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Autumn Care of Cornelius

19530 Mount Zion Parkway, Cornelius, NC 28031 · For profit - Corporation · 102 certified beds · (704) 997-2970 Medicare & Medicaid certified

Call the home — (704) 997-2970 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jul 2025Resident-funds citation (F0569)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
20036 Zion Ave Ste 100 · (704) 801-7400 · Call to confirm hours
Pharmacy
21500 Catawba Ave · (704) 655-1991 · Call to confirm hours
Grocery
21720 Catawba Ave · (704) 895-5351 · Call to confirm hours
Park
Bailey Park Soccer Field · Typically dawn to dusk
Place of worship
MTZ Kids0.3 mi
19600 Zion Ave · (704) 892-8566

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 held steady at 2 stars. From monthly CMS archive snapshots.

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

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 increased11.8%15.6%15.4%better
Long-stay residents who lose too much weight6.6%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%2.3%2.0%better
Long-stay residents with depressive symptoms5.8%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.6%3.5%3.3%worse
Long-stay residents whose ability to walk worsened16.0%18.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.9%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine97.3%94.1%95.3%typical
Long-stay residents with pressure ulcers3.4%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control21.8%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine73.4%78.1%79.4%typical
Short-stay residents rehospitalized after admission25.0%22.9%22.6%worse
Short-stay residents with an outpatient ER visit12.2%12.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.711.781.67typical
Long-stay outpatient ER visits per 1,000 resident days1.661.801.80typical

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.

59.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 238 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.6%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
61.0%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 61.0% 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 136 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF59.6%CMS range 54.1–65.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.6–13.610.7%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 discharge61.0%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 discharge66.2%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 discharge53.7%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 identified92.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%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 hospitalization6.0%CMS range 3.6–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.751.02Oct 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
0.97
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.50
Total nurse hours/ resident / day
0.28
RN hoursweekends
48.3%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 95.3 residents a day — about 93% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.50 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 2.06 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 3.27 hrs/resident/day on weekends vs 3.59 on weekdays — 9% thinner on weekends. RN hours go from 0.55 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-07-25)
7
at the previous standard inspection (2024-05-02)

Deficiencies are more than at the previous inspection — worsening. 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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2025-07-25 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and dietary staff, Registered Dietitian (RD), and Regional Registered Dietitian interviews, the facility failed to provide food items as specified by the approved menu. This practice had the potential to affect 11 residents receiving a regular diet and 2 residents receiving a puree diet (consisting of foods with a pudding-like texture) on 1 of 4 units (700/800 hall). Findings included:A review of the approved menu for residents receiving a regular diet on 07/23/25 revealed the following foods were on the menu: chili and beans, garden salad with dressing, cornbread, and carrot cake. Alternate food items for the lunch meal included mixed vegetables and noodles. A review of the approved menu for residents receiving a puree diet revealed the following foods were on the menu: chili and beans, steamed squash, puree bread, and carrot cake. a. An observation of Dietary Aide #1 on the 700/800 hall on 07/23/25 from 12:10 PM through 12:19 PM revealed he checked the temperature of the garden salad, and the temperature was 43 degrees Fahrenheit. Dietary Aide…

