Pelican Health at Charlotte

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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.

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.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 67.9 residents a day — about 57% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.91 hrs/resident/day on weekends vs 3.48 on weekdays — 16% thinner on weekends. RN hours go from 0.78 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

Deficiencies are unchanged from the previous inspection. 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.

39 citations, most serious first. The 16 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 observations, record review and interviews with the resident, staff, Responsible Party (RP), Wound Nurse Practitioner, and Medical Director, failed to recognize the severity of the injury, the extent of bleeding, and the resident's increased risk for bleeding due to her daily anticoagulant medication (helps prevent blood from forming clots). On 01/20/26 Nurse Aide #1 pulled Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. Resident #25 reported a pain scale of 10 on a scale of 1 to 10 (0 being no pain and 10 being the worst possible pain. Nurse #1 observed a 1-inch laceration to the residents left lower extremity, applied pressure for 5 minutes to stop the bleeding and applied a pressure…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2026-03-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with the resident, staff, Responsible Party, Wound Nurse Practitioner, and Medical Director, the facility failed to provide care in a safe manner and ensure a resident's environment remained free of an accident hazard for a dependent resident on Eliquis (an anticoagulant medication that prevents blood from clotting). On 01/20/26 Nurse Aide (NA) #1 transferred Resident #25 using a mechanical lift from the bed to the Resident's wheelchair. Nurse Aide #1 proceeded to pull Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. Resident #25 complained of a pain, on a scale of 10 with 10 being the worst possible pain. She sustained a 1-inch laceration to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-02-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Nurse Practitioner, staff and resident interviews, the facility failed to provide a safe transfer using a mechanical lift for Resident #43. On 3/9/24 Nurse Aide (NA) #1 and NA #2 were transferring Resident #43 with the mechanical lift when a strap that was frayed on the left side of the lift pad broke, and Resident #43 fell approximately 3 feet to the tile floor hitting her head and landing on her right side. Resident #43 was assessed by Nurse #3 and was observed to have a huge hematoma (collection of blood underneath the skin) to the back right side of her head and reported her whole right side hurt. Resident #43 was transported to the Emergency Department (ED) for further evaluation. Computed tomography (CT) scans and x-rays obtained in the ED were negative for fracture or injury. While in the ED Resident #43 experienced acute respiratory insufficiency related to rib pain and/or narcotic administration. Resident #43 returned to the facility on [DATE]. Resident #43 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-08-29 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record reviews and staff interviews, the facility failed to ensure Medication Aide (Agency MA #1) and other nursing staff were trained and competent in cleaning and disinfecting glucometers (blood glucose machine) according to manufacturer recommendations using an Environmental Protection Agency (EPA) approved disinfectant cloth, between resident usage. Agency MA #1 was observed not cleaning and disinfecting a shared glucometer between use with three residents (Resident #28, Resident #30, and Resident #57). Interviews with Nurse #2, Nurse #6 and Nurse #10 revealed each nurse was unable to describe glucometer disinfection procedures. This deficient practice involved four of four nursing staff. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (Agency MA #1) demonstrated she was not competently disinfecting a shared glucometer between resident use per manufacturer's recommendations. The immediate jeopardy was removed on 8/23/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-08-29 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). This practice affected 3 of 4 residents on the assigned unit and could potentially affect 17 residents in the facility who required glucose monitoring. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (MA #1) hired through an agency was observed to perform blood glucose checks on residents…

