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White Oak Manor - Charlotte

4009 Craig Avenue, Charlotte, NC 28211 · For profit - Corporation · 180 certified beds · (704) 365-2620 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 immediate-jeopardy citations$69,804 in federal fines
Insights

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

Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $69,804 in federal fines (most recent 2026-04-13)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5109 Monroe Rd · (704) 364-4216 · Call to confirm hours
Pharmacy
1640 Oakhurst Commons Dr · (980) 273-1810 · Call to confirm hours
Grocery
Food Lion0.9 mi
931 N Wendover Rd · (704) 367-1849 · Call to confirm hours
Park
3533 Craig Ave · (704) 643-5725 · Typically dawn to dusk
Place of worship
3936 Craig Ave · (704) 367-2224

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%15.6%15.4%better
Long-stay residents who lose too much weight2.8%7.2%5.4%better
Long-stay residents with a catheter left in their bladder1.9%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.9%2.3%2.0%better
Long-stay residents with depressive symptoms2.9%5.9%6.5%better
Long-stay residents who were physically restrained0.6%0.0%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.2%3.5%3.3%typical
Long-stay residents whose ability to walk worsened14.0%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.0%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine69.6%94.1%95.3%worse
Long-stay residents with pressure ulcers5.0%5.5%4.7%typical
Long-stay residents with worsening bladder/bowel control15.2%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.5%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.5%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine70.1%78.1%79.4%worse
Short-stay residents rehospitalized after admission13.3%22.9%22.6%better
Short-stay residents with an outpatient ER visit2.8%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.461.781.67better
Long-stay outpatient ER visits per 1,000 resident days0.831.801.80better

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

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

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

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

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

45.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.5%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
56.5%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 56.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.5%CMS range 34.3–55.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.4–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.0–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.47
RN hours/ resident / day
0.93
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.20
RN hoursweekends
48.6%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 141.2 residents a day — about 78% 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.70 on weekdays — 16% thinner on weekends. RN hours go from 0.58 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-04-13)
5
at the previous standard inspection (2025-03-27)

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.

ABCDEFGHIJKL

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

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-04-13 · 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 Nurse Practitioner (NP) and staff, the facility failed to prevent a resident with severe cognitive impairment, wandering and exit seeking behavior and at high risk for falls, from exiting the facility unsupervised without staff's knowledge. On two consecutive nights Resident #89 exited the facility through an unlocked emergency exit door near the back of the facility that was in working order, but the door had been manually unlocked, and the door alarm had been turned off with a key and therefore did not alarm. On 6/28/25 at an undetermined time early in the morning (it was still dark outside) Nurse #1 noticed Resident #89 was not walking in the hallway and was not in his room. Nurse #1 approached Nurse Aide #1 who was on the end of the hallway near the emergency exit door and reported she had not seen Resident #89 but had heard a door slam near the emergency exit. Nurse Aide #1 indicated another resident that resided in a room near the emergency exit…

    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 before2025-10-27 · 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 record review and interviews with the Family Member, facility staff, Nurse Practitioner, and Medical Director, the facility failed to resume Eliquis, an anticoagulant commonly known as blood thinner, for Resident #1. Upon admission in March 2025, Resident #1 was prescribed Eliquis due to a history of deep vein thrombosis and pulmonary embolus. The medication was temporarily discontinued on 7/2/2025, in preparation for a scheduled medical procedure performed on 7/7/2025. However, the facility did not restart Eliquis until 10/1/2025, nearly three months later, after the resident began exhibiting symptoms including shortness of breath, bilateral lower extremity (BLE) edema, and a need for supplemental oxygen. On 10/7/2025, Resident #1 was transferred to the Emergency Department, where he was diagnosed with bilateral pulmonary emboli (blood clot in the lungs), including a complete occlusion (blockage) in the right lower lobe suggestive of pulmonary infarction (death of lung tissue due to occlusion of blood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food preparation area clean and orderly and store a scoop without the potential for cross-contamination. These practices occurred in 1 of 2 walk-in coolers, 1 of 1 food preparation areas, and 3 of 3 Nourishment rooms (Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER]). These practices had the potential to affect food served to residents. The findings included:a. An initial tour of the main kitchen occurred on 4/6/26 at 10:05 AM with the Dietary Manager. The following concerns were identified:- Visible dirt and grime build up present on the three water spigots above the cooking range.- A plastic scoop was left in the rice bin with the handle and bottom touching the rice in the food preparation area. - A cardboard flat of 9 croissants was cut open with no open or use by date was found in walk-in cooler #2. Seven croissants had been…

