Smoky Ridge Health and Rehabilitation
310 Pensacola Road, Burnsville, NC 28714 · For profit - Limited Liability company · 140 certified beds · (828) 682-9759 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $59,631 in federal fines (most recent 2024-03-20)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.2% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.5% | 7.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.8% | 2.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 31.8% | 5.9% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.5% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.0% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 38.2% | 21.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 5.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.7% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.3% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.0% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 53.8% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.4% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.6% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.64 | 1.80 | 1.80 | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
52.8% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.8% 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 80 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.8%CMS range 43.5–61.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.6–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 43.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 63.6% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 95.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.5%CMS range 2.9–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 101.1 residents a day — about 72% occupied, or roughly 39 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.75 hrs/resident/day on weekends vs 3.22 on weekdays — 15% thinner on weekends. RN hours go from 0.81 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2024-03-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, Family Member, and staff interviews, the facility failed to protect the resident's right to be free from employee to resident abuse for 1 of 3 residents reviewed for abuse (Resident #1). Nurse #1 reported that Resident #1 hit Nurse Aide (NA) #1 in the face while she was providing care to him. Nurse #1 observed NA #1 grab Resident #1's arm and push it towards his stomach and hold it there while leaning in Resident #1 face and saying, don't you ever hit me again, do you understand?. Three days after the incident Resident #1 was observed to have a small round circular bruise on top of his right forearm and a faded circular bruise on the side of his right forearm. A reasonable person would expect to be free from abuse in their own home and could experience anger, fear, anxiety, and depressed mood. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-26 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls, medications received, and hospice for 4 of 21 residents reviewed for accuracy of MDS assessments (Resident #12, #7, #9 and #10). Findings included: 1. Resident #12 was admitted to the facility on [DATE]. A nurse's progress note revealed on 5/11/26, Resident #12 was found sitting on the floor beside the bed and reported he tried to get up and fell. Resident #12's vital signs and range of motion were assessed as being within normal limits, there were no visible signs of an injury, and he was assisted back to bed. A review of discharge MDS assessment dated [DATE] coded for falls since admission/entry or reentry or the prior assessment indicated Resident #12 had no falls. A joint interview with MDS Coordinator #1 and MDS Coordinator #2 was conducted on 06/26/26 at 11:34 AM. MDS Coordinator #1 stated Resident #12's fall on 5/11/26 should have been coded on the 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.
- Potential for harm · Dcited before2026-06-26 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) reevaluation after a significant change in physical or mental status was identified for a resident previously determined to have a Level II PASRR. This deficient practice affected 1 of 2 sampled residents reviewed for PASRR (Resident #90).Findings included:Resident #90 was admitted to the facility on [DATE]. Her cumulative diagnoses included anxiety disorder, bipolar disorder, depression, and Post-traumatic Stress Disorder (PTSD).A PASRR Level II Determination Letter dated 12/08/23 revealed Resident #90 had a Level II PASRR with no effective date and nursing facility placement was appropriate.A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Resident #90's active…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to maintain accurate advance directive information throughout the electronic and paper medical records for 1 of 3 residents reviewed for advance directive (Resident #73). Findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and history of pulmonary embolism (blood clot blocking blood flow to the lungs). The admission Minimum Data (MDS) assessment indicated Resident #73's cognition was intact. A review of the paper medical records revealed on [DATE] Resident #73 signed a Medical Scope of Treatment (MOST) form and checked if no pulse and not breathing attempt cardiopulmonary resuscitation (CPR). A review of Resident #73's electronic medical record revealed a physician's order dated [DATE] for code status Do Not Resuscitate (DNR) created by the Unit Manager. During an interview on [DATE] at 1:05 PM Nurse #9 revealed she was Resident #73's assigned nurse and in an emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with staff, the facility failed to protect a resident's right to be free from misappropriation of a controlled narcotic pain medication for 1 of 10 residents reviewed for abuse (Resident #93). Findings included: The facility's Abuse, Neglect, and Exploitation policy dated 09/01/24 revealed the policy and procedures was created to protect residents against abuse that included misappropriation of resident property defined in part as the deliberate misplacement, exploitation, or permanent use of resident's belongings without consent. Resident #93 was admitted to the facility on [DATE]. The physician orders for Resident #93 included to administer hydrocodone-acetaminophen 5-325 milligrams (mg) with directions to give two tablets every six hours for pain started on 11/19/24. A review of the Resident #93's medical record revealed the resident resided on the 400 Hall on 12/05/24 and 12/06/24. A review of the Medication Administration Records (MAR) for Resident #93…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of pressure ulcer care (Resident #96), fall (Resident #35), and discharge (Resident #84) for 3 of 20 residents reviewed for MDS accuracy. 