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Sapphire Ridge Health and Rehabilitation

115 N Country Club Road, Brevard, NC 28712 · For profit - Limited Liability company · 147 certified beds · (828) 884-2031 Medicare & Medicaid certified

Call the home — (828) 884-2031 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Mar 2025Resident-funds citation (F0565)$22,568 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,568 in federal fines (most recent 2023-11-17)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
15 Rosman Hwy, Brevard, NC 28712 · (828) 884-2990 · Call to confirm hours
Pharmacy
CVS<0.1 mi
(828) 884-5156 · Call to confirm hours
Grocery
50 S Broad St · (828) 966-8689 · Call to confirm hours
Park
335 S Broad St · (828) 884-3156 · Typically dawn to dusk

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 2 of 5
Long-stay residentspeople who live here 4 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 fell from 3 to 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 increased14.0%15.6%15.4%typical
Long-stay residents who lose too much weight10.1%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection2.1%2.3%2.0%typical
Long-stay residents with depressive symptoms3.0%5.9%6.5%better
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 injury6.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened11.1%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.2%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine89.4%94.1%95.3%typical
Long-stay residents with pressure ulcers7.9%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control24.8%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.1%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.2%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine65.7%78.1%79.4%worse
Short-stay residents rehospitalized after admission26.3%22.9%22.6%worse
Short-stay residents with an outpatient ER visit9.9%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.821.781.67better
Long-stay outpatient ER visits per 1,000 resident days2.121.801.80worse

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.

37.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.6%U.S. median 51.5%
Got home and stayed home
12.4%U.S. median 10.7%
Went back to hospital
54.5%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 54.5% 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 44 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF37.6%CMS range 26.1–50.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 6.9–18.210.7%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 discharge54.5%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 discharge29.6%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 discharge43.2%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened10.3%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 hospitalization7.6%CMS range 4.2–15.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

0.47
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.40
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.41
RN hoursweekends
43.0%
Total nursing turnover
53.8%
RN turnover

How full it usually is: this home is certified for 147 beds and averages 104.0 residents a day — about 71% occupied, or roughly 43 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.15 hrs/resident/day on weekends vs 3.60 on weekdays — 13% thinner on weekends. RN hours go from 0.49 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-05-07)
12
at the previous standard inspection (2025-03-07)

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and staff interviews, the facility failed to date open containers of nutritional supplements and failed to remove nutritional supplements stored past the use by date in 2 of 3 nourishment room refrigerators (North and South Units). This practice had the potential to affect residents receiving nutritional supplements.Findings included:Observations of the nourishment room refrigerators on the North and South Units conducted on 05/06/26 at 10:29 AM through 10:41 AM with the Dietary Manager (DM) revealed:a. Stored in the North Unit nourishment room refrigerator was a one-quart sized nutritional shake with no date to indicate when it was opened. The manufacturer's label on the container read, use within 4 days after opening if refrigerated.b. Stored in the South Unit nourishment room refrigerator were two one-quart sized nutritional shakes dated 4/24 and 4/28. The manufacturer's label on the containers read, use within 4 days after opening if refrigerated. Also stored was one opened and undated 8-ounce sized diabetic nutritional shake. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0645 — isolated
    PASARR 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 submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with a serious mental health disorder for 1 of 2 residents reviewed for PASRR (Resident #11).Findings included:A PASRR Determination Notification letter dated 10/27/25 revealed Resident #11 had a Level I PASRR with no expiration date.Resident #11 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance.A psychiatric progress note dated 10/29/25 revealed Resident #11 admitted to the facility from another facility and per the records received from the previous facility, she had a history of bipolar disorder for many years and recent behavioral and psychological symptoms of dementia (BPSD, refers to non-cognitive symptoms and behaviors such as agitation, aggression, anxiety,…

