed for UTI (Resident #6). Resident #6 was sent to the emergency department on 6/22/24 due to being found with seizure-like symptoms, requiring hospital admission for acute metabolic encephalopathy (an alteration in consciousness caused by large-scale brain dysfunction from impaired cerebral metabolism) due to a UTI with extended-spectrum beta-lactamase (ESBL, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2023-06-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observation, record review, staff interviews, Responsible Party (RP) interview, and Physician interview the facility failed to provide supervision of a resident with severe cognitive impairment and known exit seeking behaviors to prevent an unsupervised exit for 1 of 7 residents reviewed for accidents (Resident #56). On 1/01/23 Resident #56 exited the facility out the dining room exit doors unsupervised and without staff knowledge. An alarm sounded, however the alarm announcement was muffled and had static which made the announcement unclear, so the staff were not aware the announcement was in reference to an elopement. Staff did not respond to the alarm due to the poor quality of sound and did not initiate a search for Resident #56. Resident #56 was found by a visitor outside the facility near the dining room door. This dining room door had a one lane exit road on its left that was bordered by a brush covered area on the opposing side and to the right of the dining room door was an access road 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-12-04 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Responsible Party, Law Enforcement and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #1) took checks from Resident #92 without her knowledge, cashed one of the checks for $1000.00, and attempted to cash additional checks. The deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #92). Findings included: Resident #92 was admitted to the facility on [DATE]. An initial allegation report dated [DATE] completed by the Former Administrator showed that she (the Former Administrator) received an email from the Responsible Party of Resident #92, who also had Power of Attorney, on [DATE]. The Responsible Party of Resident #92 made the Former Administrator aware that someone had forged and cashed multiple checks from Resident #92's bank account. The report stated that the Responsible Party of Resident #92 did not accuse any one person and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0637 — isolated
    Assess 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 interview, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) after enrollment in a hospice program for 1 of 3 residents reviewed for death in the facility (Resident #6).Findings included:Resident #6 was admitted to the facility on [DATE] with a diagnosis of heart failure.A Long-Term Care Status Form dated 9/5/25 revealed Resident #6 was admitted to the hospice program at the facility on 9/5/25. His level of hospice care was routine hospice. No SCSA was found in Resident #6's medical record.In an interview on 12/2/25 at 3:51 PM MDS Nurse #1 stated Resident #6 was admitted to hospice services at the facility on 9/5/25. She reported she would have been responsible for completing an MDS SCSA for Resident #6 when he began receiving hospice services. She indicated she had missed this. MDS Nurse #1 stated she could not say why this had been missed.On 12/2/25 at 3:57 PM an interview with the Administrator indicated if Resident #6 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident #40) reviewed for PASRR.Findings included:Resident #40 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and schizophrenia.Resident #40's PASRR Level II determination notice dated 3/12/21 revealed nursing home placement was appropriate. It included the specialized service determination of follow-up psychiatric services by a psychiatrist. This PASRR Level II determination notice had no expiration date.Resident #40's annual MDS assessment dated [DATE] revealed he was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.On 12/2/25 at 12:23 PM an interview with MDS Nurse #2 indicated she coded the PASRR section of Resident #40's MDS assessment dated [DATE]. She stated Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to attempt alternatives prior to the installation and use of bed rails and did not assess for risk of entrapment when completing assessments for 1 of 2 residents reviewed for bed rails (Resident #67).Findings included:Resident #67 was admitted to the facility on [DATE] with a diagnosis of hypertension.Resident #67's current comprehensive care plan revealed a focus area dated as initiated on 3/8/25 and last reviewed on 9/11/25 for bilateral quarter bed rails (bed rails which extend from the head of the bed to a quarter of the way down the bed) to promote bed mobility. The goal was for Resident #67 to not demonstrate a decline in bed mobility through the next review. An intervention was for staff to assist with bed mobility as needed. Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He had no behaviors or rejection of care. He was independent with all bed mobility and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-30 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident, staff, Pharmacy Consultant and Medical Director interviews, the facility failed to have a medication error rate less than five percent as evidenced by 4 medication errors out of 33 opportunities, resulting in a medication error rate of 12.12% for 2 of 4 residents observed during the medication administration observations (Resident #18 and Resident #71). Findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute bronchitis, congestive heart failure and hypertension. Physician orders for Resident #18 included the following medications: - On 3/5/2024, Klor-Con 10 (Potassium Chloride) Extended Release 10 milliequivalent (meq) two tablets once a day. - On 3/7/2024, Fluticasone propionate spray 50 micrograms (mcg) suspension 1 spray alternating nostrils once a day for allergies. - On 7/3/2024, Polyethylene glycol 3350 powder 17 grams per dose mixed in 4-8 ounces of fluid. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a dinner meal tray line observation, staff interviews and record review, the facility failed to follow the approved menu for pureed diets for 7 of 7 residents on a pureed diet. The findings included: Review of the facility's menu dated 8/6/24 revealed the meal was a chicken sandwich, potatoes, vegetables, and baked beans. According to the menu residents on a pureed diet should have received one #10 scoop (3/8 cup or 3-4 ounces, an ivory colored handle) of pureed chicken and two #20 scoops (1.5 ounces, a yellow colored handle) of pureed bread. Observation of the dinner meal on 8/6/24 5:25 PM revealed [NAME] #1 used the one blue scoop of pureed chicken. There was no pureed bread on the serving line. In an interview on 8/6/24 at 5:33 PM, [NAME] #1 confirmed he used one blue scoop for the pureed chicken. He said he was not sure what size the blue scoop was and was unable to find the label with the number on the scoop. He said he did not add any bread to the pureed chicken or serve bread with the meal because the chicken patties were already breaded. He did not think there…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-30 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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, observations, resident interviews and staff interviews, the facility failed to maintain a complete and accurate medical record by failing to document the assessment and orders related to a resident's change in condition (Resident #6) and failed to maintain an accurate medical record for documentation of the administration of medications (Resident #6, Resident #18, Resident #71) for 3 of 33 residents whose medical records were reviewed. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses including renal (kidney) insufficiency a. Review of Resident #6's nursing Situation, Background, Appearance, and Review (SBAR) Communication Form to the provider dated 6/22/24 completed by Nurse #12 noted Resident #6 was unresponsive after a seizure. There was no assessment information on the SBAR, including no vital signs or interventions used to assist the resident. Review of Resident #6's Transfer and Discharge Information form dated 6/22/24 indicated there was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 review, and staff interviews, the facility failed to accurately document code status in the electronic medical record for 1 of 8 residents (Resident #63) reviewed for advance directives. The findings included: Resident #63 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction. A physician order dated 3/19/24 by Physician #1 stated full code status. The electronic medical record (EMR) revealed a Do Not Resuscitate (DNR) form dated 03/20/24 signed by Resident #63 and Physician #1. The care plan revised 6/26/24 indicated Resident #63 had chosen DNR status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was severely cognitively impaired. On 08/06/24 at 01:16 PM an interview was conducted with the Admissions Coordinator. She stated she verified advance directives/code status upon admission. If a newly admitted resident had no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0582 — isolated
    Give 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 staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services for 1 of 3 (Resident #30) residents reviewed for beneficiary protection review. The findings included: Resident #30 was readmitted to the facility on [DATE] and admitted to Medicare Part A services. Resident #30's Medicare Part A skilled services ended on 4/24/24 with days remaining and she remained in the facility. Review of Resident #30's medical records revealed a NOMNC (Notice of Medicare Non-Coverage) was given by phone to the resident's power of attorney on 4/22/24. Record review revealed no SNF ABN was provided to the resident or the resident's power of attorney. An interview was conducted with the facility Social Worker on 8/05/24 at 4:33 PM who stated she was responsible for issuing the NOMNC with the resident or responsible party. She said she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code smoking, the use of antiplatelets (medications that prevents blood cells from clumping together to form a clot), and the use of opioids (medications used for relieving pain) for 3 of 33 residents whose Minimum Data Set (MDS) assessments were reviewed (Resident # 3, Resident #54 and Resident #31). Findings included: 1.Resident #31 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease (COPD). A Smoking Assessment completed by nursing staff dated 1/27/24 indicated Resident #31 was a non-smoker or intended not to smoke. Nursing documentation dated 1/31/24 written by Nurse #2 revealed Resident #31 had gone outside to smoke and had taken his oxygen off before lighting his cigarette. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he had moderate cognitive impairment and was on oxygen therapy. The Current Tobacco use section was marked No. During an interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2024-08-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement an comprehensive individualized person centered care plan in the areas of smoking and antipsychotic medications for 2 of 32 residents reviewed for comprehensive care plans (Resident #65, Resident #31). Findings included: 1. Resident #31 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease (COPD). A Smoking Assessment completed by nursing staff dated 1/27/24 indicated Resident #31 was a non-smoker or intended not to smoke. Nursing documentation dated 1/31/24 written by Nurse #2 revealed Resident #31 had gone outside to smoke and had taken his oxygen off before lighting his cigarette. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had moderate cognitive impairment and was coded No for current tobacco use. A Smoking Assessment 4/18/24 completed by nursing staff indicated Resident #31 was a safe smoker. At the bottom of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    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 Family Member, Adult Protective Services, Home Health Agency, staff, and physician interview, the facility failed to provide a safe discharge planning process for 1 of 1 resident (Resident #277) reviewed for discharge from the facility. Resident #277 was discharged home on 8/1/24 to an independent living apartment. The facility failed to ensure the resident had a caregiver who could provide care, ensure that resident had a means to obtain medications needed at home, and secure a home health provider for continuity of care. Findings included: Resident #277's hospital Discharge summary dated [DATE] noted that prior to hospitalization, Resident #277 was living with Family Member #1, who said she was no longer able to care for the resident. The summary noted the resident was bedbound, required a lot of family support, and refused to eat and to take her medications at home. Resident #277 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection, sepsis (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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 a Family Member and staff interview, the facility failed to provide a complete discharge summary for 1 of 1 resident (Resident #277) reviewed for discharge to the community. Findings included: Resident #277 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL, an enzyme produced by some bacteria that makes them resistant to many antibiotics), sepsis (a life-threatening emergency to the body's response to an infection), a chronic disease of the immune system, and a history of deep vein thrombosis in both legs (blood clots). She discharged home to the community on 8/1/24. An admission Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #277 was cognitively intact and required extensive/maximum assistance (caregiver does more than half of the effort) for toileting, upper and lower body dressing, personal hygiene, and transfers. Review of Resident #277's Physical Therapy (PT) Discharge…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Physician, and Pharmacy Consultant interviews, the Pharmacy Consultant failed to identify on a drug regimen review a resident was prescribed and received an antibiotic that was not effective to treat a urinary tract infection (UTI) for 1 of 6 residents reviewed for pharmacy reviews (Resident #6) received an antibiotic ). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including renal (kidney) insufficiency and congestive heart failure (CHF). Review of Resident #6's urinalysis culture and sensitivity (C&S) results dated 6/10/24 revealed she had a UTI and the bacteria identified was Escherichia coli (E. coli) which was positive for ESBL. Continued review of Resident #6's C&S results dated 6/10/24 revealed the bacteria was resistant to the effects of the antibiotic levofloxacin. Review of Resident #6's nursing progress notes dated 6/17/2024 by the ADON revealed the C&S results were reviewed with the physician, who ordered the antibiotic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to practice infection control measures when Nurse Aide (NA) #3 did not apply a gown and gloves before entering a resident's room on contact isolation to deliver a meal tray (Resident #177) and when Nurse #3 and NA #5 did not wear gowns when providing gastrostomy tube, urinary catheter and wound care to a resident on enhanced barrier precautions (Resident #68) for 