1. Resident #96 was admitted to the facility 05/28/24 with a diagnosis including rhabdomyolysis (breakdown of muscle tissue). Review of Resident #96's physician orders dated 05/30/24 included to apply betadine three times a day to bilateral (both sides) knee unstageable wounds, left forearm unstageable wound, right cheek unstageable wound, right thigh unstageable wound, and unstageable wound to right heel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had one stage 3 pressure ulcer (an ulcer that extends through the top two layers of skin) present upon admission, eight unstageable pressure ulcers due to coverage of wound bed by slough (soft dead tissue) and/or eschar (hard dead tissue), and one deep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed after a new mental health diagnosis for 1 of 3 residents (Resident #77) reviewed for PASRR. The findings include: Review of Resident #77's medical record revealed the resident was admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with schizoaffective disorder on 2/13/25 and no PASRR level II was completed. During an interview on 3/20/25 at 10:59 AM with the Social Worker (SW) she revealed PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. She stated she had begun working at the facility in January 2025 and was currently receiving training from the Minimum Data Set (MDS) Coordinator on how and when level II PASRR should be completed. She revealed that given Resident #77's newly added…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-20 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical or mental status for 1 of 3 sampled residents reviewed for PASRR (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included moderate intellectual disabilities and anxiety disorder. A PASRR Level II determination notification letter dated 12/31/18 revealed Resident #7 had a Level II PASRR with no expiration date. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry dated 03/19/25 revealed Resident #7 received a Level II PASRR effective 12/31/18 with no expiration date. There were no requests for re-evaluation after 12/31/18.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews the facility failed to maintain clean ceiling vents located in the dry storage room and in the kitchen, failed to maintain a clean walk-in refrigerator and remove food with signs of spoilage from the walk-in refrigerator. Additionally, the facility failed to clean and maintain 3 of 3 ice makers, and clean and maintain ice cooler scoops and holders (the kitchen ice maker, North and South nourishment room ice makers). This practice had the potential to affect food and beverages served to residents. The findings included: a. On 11/27/23 at 9:23 AM an observation of a ceiling vent in the dry storage area of the kitchen contained a build up of fluffy debris with spider webs spread across the vent. An approximately 4 foot long by 6-inch strip of ceiling in front of the vent contained a black splotchy/and spotted substance covering the area. b. On 11/27/23 at 9:28 AM the walk-in refrigerator circulatory fan contained a thick build up of crumbly to touch debris that was spread to the ceiling of the walk-in refrigerator. During the same observation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-01 · tag F0867 — failed to act on quality-improvement findings — widespreadSet 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 interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions previously put in place following a COVID-19 focused survey that occurred 12/04/20. This failure was for one deficiency that was originally cited in the area of Infection Control (F-880) and was subsequently recited on the current recertification and complaint investigation survey of 12/01/23. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. Findings included: This tag is cross referenced to: F880: Based on observations, record review and staff interviews, the facility failed to assess the facility's water system to identify where Legionella and other waterborne pathogens could grow and spread which had the potential to affect 92 of 92 residents. The facility also failed to ensure staff implemented their infection control policies and procedures when Nurse #1 did not place a barrier between the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-01 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, record review and staff interviews, the facility failed to assess the facility's water system to identify where Legionella and other waterborne pathogens could grow and spread which had the potential to affect 92 of 92 residents. The facility also failed to ensure staff implemented their infection control policies and procedures when Nurse #1 did not place a barrier between the wound care supplies and an overbed table that had crumbs and dried debris on the surface and did not change her gloves after removing a wound dressing and before cleaning the wound for 1 of 1 sampled resident (Resident #54). Findings included: 1. Review of the facility's Emergency Preparedness Plan revealed no evidence a facility water safety risk assessment was completed to identify where Legionella or other waterborne pathogens could grow and spread in the facility's water system. During an interview on 11/30/23 at 8:56 AM, the Maintenance Director confirmed he had not completed a water safety risk assessment for the facility. He explained the facility utilized town water and it 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.
