Southpoint Rehabilitation and Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

56.0% 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 389 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 67.5% 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 117 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 0.83 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 140 beds and averages 123.8 residents a day — about 88% occupied, or roughly 16 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.53 on weekdays — 16% thinner on weekends. RN hours go from 0.64 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

38 citations, most serious first. The 15 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · J2024-04-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and a recorded 911 call, the facility failed to protect a resident's right to be free from neglect when they did not effectively respond to a medical emergency. This occurred for 1 of 1 resident reviewed for neglect. Resident #232 was found to have a critical low blood sugar of 28 and was unresponsive. Nurse #7 failed to complete a nursing clinical assessment, failed to initiate emergency procedures within the nursing home and with 911. Nurse #7 also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation to the rest of the nursing staff. Emergency medical services (EMS) were not called until 6:56 am. Resident #232 expired on [DATE]. Immediate jeopardy began on [DATE] when nursing staff failed to immediately and effectively respond to a medical emergency and was removed on [DATE] when the facility implemented an credible allegation of immediate jeopardy removal. The facility will remain out of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-04-05 · 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, staff interviews, and a recorded 911 call, the facility failed to implement emergency procedures, when a resident who was a known brittle diabetic was discovered to have a blood sugar of 28 and was unresponsive. Nurse #7 failed to complete a nursing clinical assessment, failed to initiate emergency procedures within the nursing home and with 911. Nurse #7 also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation. Resident #232 expired on [DATE]. This occurred for 1 of 1 resident reviewed for neglect (Resident #232). Immediate jeopardy began on [DATE] when the facility failed to immediately and effectively respond to a medical emergency. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy)…

  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 · J2024-04-05 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and a recorded 911 call, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures within the nursing home and with emergency medical services for 1 of 1 resident (Resident #232) reviewed for neglect. Nursing staff failed to complete nursing clinical assessments (including vital signs), failed to immediately initiate emergency procedures within the nursing home and with 911 when a nurse asked for a glucagon injection. Nursing staff also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation to the 911 operator. Resident #232 expired on [DATE]. Immediate jeopardy began on [DATE] when nursing staff failed to immediately and effectively respond to a medical emergency. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of compliance. The facility remains out of…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-01-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and Medical Director interviews, and record reviews, the facility staff failed to: 1) disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 2 of 3 residents whose blood glucose levels were checked (Residents #50 and #202). This occurred while there was a resident with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. 2) disinfect an individually assigned glucometer for a resident diagnosed with a bloodborne pathogen. This occurred for 1 of 3 residents whose blood glucose levels were observed to be checked (Resident #35). This glucometer was stored in a cloth container inside a drawer with other residents' glucometers and placed on surfaces that were not disinfected after contact. Resident glucometers can be contaminated with blood 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2023-01-10 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  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 resident, staff, and Nurse Practitioner (NP) interviews, observations and record review, the facility failed to obtain and administer a controlled substance medication ordered to treat pain for a resident admitted with a recent fracture and surgical repair of her right lower leg. Failure to receive the pain medication over a 2-day period of time resulted in the resident experiencing pain rated up to 10 on a scale of 0 to 10 (with 10 representing the worst pain imaginable) resulting in nausea and a significant interference with her sleep. This occurred for 1 of 1 resident (Resident #206) reviewed for pain. The findings included Resident #206 was admitted to the facility on [DATE] from a hospital. Her cumulative diagnoses included chronic kidney disease and a recent motor vehicle accident resulting in a right leg bimalleolar fracture with surgical intervention. A bimalleolar fracture is an ankle fracture that involves both the tibia and fibula (the lower leg bones that end on either side of the ankle).…