    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 before2026-04-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to maintain a resident's dignity when Nurse Aide (NA) #6 quickly pulled Resident #67 backward down the hall approximately 30 feet from the day room to her room while reclined in a geriatric chair for 1 of 3 sampled residents reviewed for dignity (Resident #67). A reasonable person would have expected to be treated with dignity and would have wanted to be wheeled forward in their geriatric chair.Findings included:Resident #67 was readmitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE] revealed Resident #67 was assessed as having clear speech and severe cognitive impairment. The assessment indicated Resident #67 required the use of a wheelchair for mobility. During a continuous observation on 4/6/26 at 2:45 PM in the South Hall, NA#6 was observed quickly pulling Resident #67 backward down the hall approximately 30 feet from the day room to her room while she was reclined in a geriatric chair.During an interview…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews, the facility failed to provide hair washing services for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #144). The findings included:Resident #144 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain, chronic obstructive pulmonary disease, and heart failure.Resident #144's care plan, last revised 3/23/26, had a focus area for ADL deficits due to generalized weakness Interventions included set up for hair and oral hygiene daily and assist with bathing and dressing, encouraging Resident #144 to do as much as possible. Resident #144's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and extensive assistance from staff for ADL. The MDS further revealed Resident #144 had no behaviors, and there was no rejection of care noted. A review of the facility shower schedule revealed Resident #144 was to be showered on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #5 did not wear a gown while providing catheter care for Resident #132 and Nurse Aide (NA) #3 and NA #4 failed to wear a gown while conducting a mechanical lift transfer of Resident #161 who had a feeding tube. The deficient practice occurred for 3 of 10 staff members observed for infection control practices (Nurse #5, NA #3, and NA #4).The findings included: A review of the facility's policy titled Enhanced Barrier Precautions, revised on 7/26/2022, 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 tubes,…

    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 · Dcited before2025-11-18 · 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 record review, and staff and Medical Director interviews, the facility failed to correctly transcribe a verbal physician's order for twice daily blood sugar checks resulting in no blood sugar checks being performed during a resident's admission. This affected 1 of 3 residents reviewed for services provided meet professional standards (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses which included sepsis, diabetes mellitus, failure to thrive and end stage renal disease which required hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so) three times weekly.A review of Resident #3's electronic medical record revealed a physician verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice daily. Resident #3 was not on any diabetic medication.A care plan dated 9/10/2025 indicated Resident #3 had a diagnosis of diabetes mellitus and was at risk for complications related to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and resident, staff, Family Member #1, and Pest Control Representative interviews, the facility failed to effectively manage pests in 1 of 3 resident rooms (Resident #1) reviewed for pest control and for 1 of 1 observation for pest control in the conference room.Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis of peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated he had moderately impaired cognition. An interview and observation were conducted on 09/30/25 at 10:31 AM with Resident #1. During the interview he stated he had observed flies/gnats in his room, but it was in a previous room. Resident #1 stated he had been to the hospital recently but could not recall what for and told the surveyor he had the wounds on his left lower leg prior to entering the facility. During the observation there were no…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-27 · tag F0711 — isolated
    Ensure 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, Nurse Practitioner, and Physician interviews, the medical providers failed to review the total plan of care and ensure the medication list on the Nurse Practitioner and Physician progress notes were accurate for 1 of 3 residents reviewed to ensure the facility is free of medication errors (Resident #1).Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation and benign prostatic hyperplasia. Resident #1's Nurse Practitioner (NP) progress note dated 7/02/25 untimed, read that the resident's Eliquis (blood thinner medication) would be held prior to a suprapubic catheter placement procedure. The medication list included Eliquis 5 milligrams (mg) oral (by mouth) every 12 hours. An order dated 7/02/25 at 1:37 PM was created by the NP to discontinue the Eliquis. Resident #1's NP progress note dated 7/31/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read 'I…