Show the remaining 11 citations
- Potential for harm · E2023-12-01 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. a. An observation of room [ROOM NUMBER] on 11/27/23 at 11:50 AM revealed multiple scrapes with exposed dry wall behind the resident's bed. On wall behind the residents over bed table contained 4 to 5 quarter sized dried red/brown spots on the wall. Subsequent observations made on 11/28/23 at 9:30 AM and 11/30/23 at 2:15 PM revealed the room unchanged. b. On 11/27/23 at 12:12 PM an observation of the dining room entrance doors revealed the bottom corner of both doors contained a broken door covering that was sticking out from the door. The Door covering was jagged to touch and contained sharp edges and was at foot and ankle level. Subsequent observations made on 11/29/23 at 8:39 AM and 11/30/23 at 2:15 PM revealed the door to be unchanged. c. An observation of room [ROOM NUMBER] on11/27/23 at 2:11 PM revealed 6 continuous floor tiles directly adjacent to the wall behind the door entrance to be broken and indented. Subsequent observations made on 11/30/23 at 2:15 PM revealed the room to be unchanged. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to refer residents who were admitted with mental health disorders for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination of specialized services for 3 of 3 residents reviewed for PASRR (Residents #14, #43 and #1). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, and personality disorder. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Review Resident #14's medical record revealed an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) which indicated Resident #14 had a Level I PASRR effective 02/10/10. There were no requests for a Level II PASRR evaluation submitted or completed since 02/10/10. During an interview on 11/28/23 at 4:17 PM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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, staff and medical director interviews the facility failed to monitor a resident's blood sugar for a resident with insulin-dependent diabetes for 1 of 5 residents reviewed for unnecessary medication (Resident # 69). The findings included Resident # 69 was re-admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus type 1, heart failure, vascular dementia, and respiratory failure. Resident # 69's admission Minimum Data Set (MDS) was still in progress. A review of Resident # 69's physicians orders on 11/20/23 read in part: Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 20 unit subcutaneously at bedtime for DM (11/20/23). Insulin Lispro Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals for diabetes (11/20/23). A review of Resident # 69's medication administration record (MAR) for November 2023 revealed blood sugar checks had not been checked prior to Resident # 69 receiving insulin before meals from his readmission dated of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 ensure physician progress notes were documented and completed as required for each physician visit for 2 of 2 sampled residents (Residents #14 and #84). Findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (weakness on one side of the body) and hemiparesis (complete paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, diabetes, chronic respiratory failure, chronic obstructive pulmonary disease (difficulty breathing), and hypertension. Review of Resident #14's medical record revealed a progress note which indicated he was seen by the facility Medical Director in conjunction with the Physician Assistant (PA) on 10/13/23. There were no progress notes of physician visits conducted by the Medical Director every 30 days for the first 90 days following Resident #14's admission to the facility. Review of Resident #14's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to store a 30 dose bubble pack of Metformin (an hyperglycemic medication) in the medication cart for 1 of 4 carts observed during medication pass. The facility failed to dispose of an expired medication, an unopened bottle of expired medication, Ferrex (an iron supplement), which was discovered in the 100/200 hall medication room for 1 of 2 medication rooms reviewed. The facility also failed to secure medicated creams, powder and sprays that were in clear view at the bedside for 1 of 1 sampled resident (Resident #14). Findings included: 1. An observation conducted during a medication pass on the 400 hall on 11/29/2023 at 9:45AM revealed a full bubble pack of 30 doses of Metformin that Nurse #1 left on top of the medication cart and walked away leaving the card and information unsecured. The nurse was out of the line of sight to observe the medication which was left on the medication cart. There were residents sitting in their doorways…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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, resident and staff interviews the facility failed to provide an alternative meal choice when requested for 1 of 3 residents reviewed for accommodating resident allergies, intolerances, and preferences (Resident #14). Additionally, the facility failed to provide a nutrional supplement as ordered by a physcian for 1 of 3 residents (Resident #37) . This practice had the potential to impact other residents. The findings included: 1. Resident #14 was admitted on [DATE] with diagnosis that included diabetes, hypertension, and dysphagia. A review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. On 11/28/23 at 12:10 PM Resident #14 was observed lying in bed with his overbed table across the bed containing an untouched meal tray. Resident #14 stated he can't eat that meal and when asked if he wanted something else to eat, he stated if he did, they would tell him he waited too late and should have told them before lunch. Resident #14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-01 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and staff interviews the facility failed to protect private resident health information by leaving confidential medical information unattended in an area accessible to the public on 1 of 4 medication carts (400 hall medication cart). Findings include: An observation on the 400-hall medication cart on 11/29/23 at 9:45AM revealed a report sheet on top of the cart with resident's names, room numbers, and care information. The sheet was turned right side up so anyone walking by could see the private resident information. Nurse#1 was observed in a room giving medications in a nearby room and then returned to medication cart at 9:52 AM. Interview with Nurse #1 on 11/29/23 at 4:00 PM revealed that she was aware that any resident identifying information should be secured by ensuring nothing was on top of the medication cart and the electronic health record screen was placed in privacy mode before leaving it unattended. Nurse #1 stated she should have turned the report sheet over so that the information on it could not be viewed by anyone walking by. Interview 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.