    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 before2026-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to provide assistance with denture care for 1 of 4 dependent residents reviewed for activities of daily living (Resident #100).Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses which included stroke, dysphagia (difficulty swallowing), and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #100's cognition was severely impaired, setup or clean-up assistance was needed with oral hygiene, had no natural teeth or tooth fragments (edentulous), and had no rejection of care or behaviors during the lookback period.A review of the Nurse Aide (NA) documentation for oral care/denture care revealed from 04/07/26 through 05/05/26 denture care was documented as provided three times for Resident #100 on 04/14/26, 04/25/25, and 04/26/26.The care plan dated 04/19/26 revealed Resident #100 was at risk for oral and dental health problems related to being edentulous 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 · Ecited before2025-03-07 · 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 an observation of the lunch meal tray preparation, record review, and interviews with the Dietary Manager and staff, the facility failed to provide the correct portion size of beef hamburger steak for residents receiving a mechanically altered diet. This failure had the potential to affect 18 of 97 residents who received a lunch meal tray with a mechanically altered diet. Findings included: The facility's diet consistency census report dated 03/03/25 revealed 18 of 97 residents received a mechanically altered diet. The facility's planned menu for Wednesday (03/05/25) listed beef hamburger steak as the protein being served for lunch. The portion size listed on the menu indicated each plate received one beef hamburger steak. The beef hamburger steak packaging revealed each steak was a 4-ounce portion. A continuous observation of lunch trays being prepared for residents was conducted on 03/05/25 at 11:54 AM through 1:38 PM. The Dietary Manager served one (4 ounce) beef hamburger steak for residents that received a regular diet. The Dietary Manager and [NAME] used a ladle with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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, family and staff interviews, the facility failed to serve the lunch meal at the posted times on 03/05/25 and 03/06/25 in the main dining room during 2 of 3 meal observations. The findings included: Review of the facility's meal times schedule revealed lunch was to be served in the main dining room at 12:30 PM. a. Resident #54 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 had severe cognitive impairment, required partial/moderate assistance with eating and received a mechanically altered diet. Resident #101 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] indicated Resident #101 had severe cognitive impairment, required setup or cleanup assistance with eating and received a mechanically altered diet. An observation of the lunch meal service in the main dining room on 03/05/25 at 1:10 PM revealed residents were seated at various tables eating their lunch.…

    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 · Ecited before2025-03-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and staff interviews the facility failed to remove food items stored and available for use that had signs of spoilage or were past the expiration date from the walk-in refrigerator and dry goods storage area located in the kitchen. The facility also failed to date an opened container of nectar thick milk stored in the nutrition refrigerator used for residents on the memory care unit for 1 of 2 nutrition refrigerators. This deficient practice had the potential to affect food and beverages served to residents. Findings included: The initial tour of the kitchen with the Dietary Manager on 3/3/25 at 7:55 AM revealed the following: 1a. A container of enchilada sauce with an expiration date 01/2024 stored in the walk-in refrigerator and available for use. b. A container of sliced lemons with a white, slimy discoloration with a use by date 2/28/25 stored in the walk-in refrigerator and available for use. c. A container of sliced bananas mixed with pineapple tidbits with the slices of banana that had turned brown to black in color. The use by date…

    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 · E2025-03-07 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop 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 staff interviews the facility failed to include documentation in the medical record of refusal or acceptance of influenza and pneumonia vaccinations for 5 of 5 residents (Resident #20, Resident #44, Resident #37, Resident #80, and Resident #62) reviewed for immunizations and failed to assess the eligibility to receive the influenza and pneumonia vaccines for 2 of 5 (Resident #44 and Resident #37). Findings included: 1. (a). Resident #20 was admitted to the facility 04/06/23. Review of an unsigned Vaccine Declination Form dated 08/01/24 for influenza and pneumonia vaccines revealed multiple attempts to contact Resident #20's Power of Attorney (POA) were unsuccessful. The significant change Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #20 was severely cognitively impaired. The MDS reflected Resident #20 had not received the influenza or pneumonia vaccine. Review of Resident #20's electronic medical record revealed the Vaccine Declination Form dated 08/01/24 was 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 include documentation in the medical record of refusal or acceptance of the COVID-19 vaccination for 5 of 5 residents (Resident #20, Resident #44, Resident #37, Resident #80, and Resident #62) reviewed for immunizations and failed to assess the eligibility to receive the COVID-19 vaccine for 1 of 5 (Resident #44) residents reviewed for immunizations. Findings included: 1. (a). Resident #20 was admitted to the facility on [DATE]. Review of an unsigned Vaccine Declination Form dated 08/01/24 for COVID-19 revealed multiple attempts to contact Resident #20's Power of Attorney (POA) were unsuccessful. The significant change Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #20 was severely cognitively impaired. Review of Resident #20's electronic medical record revealed the Vaccine Declination Form dated 08/01/24 was not included in her medical record. (b). Resident #44 was admitted to the facility on [DATE]. Review of a Vaccine…

