Elizabeth City Health and Rehabilitation

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.

62.4% 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 629 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.5% 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 220 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 0.80 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 170 beds and averages 150.8 residents a day — about 89% occupied, or roughly 19 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.40 hrs/resident/day on weekends vs 4.09 on weekdays — 17% thinner on weekends. RN hours go from 0.27 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 15 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · J2023-11-22 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and Medical Director interview the facility failed to notify the physician of administering long-acting insulin to Resident # 1 who had not consumed dinner and had a blood glucose level of 89 mg/dL (milligrams per deciliter). The facility failed to notify the physician after significant changes in condition for Resident #1 which included: obtaining a blood glucose level of 29 mg/dL (a normal blood glucose level range is 70 to 99 mg/dL) requiring the administration of glucagon (a manmade version of a hormone made by the pancreas that raises blood glucose levels); and obtaining a blood glucose level of 27 mg/dL, and the inability to administer glucagon to the Resident during a medical emergency. Resident #1 was one of one resident reviewed for notification of the physician. Emergency Medical Services (EMS) was contacted to take Resident #1 to the emergency room on [DATE] for hypoglycemia (low blood glucose). EMS treated Resident #1 with 1 mg glucagon intermuscular. Upon…

  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
• Immediate jeopardy · Jcited before2023-11-22 · 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, Pharmacy Nurse Consultant interview, Pharmacist interview, and Medical Director interview, the facility gave long-acting insulin to Resident #1 who had a blood sugar reading of 89 milligrams/deciliter (mg/dL) and had not eaten the dinner meal; failed to monitor the resident for any signs and symptoms of hypoglycemia (low blood glucose) after insulin administration; failed to monitor and complete ongoing thorough assessments by rechecking a blood glucose level as ordered after a hypoglycemic event requiring the intervention of glucagon (used to treat very low blood glucose); and failed to effectively respond to a medical emergency of hypoglycemia for one (Resident #1) of three residents reviewed for diabetes care. Emergency Medical Services (EMS) was contacted to take Resident #1 to the emergency room on [DATE] for hypoglycemia. EMS treated Resident #1 with 1 milligram glucagon intramuscularly. Upon arrival at the hospital, a repeat glucose level resulted in a blood…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-11-22 · 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, Pharmacist, Pharmacy Nurse Consultant, and Medical Director interviews the facility failed to demonstrate competency knowing what effective immediate interventions needed to be implemented for treatment of hypoglycemia (low blood glucose) and competency in obtaining life-saving medication from an automated medication dispensing system for one (Resident #1) of one resident reviewed for nursing competency. Emergency Medical Services (EMS) was contacted to take Resident #1 to the emergency room on [DATE] for hypoglycemia. EMS treated Resident #1 with 1 mg glucagon intermuscular. (Glucagon is a manmade version of a hormone made by the pancreas that raises blood glucose levels.) Upon arrival at the hospital, a repeat glucose level of 24 mg/dL (a normal blood glucose level is 70 to 90 milligrams per deciliter) was taken, and 50 % Dextrose was intravenously administered along with a renal diet consumed orally. Immediate Jeopardy began on 11/12/2023 when nursing staff failed to demonstrate…