  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 · E2025-04-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  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, observations, and resident and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician (Resident # 83), obtain a physician order on a resident's medical record for the use of a Bilevel positive airway pressure machine, a device that helps a person breathe by delivering pressurized air into the airways, (Resident # 296) and apply signage indicating no smoking, the use of oxygen outside the resident's room for 4 of 4 residents reviewed for oxygen use (Resident #83, #296, #101 and #49). Findings included: 1. Resident #83 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). Resident #83's care plan dated 1/31/2025 included a focus for altered respiratory status and difficulty breathing related to exacerbation of CHF. Interventions included oxygen via nasal cannula at 1 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 · D2025-04-10 · 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 observations, record reviews, and staff and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property for 1 of 3 residents reviewed for misappropriation (Resident #300). The findings included: Resident #300 was admitted to the facility on [DATE]. She was discharged on 10/27/24. Review of the facility reported incident investigation dated 10/3/24 revealed the narcotic count for 100 hall was not correct the morning of 10/2/24. During the narcotic reconciliation completed by the off going Nurse #4 and the oncoming Nurse #5, the 100-hall cart was missing one card of oxycodone HCL (hydrochloride) 5 mg tablets (17 tablets) for Resident #300. All medication carts were audited, and the missing narcotic card was not found. The local police department was notified on 10/2/24. Review of the facility's 5-day Summary investigation report dated 10/7/24 revealed that all 11:00 PM to 7:00 AM staff who worked on 10/1/24 through 10/2/24 were…

  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 · D2025-04-10 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 31 residents whose MDS assessment were reviewed (Resident #75). Findings included: Resident #75 was admitted to the facility on [DATE] and diagnoses included hypertension and heart failure. Resident #75's care plan dated 10/11/2024 included a focus for diuretic therapy related to heart failure. Interventions included administering diuretics, medications used to reduce enema (extra fluid in the body), as ordered by the physician. Physician orders dated 1/23/2025 included an order for Bumetanide, a diuretic medication, 2 milligrams (mg) every day for edema. Resident #75's March 2025 Medication Administration Record (MAR) recorded Bumetanide 2 mg was administered daily from 3/1/2025 through 3/31/2025. The quarterly MDS assessment dated [DATE] was not coded for Resident #75 receiving diuretics. In a phone interview with MDS Coordinator on 4/10/2025, she stated…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · tag F0657 — failed to keep the care plan current — isolated
  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 reviews, resident interview, resident's emergency contact interview, and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and significant change Minimum Data Set (MDS) assessments for 1 of 31 residents reviewed for care planning (Resident #62). The findings included: Resident #62 was admitted to the facility on [DATE]. The last care plan meeting documented in Resident #62's medical record was dated 3/4/2024. MDS assessments were completed for Resident #62 on the following dates: 6/8/2024 (quarterly), 7/8/2024 (significant change), 9/30/2024 (quarterly), 12/31/2024 (significant change) and 4/2/2025 (quarterly). The quarterly MDS dated [DATE] indicated Resident #62 was cognitively intact. Resident #62 was listed as the responsible party on Resident #62's medical record. In an interview with Resident #62 on 4/7/2025 at 11:10 am, Resident #62 was not able to recall receiving invitations or having meetings with interdisciplinary members 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · 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, observation, and staff and resident interviews, the facility failed to provide care according to accepted professional standards when a nurse administered medication but did not observe the resident take her medications and left them at the bedside for 1 of 1 resident with medications observed at bedside (Resident #93). Findings included: Resident #93 was admitted to the facility on [DATE]. Her active diagnoses included bilateral primary osteoarthritis of the hip, muscle weakness, lymphedema, major depressive disorder, abdominal hernia, hypertension, anxiety disorder, iron deficiency anemia, gastro-esophageal reflux disease, insomnia, other pulmonary embolism, overactive bladder, vitamin D deficiency, pain in right shoulder, syncope and collapse, and prediabetes. Review of Resident #93's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. Review of Resident #93's electronic health record on 4/8/25 at 10:43 AM revealed there was no physician's order…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · 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, observations and staff interviews, the facility failed to provide daily cholecystostomy (a surgical opening in the gallbladder to place a catheter for draining excess bile) dressings as ordered by the physician for a resident who had a biliary (a network of organs and vessels that make, store and transfer bile, a fluid the liver makes that helps digest food) tube inserted into the right upper abdominal wall for drainage of biliary fluid for 1 of 3 residents reviewed for professional standards of care (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses including chronic cholecystitis (persistent inflammation of the gallbladder) and an artificial opening of gastrointestinal tract. Resident #5's care plan dated 9/25/2024 included a focus in the alteration in gastrointestinal status due to history of acute cholecystitis that was managed with a percutaneous cholecystostomy tube due to operative risks. The quarterly Minimum Data Set assessment…