    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
  • Potential for harm · D2025-03-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide a dignified dining experience for a dependent resident seated at a table in the main dining room waiting to be served and assisted with his lunch while watching other residents in the main dining room receive and eat their lunch for 1 of 2 residents reviewed for dignity (Resident #49). The reasonable person concept was applied to this deficiency as an individual might feel forgotten or experience frustration at not being able to eat while watching others receive and eat their meals. Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side and vascular dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severe cognitive impairment. He had impairment on one side of both the upper and lower extremities 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 observations, record review, resident and staff interviews the facility failed to honor a resident's preference for twice weekly showers for 1 of 3 residents reviewed for choices (Resident #104). Findings included: Resident #104 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104's cognition was moderately impaired, she had limited range of motion affecting one side of the upper extremity, and bathe/shower was not applicable and not attempted. A review of the shower assignment revealed Resident #104's showers were scheduled on Tuesday and Friday. There was no documented shower sheets to indicate a bed bath or shower was provided on 02/25/25 (Tuesday) or 02/28/25 (Friday). A shower sheet dated 03/04/25 revealed Resident #104 had received one shower since admission on [DATE]. During an interview and observation on 03/03/25 at 2:36 PM Resident #104 revealed she 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 Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-03-07 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident and staff interviews, the facility failed to communicate resolution to concerns voiced for 1 of 2 Resident Council meetings reviewed (January 2025). Findings included: A review of the Resident Council Meeting policy revised 01/01/25 stated the facility would act upon concerns and recommendations of the Resident Council, make attempts to accommodate recommendations to the extent practicable and communicate its decisions to the Resident Council. The Resident Council meeting minutes dated 01/31/25 noted under new business that residents communicated to the Dietary Manager, who was in attendance at the meeting, their preferences for specific beverages with an outcome noted as resolved-still monitoring. It was also noted under new business that residents voiced laundry concerns regarding clothing being placed in the wrong closets. The action to the concern indicated a grievance form regarding missing items would be completed and the outcome was noted as resolved-still monitoring. A grievance form dated 01/31/25 noted attendees of the Resident Council…

    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 · D2025-03-07 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interviews the facility failed to implement their grievance policy for 1 of 1 resident (Resident #8) reviewed for grievances. Findings included: Review of the facility's grievance policy revised 01/01/25 read in part as follows: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. [Prompt Efforts to Resolve] include facility acknowledgement of a complaint grievance and actively working toward resolution of that complaint/grievance. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; and issuing written grievance decisions to the resident. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member…

    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 · D2025-03-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thorough investigation of an allegation of staff-to-resident abuse for 1 of 9 residents reviewed for abuse (Resident #8). Findings included: The facility's Abuse, Neglect, and Exploitation policy revised 03/02/23 read in part as follows: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identifying staff responsible for the investigation 2. Investigating different types of alleged violations 3. Identifying and interviewing all involved persons, including the alleged victim, alleged…

    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 · Dcited before2025-03-07 · 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, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of restraints (Resident #71), dental (Resident #20), and falls (Resident #4) for 3 of 26 resident assessments reviewed for accuracy. Findings included: 1. Resident #71 was admitted to the facility 06/12/24. Review of Resident #71's quarterly Minimum Data Assessment (MDS) dated [DATE] indicated Resident #71 had bed rails that were used daily as a restraint. Observations of Resident #71's bed on 03/05/25 at 8:49 AM and 03/07/25 at 9:17 AM revealed no bed rails were observed on his bed. An interview with the MDS Coordinator on 03/07/25 at 3:52 PM revealed Resident #71's quarterly MDS assessment was coded by an employee that did not work in the building. He stated it was difficult to accurately code MDS assessments if you were not present in the building. The MDS Coordinator stated that the MDS should not have reflected that bed rails were used as a restraint, and it…