    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
  • Potential for harm · D2025-10-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Consultant Pharmacist, Nurse Practitioner, Medical Director and Director of Nursing, the facility's Consultant Pharmacist failed to identify a significant lapse in anticoagulant therapy. Specifically, Eliquis (an anticoagulant, also known as a blood thinner) was discontinued on 7/2/25 for a surgical procedure and was not resumed until 10/1/25. This interruption in therapy was not addressed in the drug regimen reviews following the procedure, thereby failing to ensure the continuation of chronic anticoagulant treatment for Resident #1. This deficient practice was identified in 1 of 3 residents reviewed for unnecessary medications (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, type 2 diabetes, and a history of pulmonary embolus. On 3/19/25, the physician ordered Eliquis 5 milligrams (mg) by mouth every 12 hours. Resident #1's physician orders for July 2025 revealed Eliquis 5 mg by…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure dishware (divided plates and bowls) were clean for use for 1 of 1 meal service observation and failed to ensure the plate warmer was free of food debris. This practice had the potential to affect food served to residents. The findings included: On 03/26/25 at 11:30 AM observations of the lunch meal tray line revealed there were divided plates stacked on a cart to the side of the steam table in preparation for the lunch service. Seven of the divided plates were noted to have dried egg particles on the plates. There were also dried egg particles noted on the plate warmer that contained the regular plates for lunch meal service. In addition, there were plastic bowls stacked for meal service and two of the bowls were noted to have dried food particles inside the bowls and around the outside of the bowls. On 03/26/24 at 11:41 AM the food particles on the plate warmer, crumbs and dried egg particles on the divided plates and the food particles…

    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 before2025-03-27 · 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 record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents reviewed for accidents (Resident #51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51 was cognitively intact and dependent on staff for transfers. The care plan dated 12/02/24 revealed Resident #51 required 2-person assistance using the sit-to-stand lift for all transfers. An incident report dated 1/29/25 at 8:00 PM written by Nursing Supervisor #1 indicated Nurse Aide (NA) #3 was assisting Resident #51 to stand, pivot and transfer from the wheelchair to the bed and they both fell onto the bed. Resident #51 was assessed, and no injuries were noted. NA #3's written statement dated 1/29/25 indicated at approximately 8:00 PM she entered Resident #51's room to assist her into bed. Resident #51…

    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
Show the remaining 9 citations
  • Potential for harm · D2025-03-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident, staff, and Physician Assistant (PA) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #41 & Resident #101). These deficient practices occurred for 2 of 2 residents reviewed for respiratory care and services. The findings included: 1. Resident #41 was admitted to the facility on [DATE]. Resident #41 had diagnoses which included chronic respiratory failure with hypoxia. Review of the care plan dated 03/26/2024 and revised on 02/25/2025 revealed Resident #41 was at risk for respiratory complications secondary to chronic respiratory failure with hypoxia requiring supplemental oxygen. The interventions included administer oxygen as ordered and observed for signs and symptoms of respiratory complications. Review of Resident #41's electronic medical record (EMR) revealed a physician's orders dated 07/29/2024 for oxygen at 3 liters per minute (LPM) via nasal cannula continuous. Review of Resident #41's annual Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · 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 record reviews, observations and staff interviews, the facility failed to discard expired medications in 1 of 2 medication rooms (South Hall Medication Room) and failed to store a lidded container of prescription topical medicated cream that treats fungal infections in a secure locked storage area for 1 of 1 resident observed with medicated cream at the bedside (Resident #126). The findings included: 1. An observation of the South Hall Medication Room was conducted on 03/25/2025 at 3:19 PM with the Director of Nursing (DON). The observation revealed an unopened bottle of Red [NAME] Oil (omega 3 vitamin) containing 60 soft gel tablets available for use. The expired bottle of Red [NAME] Oil was located in the top cabinet of the medication storage room. A review of the pharmacy label affixed to the bottle of Red [NAME] Oil indicated the expiration date was 07/16/2024. The printed manufacturer's expiration date was illegible. During the observation, an interview with the DON was conducted. The DON confirmed…