2 of 3 residents reviewed for infection control. Finding included: Th facility's Transmission Based Precautions policy dated 4/15/2024 stated contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the patient or the patient's environment. Personal protective equipment (PPE) recommended for contact isolation included gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident and gown whenever anticipating touching environmental surfaces or equipment in close proximity to the resident. The policy stated enhanced barrier precautions…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-06-08 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide written notification for reason of discharge to hospital to the Resident and Responsible Party (RP) for 8 of 8 residents reviewed for hospitalization (Resident #28, Resident #31, Resident #60, Resident #69, Resident #50, Resident #80, Resident #2, and Resident #85). The findings included: 1. Resident #28 was admitted to the facility on [DATE]. The change in condition assessment dated [DATE] revealed Resident #28 was sent to the Emergency Department for further evaluation and amputation for acute hematogenous osteomyelitis of his left femur. A record review of the nursing progress notes revealed there was no documentation Resident #28 and his Responsible Party (RP) received written notification of the reason for transfer to the Emergency Department. Resident #28 was discharged to the hospital on 4/12/2023 and returned to the facility on 5/4/2023. In an interview with the Director of Nursing (DON) on 6/7/2023 at 9:00 a.m. she stated she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2023-06-08 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to prevent the Director of Nursing (DON) from having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents for 15 of 92 days reviewed (5/20/2022, 6/4/2022, 6/24/2022, 6/25/2022, 6/27/2022, 6/28/2022, 6/29/2022, 6/30/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/18/2022, and 7/19/2022). The findings included: A review of the staffing schedule for May, June and July 2022 showed the average facility census was 68. A record review of the schedules from 5/1/2022 through 7/31/2022, revealed the DON worked as a nurse on the floor on 5/20/2022, 6/4/2022, 6/24/2022, 6/25/2022, 6/27/2022, 6/28/2022, 6/29/2022, 6/30/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/18/2022, and 7/19/2022. An interview was conducted on 6/7/2022 at 2:40 p.m. with the Scheduler. The Scheduler revealed when a nurse called out for their shift, the Director of Nursing (DON) was used to fill the assignment. During the same interview the Scheduler further stated the DON…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2023-06-08 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, and resident interview, the facility failed to notify the Resident or Resident Representative of the facility bed hold policy for 4 of 8 residents reviewed for hospitalization (Resident #2, Resident #85, Resident #50, and Resident #80). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. The Change in Condition assessment dated [DATE] revealed Resident #2 was sent to the emergency department for further evaluation of abnormal laboratory results. Resident #2 was discharged to the hospital on 3/31/23. Record review of the nursing progress notes revealed there was no documentation Resident #2 and her Responsible Party (RP) received the bed hold policy for the 3/31/23 discharge. The Minimum Data Set quarterly assessment revealed Resident #2 was cognitively intact. An interview with Resident #2 on 6/05/23 at 12:00 pm revealed she did not recall being given the bed hold policy when she discharged on 3/31/23. During an interview on 6/07/23 at 9:00…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$120,975 in federal fines across 1 penalty.

  • $120,975 — penalty dated 2024-08-30

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.9-1.9 vs chain
Health inspection 1 of 52.6-1.6 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA 2 of 5Crawford Manor Healthcare CenterCleveland, OH

Showing 40 of 125; lowest-rated first.

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 / managerTypeRoleShareSince
SHH HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2019
WWBV HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/30/2019
BRANDT, KARENIndividualW-2 MANAGING EMPLOYEEsince 12/05/2022
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2019
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICERsince 07/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
JOINER, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/29/2020

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.9M
Net patient revenuemost recent cost report
+14.7%
Operating marginrevenue minus expenses
$976K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 14%Other / private 22%

This home reported $976K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$315per resident / day
operating cost
$9,564per month
≈ monthly operating cost
$369per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345289. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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