  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
• Actual harm · G2023-08-29 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with resident, staff, Pharmacist, Nurse Practitioner (NP #2) and the Medical Director (MD), the facility failed to acquire medications ordered for administration resulting in multiple doses of the prescribed controlled substance medication being missed for 1 of 1 resident reviewed for the provision of pharmaceutical services to meet a residents' needs (Resident #33). As a result of this deficient practice, Resident #33 had to be sent to the emergency department where she required 3 days of treatment for benzodiazepine (class of medications used to treat anxiety) withdrawal with delirium symptoms. The findings included: Resident #33 was admitted to the facility on [DATE]. Her cumulative diagnoses included depression, anxiety, and bipolar disorder. Review of the physician's orders revealed an order dated 09/25/21 which indicated Resident #33 was to receive Xanax (Alprazolam) 0.5 milligram (mg): Give one (1) tablet by mouth three (3) times a day for anxiety disorder. Review 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-29 · 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 record review and resident and staff interviews, the facility failed to treat Resident #1 with dignity and respect when staff engaged in a verbal argument with the resident utilizing profanity and yelling at the resident. The resident reported she felt angry with the way staff treated her. This deficient practice affected 1 of 1 resident reviewed for dignity (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE].An annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact and was not coded with behaviors.Resident #1's active care plan, last revised on 1/19/2026, had a focus area regarding Resident #1 having mood symptoms and poor coping strategies due to past trauma including emotional and physical abuse. The goals included Resident #1 maintaining the ability to seek out social contact and not experiencing any acute anxiety or depressed mood through the review period. The interventions included encouraging continued family…

  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 · F2026-03-02 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interviews, the facility failed to close the trash receptacle door, remove loose garbage, boxes, and debris and failed to prevent standing water from around 1 of 1 trash receptacle and 1 of 1 recycling receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests and rodents.The findings included:An observation of the outdoor trash receptacle area with the Head [NAME] on 2/22/26 at 11:30 AM revealed three used disposable gloves and one clear trash bag which contained trash on the ground to the left of the trash receptacle and one clear trash bag which contained small amounts of trash hanging out of the open trash receptacle door. There were five collapsed cardboard boxes that were floating in standing water approximately 5 inches deep in the trash and recycling receptacles area, which was approximately 15 to 20 feet wide. One blue trash bag which contained trash was floating in the standing water between the trash receptacle and the recycling receptacle. One empty carboard carton 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-02 · 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 observation, record review and resident and staff interviews, the facility failed to honor a resident's request to return to bed after arrival to the facility from dialysis services. The resident stated to a staff member that waiting for over an hour for assistance to return to bed after dialysis treatment made her feel lightheaded and even more tired. This deficient practice affected 1 of 4 residents reviewed for choices (Resident #22). The findings included: Resident #22 was readmitted to the facility on [DATE]. Her diagnoses included chronic kidney disease stage 4 with hemodialysis and type 2 diabetes mellitus. Resident #22's physician order dated 8/12/25 revealed Resident #22 received hemodialysis every Tuesday, Thursday, and Saturday. Resident #22 had a dialysis care plan in place dated 8/12/25 which revealed she was at risk for complications requiring hemodialysis; dialysis treatment days were scheduled every Tuesday, Thursday, and Saturday. Resident #22's significant change Minimum Data Set (MDS)…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and staff interviews, the facility failed to maintain the footboards on beds in a resident room in good repair (Residents #25 and #27). The deficient practice affected 1 of 21 rooms on 1 of 4 halls observed for a safe and homelike environment. The findings included:An observation conducted on 2/23/26 at 1:15 PM in the shared room of Residents #25 and Resident #27 revealed that the footboards on both residents' beds were in disrepair. Resident #25's footboard was missing the banding which left an exposed, rough area of particle board approximately 3 to 4 inches in length. Resident #27's footboard exhibited multiple damaged areas, each approximately 6 inches long, with rough, exposed particle board. The laminate covering was missing from the footboard. A review of the facility's online maintenance work order system from March 2025 to February 2026 revealed no documented requests for repair of the bed footboards for Resident #25 or Resident #27. An interview and observation were conducted with Nurse Aide (NA) #1 on 2/23/26 at 12:54 PM revealed that…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · 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 observations, record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of range of motion and mobility devices for 1 of 21 sampled residents (Resident #25).The findings included:Resident #25 was admitted to the facility on [DATE] with diagnoses of fracture of the right tibia, muscle weakness and physical debility. A care plan dated 09/05/25 revealed a focus area related to Activities of Daily Living (ADL) care. Resident #25 required assistance with her ADL. The goal was for the resident to maintain their current level of function through the next review date. Interventions included two staff member assistance using a mechanical lift with transfers. A Physical Therapy evaluation dated 11/14/25 signed by Physical Therapist #1 revealed Resident #25 demonstrated decreased bilateral lower extremity range of motion due to contractures and weakness. She demonstrated decreased function with bed mobility and wheelchair mobility. Resident #25…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-02 · tag F0761 — failed to label and store drugs safely — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident, staff and Nurse Practitioner interviews, the facility failed to secure medications found at the bedside for 1 of 2 residents reviewed for medication storage (Residents #8). The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses which included acute systolic heart failure.An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact.A review of Resident #8's physician's orders revealed an order dated 2/10/26 for a 20 milliequivalents (mEq) potassium oral capsule (Potassium Citrate) one time a day for hypokalemia. Additionally, Resident #8 did not have any past or current physician's orders to self-administer medications.A review of Resident #8's Electronic Medical Record (EMR) revealed no care plan areas or assessments for self-administering medications.An observation on 2/22/26 at 12:02 PM revealed a large white pill in a cup on the bedside table to the left of Resident #8's bed. Resident…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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 observations, record review, and staff interviews, the facility failed to keep a fire compression tank clean of debris and keep the floor grout lines clean of greasy residue and food debris. These practices occurred in 1 of 2 food preparation areas and had the potential to affect food served to residents.The findings included:An initial tour of the main kitchen occurred 2/22/26 at 11:10 AM with the Head Cook. The following concerns were identified:-Visible dirt and grime build-up present on a large fire suppression tank and its tubing. The tank and the associated equipment were attached to the wall and ceiling in a food preparation area above the toaster. -Visible food debris and grease build-up was present in the grout lines of the floor tiles in front of the cooking range.An interview with the Head [NAME] occurred on 2/22/26 at 11:25 AM. She stated the housekeeping department oversaw the cleaning of the floors in the kitchen, however, she was unsure of the cleaning schedule. The Head [NAME] stated grease and food debris would build up in the grout around the floor tiles…