  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
• Actual harm · G2023-10-28 · 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, observation, staff interview, resident interview, physician interview, physician assistant interview, and family interview the facility failed to prevent intentional inappropriate touching for one of three residents reviewed for resident-to-resident abuse. Resident #1 was observed by Resident #3 touching the breasts of Resident #2 under her shirt after the conclusion of a planned activity event with a gathering of the residents. Resident #2 did not have the cognition to express an adverse outcome, inappropriate touching of their breasts would have traumatized a reasonable female person. A family member of Resident #2 confirmed Resident #2 would have been devastated, furious, and mad at being touched inappropriately by a man if she was not cognitively impaired. Findings included: Documentation in the electronic medical record revealed Resident #1 had cumulative diagnoses some of which included stroke, hemiplegia, and vascular dementia. Documentation on a care plan for Resident #1 dated as…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide care safely when a resident (Resident #295) was provided with incontinence care. Resident #295 fell from the bed during care and sustained a 2.5-centimeter (cm) laceration to her head with bleeding and she reported pain in her back and head post fall. Resident #295 was sent to the hospital and required 3 staples to close the laceration. This was for 1 of 8 residents reviewed for accidents (Resident #295). Findings included: Resident #295 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's and contractures. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #295 had severely impaired cognition, was incontinent of bowel and bladder, and was dependent on 2 staff members for bed mobility. Record review of Resident Care Guide (no date) revealed Resident #295 was non-ambulatory, had contractures, and was dependent on staff for bathing and transfers by 2 staff members. Resident #295 was…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · E2024-04-05 · 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 of the meal service tray line, record review, interviews with the Registered Dietitian and staff, the facility failed to ensure residents on the 900 hall received the correct portion sizes based on the menu. This failure had the potential to affect 1 out of 9 halls. The findings included: Review of the document, Census List dated 4/4/24 revealed diets and consistency of food textures served for 24 residents on the 900 hall. The report indicated 19 residents received textured foods of a regular consistency, and 5 residents received mechanically soft foods. Review of the weekly menu revealed on 4/4/24 items served for lunch included pulled pork, braised cabbage, and roasted sweet potatoes. Review of the kitchen measurement chart revealed the perforated spoodle was equivalent to half a cup or 4 to 5 ounces. Review of the document, Production Sheet dated 4/4/24 included the portion sizes of food items listed on the lunch menu. For mechanically soft and regular textured diets, the pulled pork portion size was 4 ounces. A continuous observation of lunch meal service…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-11-22 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately document a blood glucose reading as ordered for one (Resident #1) of one resident reviewed for accuracy of medical records. Findings included: Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses some of which included Type 2 Diabetes Mellitus and end stage renal disease. Resident #1 had a physician's order initiated on 11/8/2023 for Accu-checks twice a day at 6:00 AM and 9:00 PM to measure blood glucose levels. Documentation in the nursing notes for 11/12/2023 at 3:51 AM written by Nurse #3 revealed, Resident (#1) screaming out loud and thrashing around in the bed pushing back at staff trying to give him help. Resident (#1) was also sweating profusely. This nurse was able to check resident's blood [glucose] and the result was 29 (mg/dL). Using standing orders for glucagon emergency kit for low blood [glucose] one single dose 1 [milliliter subcutaneously] was given. Will recheck blood [glucose] in 15 minutes. 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 before2023-11-22 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with Medical Director, Pharmacy Nurse Consultant, Pharmacist, and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the focused infection control and complaint investigation survey of 1/19/21 and the recertification and complaint investigation survey of 1/27/23. This was for 3 deficiencies recited on the current complaint investigation survey of 11/22/23 in the areas of: Notification of Changes (F580), Quality of Care/Professional Standards (F684), and Complete and Accurate Medical Records (842). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F580: Based on record review, staff interviews, and Medical Director interview the facility failed to notify the physician of administering long-acting…

  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 · D2023-10-28 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 interview the facility failed to identify resident to resident abuse and failed to immediately report resident to resident abuse to the Administrator and Director of Nursing per facility policy for one of three abuse investigations reviewed. Findings included: Documentation in the abuse policies and procedures of the facility dated last reviewed on 10/2022 defined sexual abuse as, Nonconsensual sexual contact of any type with a resident or contact with any person incapable of giving consent. The same abuse policy and procedure revealed under section B. Intervention 1. Upon receiving reports of abuse, the supervisor, Administrator, and Director of Nursing are immediately notified. Documentation in the electronic medical record revealed Resident #1 had cumulative diagnoses some of which included stroke, hemiplegia, and vascular dementia. Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a BIMS (Basic Interview for Mental Status)…

  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 · E2023-01-27 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  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 Responsible Party (RP) interview, the facility failed to provide an ongoing resident centered activities program that include one on one (1:1) activities to meet the interests of a resident that did not participate in group activities for 1 of 2 residents reviewed for activities (Resident #110). Findings included: Resident #110 was admitted to the facility on [DATE] with a diagnosis of Parkinson's. Record review of the Activity Progress Note dated 10/14/22 at 12:32 pm revealed the Activities Director met with Resident #110 and she reported she enjoyed animals, playing games, keeping up with the news, listening to country music, and watching television. Activity staff were to encourage group and independent activities and monitor for resident's individual activity needs. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #110 had moderate cognitive impairment. Resident #110 reported it was very important to her to listen to the music 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-01-27 · 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