    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 before2025-07-25 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, staff and resident interview, the facility failed to reassess for the ability to self-administer medications for a resident who was self-administering a medication for 1 of 1 resident reviewed for self-administering medications (Resident #10).The findings included:Resident #10 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD).Review of Resident #10's physician orders dated 08/06/24 for calcium carbonate chewable tablets 500 milligrams, take two tablets every eight hours as needed for GERD.Review of Resident #10's Self-Administration assessment dated [DATE] indicated the Resident did not want to self-administer medications.Review of Resident #10's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact.On 07/22/25 at 1:05 PM during an interview and observation of Resident #10 it was noted that there was a bottle of antiacid tablets approximately 1/4 full of tablets of various…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Law Enforcement Detective and staff interviews, the facility failed to assure residents' property was safeguarded and staff did not misappropriate the residents' property for personal gain. Nurse Aide #1 used Resident #118's credit card to make unauthorized purchases totaling $757.73 without Resident #118's permission or knowledge and Housekeeper #1 used Resident #119's credit card to make an unauthorized purchase totaling $152.13 without Resident #119's permission or knowledge for 2 of 3 residents reviewed for misappropriation of resident property (Resident #118 and Resident #119).Findings included:The facility's Resident Abuse policy, last revised on 08/30/23, revealed in part, the facility would ensure all residents were free from misappropriation of property.1. Resident #118 was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #118 with intact cognition.Review of the facility's investigation revealed on 12/12/24 at…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · 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 review, and staff interviews the facility failed to ensure Nurse #7 suctioned a resident's tracheostomy (a surgical opening in the neck to allow breathing) using sterile technique (a way of providing care that attempts to eliminate germs to prevent infection) for 1 of 1 resident reviewed for tracheostomy care (Resident #1).Findings included:Resident #1 was admitted to the facility 07/07/25 with diagnoses including pneumonia and respiratory failure (when the lungs can't properly exchange oxygen and carbon dioxide). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and received tracheostomy care and suctioning. Review of a respiratory care plan initiated 07/07/25 revealed Resident #1 had a tracheostomy and interventions included providing oxygen as ordered and suctioning her tracheostomy as needed. A continuous observation of Nurse #7 on 07/25/25 from 10:50 AM to 11:20 AM revealed she was providing tracheostomy care for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · 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 review and interviews, the facility failed to ensure accurate accounting for the receipt of nine (9) tablets of controlled medications. This was for 1 of 1 facility emergency-controlled medication storage areas.The findings included:Review of a pharmacy order sheet for scheduled I and II controlled medications revealed one (1) oxycodone immediate release (IR) 5 milligrams (mg) was ordered on 08/07/24.Review of a pharmacy order sheet for scheduled IV controlled medications revealed four (4) lorazepam 0.5 mg tablets and four (4) tramadol 50 mg tablets were ordered on 08/07/24.Review of a pharmacy delivery sheet for controlled medications revealed the following controlled medications were delivered to the facility on [DATE]: (1) oxycodone IR 5 mg tablet, (4) tramadol 50 mg tablets and (4) lorazepam 0.5 mg tablets. The delivery sheet was signed by the delivery driver and Nurse #5.On 07/22/2025 at 3:03 PM an interview was conducted with the Director of Nursing (DON) who explained that on 08/09/24 she…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-07-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities, resulting in a medication error rate of 12% for 3 of 5 residents observed during the medication administration (Resident #79, Resident #84 and Resident #26).The findings included:The manufacturer's instructions for a prefilled insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary.1. Resident #79 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of 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 before2025-07-25 · 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 staff interviews, the facility failed to secure 3 bottles of medicated powder observed in a resident's room for 1 of 1 resident reviewed for medication storage (Resident #19).Findings included:Resident #19 was admitted to the facility 08/13/24 with diagnoses including obstructive uropathy (a condition that occurs when urine cannot drain out of the body) and macular degeneration (an eye disease that causes vision loss). The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and required partial/moderate assistance with bed to chair transfers. An observation of Resident #19's dresser on 07/21/25 at 3:10 PM revealed two 15 gram (gm) and one 60 gm bottles of Nystatin powder (antifungal medication) 100,000 units/gm sitting on top. Additional observations Of Resident #19's dresser on 07/22/25 at 1:55 PM, on 07/23/25 at 8:22 AM, on 07/24/25 at 8:42 AM, and on 07/25/25 at 10:32 AM revealed two 15 gm and one 60 gm bottles…