  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 before2025-04-10 · 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 staff interviews, the facility failed to maintain a secure medication cart and accurate controlled medication records for 1 of 2 residents (Resident #301) reviewed for use of controlled medications. The findings included: Resident #301 was admitted to the facility on [DATE] and was discharged on 10/24/2024. Review of the facility reported incident investigation dated 10/3/24 revealed the narcotic count for 100 hall was not correct the morning of 10/2/24 during narcotic reconciliation completed by the off going Nurse #4 and oncoming Nurse #5. The 100-hall cart was found to be missing 1 narcotic count sheet for oxycodone HCL (hydrochloride) for Resident #301. An investigation was initiated, all medication carts were audited, and the missing narcotic count sheet for Resident #301 was not found. On 4/9/25 at 12:17 PM an interview with the Director of Nursing (DON) was conducted. She stated the discrepancy with the narcotic count for the 100-hall cart was reported to her and 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and staff interviews, the facility failed to maintain a complete and accurate medical record when documenting cholecystostomy care for 1 of 31 residents who medical records were reviewed (Resident #5). Findings included: Resident #5's April 2025 Medication Administration Record (MAR) recorded the cholecystostomy dressing had been changed by Nurse #13 on 4/6/2025 at 8:00 am and by Nurse #14 at 8:00 pm. On 4/7/2025 at 1:02 pm, Resident #5's right upper abdominal dressing was observed dated 4/5/2025 as last changed. In a phone interview with Nurse #13 on 4/10/2025 at 2:46 pm, she stated she was assigned to Resident #5 on 4/6/2025 from 7:00 am to 3:00 pm and the documentation on Resident#5's MAR on 4/6/2025 that recorded she provided the scheduled 8:00 am cholecystostomy dressing change was inaccurate documentation. Nurse #13 stated she did not change Resident #5's cholecystostomy dressing on 4/6/2025 and should not have recorded the cholecystostomy dressing was changed when the care was not provided. In a phone interview with Nurse #14 on 4/10/2025 at 2:59 pm,…

  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 before2024-11-19 · 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 observation, record review, and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene between the removal of soiled gloves and the application of clean gloves during wound care for 1 of 5 staff observed for infection control practices (Nurse #1). Findings included: A review of the facility policy titled Handwashing/Hand hygiene revised 2023 provided by the facility revealed in part: This facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves. During observation on 11/19/24 at 10:11 AM Treatment Nurse #1 and Treatment Nurse #2 were observed providing wound care to Resident #2. Treatment Nurse #1 was observed to perform hand hygiene and apply clean gloves. She then removed the soiled dressing from Resident #71's sacral wound using her gloved hands and discarded the soiled dressing.…

  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 before2024-05-24 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 with residents, staff, physician assistant, and pharmacists, the facility failed to ensure antibiotics were available for the nurses who were responsible for administering the antibiotics. This resulted in a delay of over 24 hours in initiating antibiotic therapy for two residents (Residents # 5 and # 6) out of five sampled residents whose medications were reviewed. The finding included: 1. Resident # 6 was admitted to the facility on [DATE]. According to Resident # 6's 5/17/24 hospital discharge summary, Resident # 6 had been hospitalized from [DATE] until 5/17/24 secondary to an infection of her left prosthetic knee joint. While hospitalized the resident underwent knee surgery and was followed by an infectious disease physician. Upon discharge from the hospital on 5/17/24, the resident was ordered to receive the antibiotic cefazolin intravenously every eight hours through the date of 6/21/24. Review of the discharging hospital's Medication Administration Record for 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$48,523 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $48,523 — penalty dated 2024-04-05
• Medicare payment denial — starting 2024-05-04 for 34 days

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

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $806K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

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

What families pay in NC