    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 before2025-03-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #63. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Treatment Nurse). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: - Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) - After contact with a resident's mucous membranes and body fluids or excretions; - After handling soiled or used linens, dressings, bedpans, catheters, and urinals; - After removing gloves or aprons; and - After completing duty. A wound observation was made on 03/25/25 at 2:13 PM on Resident #63 with the Treatment Nurse. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, family and staff interviews and record review, the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 fed Resident #10 while 5 residents who were seated at the same table did not have their lunch. This failure occurred for 5 of 5 residents sampled for dignity (Residents #8, #39, #119, #70 and #100). The reasonable person concept was applied as individuals have the expectation of dining in a dignified environment. The findings included: 1a. Resident #8 was re-admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #8 with clear speech, adequate hearing/vision, no corrective lenses, or hearing aids, understood, able to understand, severely impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded Resident #8 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, resident and staff interviews, the facility failed to provide a written decision/resolution regarding a grievance related to missing bras belonging to Resident #52 and failed to submit a grievance per the facility's grievance policy for 3 of 3 residents (Resident #52's missing supply of salad dressing, Resident #446's missing property and Resident #141's concerns related to a disrespectful staff). Findings included: A review of the facility Grievances Policy dated 2/2018 revealed in part The facility recognizes two levels of communication: 1. Concern- A concern is defined as an oral communication that can be resolved immediately. 2. Grievance- A grievance is a written statement, which implies a breach of care or service. A follow-up telephone call or on-site conference shall be held within 5 working days from receipt of a grievance with a complainant outlining corrective action taken. A written decision regarding grievance issued to the resident and/or representative. A…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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, resident/ family and staff interviews, the facility failed to schedule, invite residents/representatives, and hold care plan meetings for 3 of 3 residents (#52, #28, #4) reviewed for care planning. Findings included: A. Resident # 52 was admitted to the facility on [DATE] with diagnoses inclusive of respiratory failure. A review of the medical record indicated the last care plan meeting for Resident #52 took place on 3/15/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she had not been invited to a care plan meeting since 2022. B. Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of anxiety and acid reflux. A review of the medical record indicated the last care plan meeting for Resident #28 took place on 7/19/22. A quarterly MDS assessment dated [DATE] indicated Resident #28 had moderate cognitive impairment. During an interview on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0626 — isolated
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review interviews with the Hospital Case Manager, Veterans Affairs (VA) Case Manager and staff, the facility failed to allow a resident to return the facility after a facility-initiated transfer to the hospital for 1 of 1 (Resident #445) resident reviewed for readmission from the hospital. The findings included: Resident #445 was admitted to the facility on [DATE]. His diagnoses included epilepsy, acute respiratory failure with hypoxia, schizophrenia, delirium. The face sheet of Resident #445 stated that his discharge status was anticipated to return to the community from his short term stay at the facility. He had VA benefits that paid for the 32 day stay through the Corporate Nursing Home contract. A nurses note dated 6/20/23 at 10:56 PM read in part, Resident #445 was noted to be in bed with wet/clammy skin, drooling, and body jerking. Resident #445 was able to respond to name being called. Medical Doctor (MD) notified, and orders were to send Resident #445 to the hospital with a diagnosis 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0806 — failed to honor food preferences — isolated
    Ensure 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 observations, resident and staff interviews and record review, the facility failed to honor food preferences for 2 of 2 residents reviewed for food preferences (Resident #19 and #52). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease, and renal insufficiency. Review of a Physician (MD) Orders diet list revealed a MD order dated 3/19/20 for a regular diet for Resident #19. An annual Minimum Data Set assessment dated [DATE] assessed Resident #19 with clear speech, adequate hearing, impaired vision without corrective lenses, understood, able to understand, moderately impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded that Resident #19 was at risk for nutritional decline due to her diagnoses and a history of weight loss. Interventions included providing food preferences when possible. Resident #19 was observed in her room and interviewed on 12/04/23…

    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 · D2023-12-08 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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, resident and staff interviews and record review, the facility failed to provide Resident #95 a renal diet per physician order for 1 of 1 sampled resident reviewed for therapeutic diets. The findings included: Resident #95 was admitted to the facility on [DATE]. Diagnoses included hypertensive chronic kidney disease stage 5, end stage renal disease, and dependence on renal dialysis. Review of the medical record revealed a physician (MD) order dated 7/24/23 for a liberalized renal diet. An annual Minimum Data Set assessment dated [DATE] assessed Resident #95 with clear speech, adequate hearing/vision, understood, able to understand, intact cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded that Resident #95 was at risk for nutritional decline due to end stage renal disease, hemodialysis, and a therapeutic diet. Interventions included providing a diet as ordered. Resident #95 was observed in her room and interviewed on 12/04/23 at 12:54…

    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

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

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

Fines & penalties

$69,804 in federal fines across 3 penalties.

  • $43,641 — penalty dated 2026-04-13
  • $10,010 — penalty dated 2025-10-27
  • $16,153 — penalty dated 2025-10-27

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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$14.6M
Net patient revenuemost recent cost report
+6.3%
Operating marginrevenue minus expenses
$2.1M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 3%Other / private 41%

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$275per resident / day
operating cost
$8,350per month
≈ monthly operating cost
$293per day
avg. revenue, all payers

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

What families pay in NC

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345238. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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