    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 · D2025-07-25 · 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, record review, resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 1 resident reviewed for food preferences (Resident #88).Findings included:Resident #88 was admitted to the facility 03/08/23.Review of Resident #88's physician orders revealed an order dated 05/31/24 for a low concentrated sugar diet (a diet that reduces or eliminates foods with high amounts of sugar).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact, was able to make herself understood, and was able to understand others. Resident #88's nutrition care plan, last edited 06/23/25, revealed she had increased nutrition/hydration risks related in part to diabetes and interventions included monitoring her dietary intake and respecting/honoring resident dietary choices.The Dietary Manager (DM) was observed to interview Resident #88 on 07/21/25 at 1:04 PM. During the interview Resident #88 informed the DM that she 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 · Dcited before2025-07-25 · 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 ensure staff implemented their infection control policy for hand hygiene when a nurse aide failed to remove dirty gloves and perform hand hygiene during incontinence care for Resident #1. This deficient practice was identified for 1 of 7 staff members observed for infection control practices (Nurse Aide #4). Findings included:Review of the facility's policy titled Hand Hygiene/Handwashing Policy last revised 02/28/25 read in part as follows: Hand hygiene is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by handwashing. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: before moving from work on a soiled body site to a clean body site on the same patient, after contact with bodily fluids, and immediately after glove removal.A continuous observation of Nurse Aide (NA) #3 on 07/23/25 from 8:41 AM through 9:05 AM revealed NA #3 provided incontinence…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Responsible Party and staff interviews, the facility failed to refund the balance of an expired resident's personal fund account within thirty days to the individual or probate jurisdiction administering the resident's estate (Resident #107) and failed to refund Social Security checks received after a resident transferred to another nursing facility (Resident #104) for 2 of 2 residents reviewed for personal funds.Findings included:1. Resident #107 was admitted to the facility on [DATE].A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 passed away at the facility.The Resident Statement for Resident #107 with a billing date of [DATE] revealed a payment in the amount of $10,304.00 received on [DATE] was applied to room charges for the period [DATE] to [DATE] totaling $2,944.00 resulting in an overpayment in the amount of $7,360.00.Review of the refund requests for Resident #107 provided by the Business Office Manager on [DATE] at 1:00 PM revealed an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2024-05-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to prevent urinary catheter bags from touching the floor for 2 of 3 residents (Resident #11 and Resident #17) reviewed for urinary catheters. The findings included: 1. Resident #17 with a cumulative diagnosis that included urinary retention. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she was always incontinent of urine. The MDS was also coded as not having an indwelling urinary catheter. A review of Resident #17's care plan revealed there was no care plan for a urinary catheter. A review of a Urology consult dated 04/12/24 revealed a #16 urinary catheter with 10 cubic centimeters (cc) was inserted into the bladder for significant history of Parkinson Disease, urinary infections, incontinence of bladder and bowel and immobility. Change the urinary catheter monthly at nursing facility. A review of Resident #17's physician orders dated…