  Based on observation and staff interviews, the facility failed to remove expired medications stored in 1 of 2 medication rooms observed (Sycamore Medication Room). Findings included: During an observation on 1/26/23 at 12:10 pm of the Sycamore Medication Room with the Assistant Director of Nursing (ADON) the following expired medication were observed. The expiration dates were confirmed by the ADON prior to removal of the medications. 1 box with 60 Heparin lock flush solution syringes with expiration date of 9/2021. 1 box with 19 Heparin lock flush solution syringes with expiration date of 7/2022. 1 box with 60 Heparin lock flush solution syringes with expiration date of 9/2022. 1 box with 60 Heparin lock flush solution syringes with expiration date of 11/2022. 1 box with 30 Heparin lock flush solution syringes with expiration date of 11/2022. During an interview on 1/26/23 at 12:10 pm the ADON stated the Unit Manager was responsible to ensure the expired medication was returned to pharmacy. During an interview on 1/26/23 at 12:29 pm the Unit Manager stated the syringes were not…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-01-27 · 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 record review, staff, and the facility ' s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the 1/19/21 focused infection control and complaint investigation survey and the 11/18/21 recertification survey. This was for 2 recited deficiencies on the current recertification and complaint investigation survey of 1/27/23 in the areas of infection control (F880) and label/store drugs and biologicals (F761). The continued failure during two or more federal surveys of record shows a pattern of facility ' s inability to sustain an effective QAA committee. The findings included: This tag was cross referenced to: a. F880: Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures (1) when Nurse Aide (NA) #1 failed to remove isolation gown and gloves and perform hand hygiene before exiting a COVID-19 isolation room, (2) Nurse #1 failed to replace oxygen tubing that was on floor before placing in residents'…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-01-27 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures (1) when Nurse Aide (NA) #1 failed to remove isolation gown and gloves and perform hand hygiene before exiting a COVID-19 isolation room, (2) Nurse #1 failed to replace oxygen tubing that was on floor before placing in residents' nose (Resident #87), and (3) failed to perform hand hygiene between 4 of 4 residents when passing meal trays (Resident #101, Resident #70, Resident #62, Resident #115). Findings included: The facility was in COVID-19 outbreak status as of 1/12/23. Record review of the prior four-week period of COVID-19 facility testing revealed 4 staff and 13 residents had tested positive. The dates of the most recent staff and resident positive COVID-19 results were 1/11/23, 1/19/23, 1/20/23, and 1/21/23. Record review of the facility policy titled Policies and Practices Infection Control dated 10/2022 revealed the facility's infection control policies and practices 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-01-27 · 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 interview the facility failed to code the Minimum Data Set assessment accurately for 1 of 5 sampled residents (Resident #51) reviewed for nutrition. The findings included: Resident #51 was admitted to the facility on [DATE] with multiple diagnoses that included chronic heart failure, chronic obstructive pulmonary disease, dysphagia and failure to thrive. The quarterly Minimum Data Set, dated [DATE] indicated Resident # 51 was on a physician- prescribed weight loss regimen. Review of the care plan dated 1/24/23 revealed Resident #51 had significant weight loss related to diuretics resolving fluid issues. Staff were to provide supplements as ordered. Review of the physicians' orders revealed Resident #51 was to receive a No added Salt, mechanical soft diet. An interview with MDS nurse #1 on 1/27/23 at 1:18 PM revealed the resident was not on a prescribed weight loss diet and was coded inaccurately on the current MDS assessment. An interview with the Dietary Manager on 1/27/23 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-01-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview the facility failed to provide Activities of Daily Living (ADL) care for 1 of 3 residents (Resident #30) who was dependent on facility staff for ADL care. The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (A condition the affects the nervous system and causes problems with sensation and coordination). A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact and was totally dependent on staff for personal hygiene. Resident #30 ' s care plan last reviewed 11/7/22 revealed a goal that Activities of Daily Living/Personal Care would be provided by staff due to resident ' s impaired mobility. An observation and interview with Resident #30 on 1/24/23 at 9:30 AM revealed she had facial chin hair. Resident #30 stated that she liked to keep the hair on her chin shaved. She stated that staff usually shaved her chin when giving her a bath. 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.

  Quality of Life and Care 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

$77,760 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $77,760 — penalty dated 2023-10-28
• Medicare payment denial — starting 2023-11-16 for 14 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 SANSTONE HEALTH & REHABILITATION — 18 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

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 $6.5M paid to related parties — landlords or management companies under common ownership — equal to about 32% 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

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