    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 before2025-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interviews the facility failed to provide assistance with nail care and shaving for 1 of 5 dependent residents reviewed for activities of daily living (Resident #99). Findings included: 1. Resident #99 was admitted to the facility on [DATE] with diagnoses including a right femur (upper leg bone) fracture, presence of artificial hip joint, and epilepsy (a brain condition causing recurring seizures with varying symptoms). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #99 had impaired range of motion affecting one side of the lower extremity and required setup/clean up assistance for personal hygiene and substantial to maximal assistance for shower/bathing. The care plan revised on 2/12/25 revealed Resident #99 had a deficit in the ability to perform activities of daily living related to a fracture of the right…

    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 · E2023-11-17 · tag F0622 — pattern
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Medical Director and staff interviews, the facility failed to provide written documentation which stated the reason the facility could not meet the residents' needs for 2 of 4 residents reviewed for transfer and discharge (Residents #87 and #184). The findings included: 1. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included dementia without behavioral disturbance and adjustment disorder with anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #87 had severe impairment in cognition. He wandered 4 to 6 days and displayed no behaviors such as physical or verbal aggression and no hallucinations or delusions during the MDS assessment period. A physician's order dated 07/31/23 read, transfer to ER (Emergency Room) for evaluation. A Social Worker (SW) progress note dated 07/31/23 at 10:03 AM read in part, SW was informed that Resident #87 hit another resident. SW completed immediate discharge notice due to being a danger to other…

    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 · E2023-11-17 · tag F0626 — pattern
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    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, Responsible Party, Hospital Case Manager, Medical Director and staff interviews, the facility failed to allow residents to return to the facility after being sent to the hospital for a psychiatric evaluation using the residents' behaviors prior to discharge as a basis for their decision for 2 of 4 residents reviewed for transfer and discharge (Residents #87 and #184). The findings included: 1. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included dementia without behavioral disturbance, psychotic disturbance and adjustment disorder with anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #87 had severe impairment in cognition. He wandered 4 to 6 days and displayed no behaviors such as physical or verbal aggression and no hallucinations or delusions during the MDS assessment period. A behavioral care plan initiated on 07/26/23 revealed Resident #87 had the potential to be physically aggressive related to dementia. Interventions…

    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 · E2023-11-17 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and the Medical Director (MD), the facility failed to check capillary blood glucose prior to administering insulin lispro (a rapid acting medication used to treat high blood sugar) for 1 of 2 resident reviewed for insulin administration (Resident #88). Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, type 2 diabetes mellitus, and vascular dementia. Resident #88 was discharged back to the community on 02/18/23. Review of the admission Minimum Data Set assessment dated [DATE] indicated Resident #88's cognition was moderately impaired and insulin injections were received during the lookback period. The care plan focus area for diabetes initiated on 01/30/23 included interventions to administer medication as ordered and monitor and document for side effects and effectiveness; obtain fasting serum blood sugar (capillary blood glucose levels) as ordered by the doctor; monitor and document 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 · E2023-11-17 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and record reviews, the facility failed to remove expired medications in accordance with manufacturer's expiration dates for 1 of 3 medication storage rooms and 1 of 6 medications carts observed during medication storage checks (South Wing medication storage room and Memory care unit medication cart). The findings included: 1. A medication storage audit was conducted on 11/15/23 at 11:08 AM for the South Wing medication storage room in the presence of Nurse #2. One bottle containing approximately 130 milliliters (ml) of used Omeprazole (medication used to treat heartburn) 2 milligrams (mg)/ml suspension that expired on 11/03/23 was found in the locked refrigerator within the locked metal box and was ready to be used. At the same time, 4 unopened bottles of Lorazepam (medication used to treat anxiety) 2 mg/ml injection liquid that expired on 05/31/23 were found in the same metal box and were ready to be used as well. During an interview conducted on 11/15/23 at 11:11 AM, Nurse #2 stated that she was instructed to check each medication for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-17 · 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 breakfast meal tray line observation, record review, and staff interviews the facility failed to serve fortified oatmeal in a six-ounce portion per the menu. This failure had the potential to affect 15 residents receiving fortified foods. Findings included: The recipe for the breakfast meal on 11/15/23 revealed residents receiving fortified food were to receive a six-ounce portion of fortified oatmeal. In an interview with [NAME] #1 on 11/15/23 at 7:35 AM he stated the recipe contained information on portion size and indicated which size scoop or utensil should be used to plate the food. A continuous observation of the breakfast meal tray line on 11/15/23 from 7:37 AM through 8:10 AM revealed [NAME] #1 began plating food and used a number eight scoop (which contained four ounces) to serve fortified oatmeal to residents receiving fortified food. An interview with the Regional Director of (Culinary) Operations on 11/17/23 at 12:44 PM revealed each individual tray ticket contained the portion size of each item the resident was to receive, and she expected portions to be…