    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 before2024-05-02 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart). The findings included: Review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility should store Schedule II-V controlled substances in a separate…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-02 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on test tray observations, resident, and staff interviews the facility failed to serve food that was palatable in taste for 7 of 7 residents reviewed for food (Resident #25, Resident #26, Resident #30, Resident #47, Resident #77, Resident #124, and Resident #126). This practice had the potential to affect other residents. The findings included: 1a. Resident #25 was admitted to the facility 10/14/21. A review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required set up assistance with eating activity. An interview was conducted with Resident #25 on 05/01/24 at 2:50 PM. The Resident was sitting in her wheelchair at her bedside and when asked about her lunch she remarked that they served her beef stir fry, rice and a roll with mango mousse for dessert. The Resident explained that she could not eat the beef stir fry because it was too salty, so she ate the rice, roll and the mousse. The Resident stated she would have to wait until supper 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-02 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 06/04/21. This failure was for two deficiencies that were originally cited in the areas of Resident Assessment (F636) and Pharmacy Services (F761) that were subsequently recited on the current recertification and complaint investigation survey of 05/02/24. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F636: Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #52). During the recertification and complaint survey of 06/04/21 the facility failed to complete 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, staff and Resident interviews the facility failed to assess the resident for the ability to self-administer medications for 1 of 1 resident (Resident #25) reviewed for self-administration of medication. The findings included: Resident #25 was admitted to the facility on [DATE]. A review of Resident #25's physician orders revealed an order dated 04/01/23 for Fluticasone Propionate Nasal Suspension 50 micrograms per activation (mcg/act) 2 sprays, in both nostrils one time a day for allergies. The order did not include the Resident could self-administer the medication. A further review of Resident #25's physician orders revealed there were no orders for over the counter pain patches or an albuterol sulfate inhaler. There was no Self Administration assessment for an inhaler or pain patch. A review of Resident #25's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. A review of Resident #25's medical record revealed a Self-Administration…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #32). The findings included: Resident #67 was admitted to the facility on [DATE] with diagnosis that included depression. Review of a physician order dated 01/11/24 read; Fluoxetine HCL (antidepressant) 10 mg by mouth every day for depression. Review of the comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and had no behaviors, rejection of care, or wandering and no signs of delirium were noted during the assessment reference period. The MDS indicated that Resident #67's diagnosis included depression and that he had taken an antidepressant during the assessment reference period. Review of the triggered Care Area Assessment (CAA) worksheet for Psychosocial wellbeing dated 01/23/24 had the following boxes checked:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to develop a care plan that included an area of focus for a urinary catheter for 1 of 3 residents (Resident #17) reviewed for urinary catheters. The finding included: Resident #17 was admitted to the facility on [DATE] with a cumulative diagnosis including urinary retention. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she was always incontinent of urine. The MDS was coded as not having an indwelling urinary catheter. A review of Resident #17's care plan last reviewed on 04/24/24 revealed there was no care plan for a urinary catheter. A review of a Urology consult dated 04/12/24 revealed a #16 urinary catheter with 10 cubic centimeters (cc) was inserted into the bladder for significant history of Parkinson Disease, urinary infections, incontinence of bladder and bowel and immobility. Change urinary catheter monthly at nursing facility. A…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-07 · tag F0814 — failed to dispose of garbage properly — pattern
    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 ensure the area around the dumpster was free of trash and debris for 1 of 2 dumpster reviewed. The findings included: An observation of the dumpster area and interview with the Dietary Manager (DM) was conducted on 01/03/23 at 11:05 AM. The observation revealed 2 dumpsters one for cardboard that was noted to be empty. The other dumpster was for trash, the door on the left side was open and a clear trash bag that was busted laid next to the open door. The bag was busted with food and trash littered all over the ground and up against the dumpster. There were multiple clear bags that were busted and debris of food, food pans, cups, utensils, broken and unbroken plates, glass plates, used gloves, glove boxes, and paper was littered approximately ten feet around the dumpster area. The DM stated she was not sure who was responsible for cleaning the dumpster area. An interview was conducted with Dietary Aide (DA) #1 on 01/03/23 at 11:08 AM. DA #1 stated that the DM had summoned him to the dumpster area with a broom and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-07 · 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 record review, observations, and interviews with staff the facility 1) failed to implement their policy and procedures for Hand Hygiene when Nurse Aide #2 did not perform hand hygiene before donning gloves and after possible contact with body fluids before touching other surfaces in the room for 1 of 1 resident reviewed for incontinence care (Resident #49), 2) failed to store soiled linens off the floor for 1 of 1 laundry room, 3) failed to follow the Droplet Precautions signage posted by the door of a resident's room when 1 of 1 staff (Activity Assistant #1) did not don a gown while feeding a resident for 1 of 4 residents on droplet/contact precautions (Resident #98). The findings included: Review of the facilities Hand Hygiene/Hand Washing policy revised on 07/14/21 read in part, hand washing was the most important component for preventing the spread of infection and the use of gloves does not replace the need for hand cleaning. The policy provided guidance when to perform hand hygiene including before and after having direct contact with residents and after contact with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-07 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to honor a resident choice to get out of bed everyday for 1 of 3 residents reviewed for choices (Resident #44). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction. Review of a care plan updated on 07/12/22 read in part, Resident #44 had deficits in activities of daily living. The goal read, Resident #44 will maintain current level of function through the next review period. The interventions included transfer with total body lift with two-person assistance. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #44 was cognitively intact and required extensive assistance of two staff members with transfers. The MDS further revealed no rejection of care was noted during the assessment reference period. Resident #44 was interviewed on 01/03/23 at 2:09 PM and revealed that last Saturday and Sunday (12/31/22 and 01/01/23) she 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interviews, and policy review the facility failed to thoroughly investigate alleged abuse and protect residents from further abuse and failed to implement their abuse policy and procedure in the area of reporting to the State Survey Agency when they received an allegation of staff to resident abuse for 1 of 3 residents (Resident #57) reviewed for abuse. Findings included: Review of the facility's policy titled Abuse, Neglect, and Exploitation last revised 10/03/22 read in part as follows, It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Further review of the policy read in part as follows: Section 4 If a staff…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of document titled Preadmission Screening Resident Review (Pasrr) dated 06/07/22 indicated that Resident #9 was determined to be Level 2 Pasrr. Resident #9 was admitted to the facility on [DATE] with diagnoses that included paranoid personality disorder and traumatic brain injury. Review of the admission comprehensive Minimum Data Set (MDS) dated [DATE] indicated that Resident #9 did not have a Level 2 Pasrr and was completed by the MDS Coordinator. The MDS Coordinator was interviewed on 01/06/23 at 12:31 PM. The MDS Coordinator confirmed she had completed the admission comprehensive MDS dated [DATE] for Resident #9 and confirmed he had a Level 2 Pasrr in place. She stated it was probably an accident, I meant to click yes and accidentally clicked no. The MDS Coordinator stated she would correct the mistake immediately. The Director of Nursing (DON) was interviewed on 01/06/23 at 4:34 PM. The DON stated that she expected the MDS assessments to be completed accurately including the Pasrr information. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff the facility failed to clarify a physician's order for pain medication to include the frequency of administration between doses for 1 of 5 residents reviewed for pain (Resident #96). The findings included: Resident #96 was admitted to the facility on [DATE] with diagnoses including a displaced fracture of left femur. Review of the care plan focus for pain initiated on 12/21/22 revealed Resident #96's pain was related to a left hip fracture. Interventions included administer medications as ordered. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #96 as being cognitively intact. The MDS revealed scheduled and as needed pain medication was received or offered during the assessment period. Review of the physician's order written on 12/31/22 instructed to give tramadol (an analgesic opioid pain medication) 50 mg as needed for pain. The order did not include frequency of administration between each dose. The physician's order 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-07 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and family interviews the facility failed to fully complete and ensure the accuracy of a recapitulation of stay for 1 of 3 residents reviewed for discharge (Resident #143). The findings included: Resident #143 was admitted to the facility on [DATE] with diagnoses that included sequelae of cerebral infarction (stroke) and dysphagia (trouble swallowing). Resident #143 discharged to the community on 08/15/22. Review of the comprehensive admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #143 was severely cognitively impaired for daily decision making and required extensive assistance with activities of daily living to include bed mobility, toileting, dressing, and personal hygiene. Review of a physician order dated 08/03/22 read cardiac puree diet with nectar thick liquids. Review of a physician order dated 08/15/22 read; stable for discharge home on [DATE] with home health. Review of a facility document titled Discharge Instructions dated 08/15/22 revealed a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-07 · 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 record review and interviews with staff the facility failed to obtain a physician's order for use of a continuous positive airway pressure (CPAP) machine for a resident admitted with a diagnosis of moderate obstructive sleep apnea (sleep-related breathing disorder) for 1 of 2 residents reviewed for oxygen (Resident #251). The findings included: Review of the hospital discharge summary revealed Resident #251 was admitted on [DATE] with an active list of problems and diagnoses that included moderate obstructive sleep apnea. The hospital discharge also included a summarization of Resident #251's medical history that listed obstructive sleep apnea with the use of a CPAP. Resident #251 was discharge from the hospital on [DATE] with no physician orders in place for the use of a CPAP. Resident #251 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease (a chronic inflammatory lung disease obstructing airflow). Resident #251 was discharged 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
  • Potential for harm · Dcited before2023-01-07 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 06/04/21 and the focused infection control and complaint survey of 7/23/2020. This was for two deficiencies that were originally cited in June and July 2020 in the area of respiratory care and infection control and prevention and was subsequently recited on the current recertification survey of 01/07/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance Program. The Findings Included: This tag is cross referred to: F695 - Based on record review and interviews with staff the facility failed to obtain a physician's order for use of a continuous positive airway pressure (CPAP) machine for a resident admitted with a diagnosis of moderate obstructive sleep apnea (sleep-related breathing disorder)…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“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

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA 2 of 5Crawford Manor Healthcare CenterCleveland, OH

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
SHG AUTUMN, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2016
OHI ASSET NC CORNELIUS LPOrganization5% OR GREATER SECURITY INTERESTsince 03/01/2016
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/01/2016
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
HOPPING, DARINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/21/2021
CIBC BANK USAOrganizationADP OF THE SNFsince 03/31/2021
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 03/01/2016
WALKER & ASSOCIATES PCOrganizationADP OF THE SNFsince 12/18/2023

CMS files one row per role, so the 17 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$11.8M
Net patient revenuemost recent cost report
+5.1%
Operating marginrevenue minus expenses
$1.4M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 9%Other / private 43%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$339per resident / day
operating cost
$10,318per month
≈ monthly operating cost
$358per 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 345567. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, 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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