- Potential for harm · Dcited before2023-12-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #8 was admitted to the facility on [DATE] with diagnoses including hypertension. Review of the Smoking Safety Screen dated 01/24/23 for Resident #8 revealed he was able to verbalize he understood the smoking policy and indicated Resident #8 required supervision with smoking. The admission MDS assessment dated [DATE] indicated Resident #8 did not use tobacco. During an interview on 12/01/23 at 11:33 AM the MDS Coordinator stated Resident #8 used tobacco during the lookback period of the admission MDS assessment dated [DATE]. The MDS Coordinator confirmed the assessment was incorrectly coded no for tobacco use and she would make a modification to indicate Resident #8 used tobacco. An interview was conducted on 12/01/23 at 12:41 PM with the Administrator and DON. The Administrator stated the MDS should be correctly coded and reflect Resident #8 used tobacco. 3. Resident #88 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis. The discharge MDS assessment dated [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.
- Potential for harm · D2023-12-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to develop a person-centered comprehensive care plan for 2 of 21 (Resident #241 and Resident #62) residents reviewed for comprehensive care plans. Findings included: 1. Resident #241 was admitted to the facility 06/08/23 with diagnoses including pulmonary embolism (a blood clot in the lung) and heart failure. Resident #241 was discharged to the community 08/29/23. Review of Resident #241's medical record revealed a physician's order dated 06/08/23 for Apixaban (anticoagulant) 5 milligrams (mg) twice a day for pulmonary embolism. Review of Resident #241's Medication Administration Record (MAR) for June 2023 revealed he received Apixaban as ordered. Resident #241's comprehensive care plan last updated 06/12/23 was reviewed and did not reveal any care plan focus or interventions related to receiving anticoagulation medication. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #241 was cognitively intact and received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to ensure a resident did not receive a straw for 1 of 7 residents (Resident #54) reviewed for accidents. This failure placed Resident #54 at risk for choking/aspiration (inhaling food or fluids into the lungs). Findings included: Resident #54 was admitted to the facility 04/25/23 with diagnoses including dysphagia (difficulty swallowing) and malnutrition. A Speech Therapy (ST) Discharge summary dated [DATE] revealed Resident #54 received dysphagia therapy from 06/20/23 through 07/28/23. The note read in part provided skilled ST to address swallow function in order to determine least restrictive/safest diet, maximize overall safety and efficiency during PO (oral) intake, reduce risk of aspiration and associated respiratory compromise, and maintain adequate nutrition and hydration. To facilitate safety and efficiency it is recommended the patient use the following strategies and/or maneuvers during oral intake: no straws and general…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-12-01 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a test tray, the facility failed to provide warm and palatable food for regular and mechanical soft diets for 1 of 1 resident reviewed for food palatability(Resident #84). The findings included: Resident #84 was admitted on [DATE]. His admission Minimum Data Set (MDS) dated [DATE] coded Resident #84 as moderately cognitively impaired with diagnoses that included dementia, and cognitive communication deficit. Resident #84's physician's diet order was regular consistency. On 11/27/23 at 10:30 AM Resident # 84 stated the food he receives was always cold, and the staff accommodated the best they can. Resident # 84 said he was a vegetarian, and the facility did their best to provide a vegetarian diet, and they would reheat his food when he asked. Interviews with Nurse Aide (NA) #1 and NA #2 occurred at the same time on 11/29/23 at 09:24 AM. The two NAs stated that on occasion a resident would tell them their food was cold when they received it. Both NAs stated the food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$59,631 in federal fines across 1 penalty.
- $59,631 — penalty dated 2024-03-20
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 BRIGHTON HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.5 | +0.5 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 1.9 | +1.1 vs chain |
| Quality measures | 2 of 5 | 1.6 | +0.4 vs chain |
The other 7 homes this chain runs (chain average 1.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CTNC HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 38% | since 03/04/2022 |
| FISCHER, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 29% | since 03/04/2022 |
| LEFKOWITZ, ZEV | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 29% | since 03/04/2022 |
| ETNC HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 06/11/2025 |
| TREFF, CYNTHIA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 38% | since 03/04/2022 |
| TREFF, ESTHER | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/11/2025 |
| 310 PENSACOLA RD LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 03/04/2022 |
| SHADE, CARLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/04/2022 |
| BRIGHTON MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 03/04/2022 |
| TURBETT, TIMOTHY | Individual | ADP OF THE SNF | — | since 03/13/2023 |
CMS files one row per role, so the 18 rows in the source record cover these 10 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.
This home reported $574K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345305. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-26, 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.