    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 · Ecited before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and facility staff interview the facility failed to maintain a clean walk-in cooler for 1 of 1 walk-in coolers and maintain the tiled floor where the steam table was located in good repair. Findings included: 1. An initial observation of the walk-in cooler on 11/13/23 at 9:16 AM revealed a black/brown substance that was easily removable with a wet paper towel on all 4 walls of the cooler and scattered stains to the floor. An interview with the Interim Dietary Manager on 11/13/23 at 9:17 AM revealed she became the Interim Dietary Manager on 11/10/23 but she expected the cooler walls and floor to be clean. An interview with the Administrator on 11/17/23 at 2:46 PM revealed she expected the walk-in cooler to be clean and free of debris. 2. An observation of the floor in the room where the steam table was located on 11/13/23 at 9:20 AM revealed multiple broken tiles with exposed concrete flooring throughout the room. An interview with the Maintenance Director on 11/16/23 at 1:57 PM revealed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-17 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the complaint investigation survey completed on 09/20/21 and the recertification survey completed on 06/03/22. This was for two repeat deficiencies, one in the area quality of care originally cited on 09/20/21 during a complaint investigation survey and one in the area of food procurement, store/prepare/serve originally cited on 06/03/22 during a recertification survey. Both deficiencies were subsequently recited on 11/17/23 during the recertification and complaint investigation survey. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F684: Based on record review and interviews with staff and the Medical Director (MD), the facility failed to check capillary…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · 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 reviews and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 3 of 19 sampled residents reviewed for advanced directives (Residents #60, #63 and #71). Findings included: 1. Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's Electronic Health Record (EHR) revealed a physician's order dated [DATE] for a Full Code status. The profile section of Resident #60's EHR also indicated a Full Code status. Review of the advanced directive care plan initiated on [DATE] revealed Resident #60 was a full code. The goal was to have his advanced directives followed by the staff. Interventions included performing cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The care plan had never been revised since its initiation. The quarterly Minimum Data (MDS) assessment dated [DATE] coded Resident #60 with severely impaired cognition. Resident #60's hard copy advanced directive located at the nurse's station…

    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 before2023-11-17 · 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 3. Resident #2 was admitted to the facility on [DATE] and the active diagnoses included dementia, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had one unstageable pressure ulcer that was not present on admission. Review of the significant change MDS assessment dated [DATE] revealed Resident #2 had one unstageable pressure that was present on admission. Review of Resident #2's medical records revealed the resident had not left facility from 10/13/23 through 10/20/23. During an interview on 11/17/23 at 11:04 AM the Regional MDS Consultant stated Resident #2 had an unstageable pressure ulcer on the sacrum she acquired while at the facility. He stated the significant change MDS dated [DATE] was an error in coding the pressure was present on admission. An interview was conducted with the Administrator on 11/17/23 at 4:12 PM. The Administrator stated she expected the MDS to be accurate. Based on record review and staff interviews, the facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a care plan that incorporated the Preadmission Screening and Resident Review (PASRR) Level II determination recommendations for a resident with an active diagnosis of a serious mental illness for 1 of 1 resident reviewed for PASRR (Resident #71). Findings included: Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included bipolar disorder and anxiety. A PASRR Level II Determination Notification Letter for Resident #71 dated 02/24/23 had an expiration date of 03/26/23 and noted nursing placement was appropriate for a limited nursing facility stay, lasting no more than 30 calendar days. A PASRR Level II Determination Notification Letter for Resident #71 dated 03/30/23 had an expiration date of 05/29/23 and noted nursing placement was appropriate for a 60-day period. A PASRR Level II Determination Notification Letter for Resident #71 dated 07/31/23 had an expiration date of 09/29/23 and noted nursing…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff the facility failed to administer a water flush via gastrostomy tube (a feeding tube inserted into the stomach to provide nutrition and hydration) as ordered by the physician for 1 of 1 resident reviewed for tube feeding (Resident #67). Findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty with swallowing) and aphasia (difficulty with speech) following a cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 received fluids via tube feeding. The care plan revised on 11/13/23 indicated Resident #67 required tube feeding via gastrostomy tube related to the diagnosis of dysphagia and included interventions to provide water flushes as ordered by the physician and evaluations by the Registered Dietitian (RD) quarterly and as needed. Review of the RD evaluation dated 11/14/23 revealed Resident #67 was receiving 100 milliliters (ml) water…