  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 · Dcited before2026-03-02 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews, observations and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #4 did not wear Personal Protective Equipment (PPE) while providing urinary catheter care for Resident #5. In addition, Nurse Aide (NA) #9 failed to wear PPE while providing urinary catheter care and transferring Resident #33 from wheelchair to bed. These deficiencies occurred for 2 of 10 staff members observed for infection control practices (Nurse #4 and NA #9). The findings included:A review of the facility's policy that was undated titled Enhanced Barrier Precautions, indicated: Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. High-contact activities included dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (central lines, urinary catheters, feeding…

  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 · Ecited before2025-02-03 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with the following diagnoses, cerebral infarction (stroke), obesity and stress incontinence. A review of Resident #64's comprehensive care plan dated 12/24/24 included the following interventions, she was bedfast all or most of the time, she required hands on dependent assistance with perineal hygiene and she was not toileted. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #64 was cognitively intact. Resident #64 had no impairment of her upper extremities and had impairment to both lower extremities. Resident #64 was incontinent of both bowel and urine. She had no pressure ulcers but had moisture association skin damage. On 1/26/25…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-03 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review, observations, staff interviews and resident interviews, the facility neglected to provide a sufficient quantity of linens and size 2x incontinent briefs for 2 of 2 residents who required bariatric goods (Resident #64 and Resident #28). The findings included: Cross refer to tag F558. Based on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28).

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date 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.

Fines & penalties

$47,037 in federal fines across 6 penalties.

• $8,672 — penalty dated 2026-03-02
• $8,673 — penalty dated 2026-03-02
• $17,345 — penalty dated 2025-02-03
• $7,409 — penalty dated 2023-12-11
• $1,764 — penalty dated 2023-11-20
• $3,174 — penalty dated 2023-10-30

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

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 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 →

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

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.

About 88% 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 $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in NC