    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 · D2023-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to clean the water chamber of a continuous positive airway pressure (CPAP) machine for 1 of 2 sampled residents reviewed for respiratory care (Resident #22). Findings included: Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including dementia, Alzheimer's disease, and obstructive sleep apnea. Review of the care plan that was initiated on 03/21/21 revealed Resident #22 was at risk for altered respiratory status due to diagnosis of obstructive sleep apnea. Interventions included monitoring for signs and symptoms of respiratory distress and reporting to the physician as needed. The physician's order dated 08/04/21 revealed the nursing staff was instructed to wash the CPAP mask, tubing, and hoses with soap and warm water once daily, then air dry for evening CPAP use. The order did not include anything about cleaning the water chamber. The quarterly Minimum Date Set (MDS) dated [DATE] coded Resident #22 with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-05-07 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews with residents and staff, the facility failed to ensure residents' right to receive mail delivered on Saturdays. This had the potential to affect 107 of 107 residents in the facility.Findings included:A Resident Council group interview was conducted on 05/06/26 at 11:00 AM with Residents #46 (Resident Council President), #33, #35, #42, and #83 in attendance. In addition, the Activity Director was present during the group interview at the residents request. Resident #35 reported if mail was delivered to the facility on Saturday, it was not delivered to the residents until Monday by the Activities Director. Resident #33 and Resident #83 both voiced agreement with Resident #35's statement and when asked, Resident #46 and Resident #42 did not disagree.During interviews on 05/06/26 at 11:00 AM and 11:44 AM, the Activity Director explained she was working as a Certified Occupational Therapist Assistant until 04/24/26 when she took over the position of the Activity Director. She stated she did not currently work weekends and was not sure how the process worked regarding…

    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
  • No harm found · B2023-11-17 · 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 reviews, Responsible Party and staff interviews, the facility failed to provide written notification to the Responsible Party regarding bed hold upon a resident's transfer to the hospital for 3 of 4 residents reviewed for hospitalization (Residents #87, #184, and #80). Findings included: 1. Resident #87 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had severe impairment in cognition. A physician's order for Resident #87 dated 07/24/23 read, recommend involuntary commitment (IVC) due to physical altercations and increased behaviors. Review of Resident #87's medical record revealed he was discharged to the hospital on [DATE] for evaluation and was readmitted to the facility on [DATE]. Further review of the medical record revealed no staff progress notes or scanned documents indicating Resident #87's Responsible Party (RP) was provided written notification of the facility's bed hold policy upon his transfer to the hospital.…

    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

$22,568 in federal fines across 1 penalty.

  • $22,568 — penalty dated 2023-11-17

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 ASCENT HEALTHCARE MANAGEMENT — 6 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 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.0+1.0 vs chain
Quality measures 2 of 52.8-0.8 vs chain
The other 5 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
PISGAH HOLDCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/01/2024
FRIEDMAN, YISROELIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
ROBINSON, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
HOLL, BLAIRIndividualADP OF THE SNFsince 07/04/2025

CMS files one row per role, so the 6 rows in the source record cover these 4 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.

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

Follow the money — this home’s finances

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

$9.5M
Net patient revenuemost recent cost report
-3.5%
Operating marginrevenue minus expenses
$1.9M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 3%Other / private 17%

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$346per resident / day
operating cost
$10,504per month
≈ monthly operating cost
$334per 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 345208. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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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