Windsor Point Continuing Care
1221 Broad Street, Fuquay-Varina, NC 27526 · For profit - Corporation · 45 certified beds · (919) 552-4580 Medicare only — no Medicaid
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 improved from 3 to 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.3% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.9% | 7.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.6% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.7% | 5.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.7% | 3.5% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 37.5% | 21.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 5.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 33.2% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.2% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 84.6% | 78.1% | 79.4% | typical |
‡ 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.
20.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 20.4%CMS range 11.8–32.3 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.7–15.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 45 beds and averages 25.0 residents a day — about 56% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.43 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.02 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.97 hrs/resident/day on weekends vs 4.62 on weekdays — 14% thinner on weekends. RN hours go from 1.10 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above 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.
10 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2024-11-27 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff and resident representative, the facility failed to provide personal privacy when a resident's door to the room was left open during incontinent care allowing the resident to be visible from the hallway for 1 of 2 residents (Resident #16) reviewed for privacy. A reasonable person has an expectation of privacy during care and would have experienced feelings such as embarrassment. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, glaucoma, and age-related physical debility. Resident #16's Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, was always incontinent of bowel and bladder, and was totally dependent on staff for toilet hygiene. Observation on 11/25/24 at 10:38 a.m. revealed Resident #16's room was close to the nurses' station at the beginning of the hallway. A continuous observation on 11/27/24 from 5:01 a.m. through 5:06…
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.
- Potential for harm · Dcited before2024-11-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 2. Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia. Physician orders dated 9/3/2024 included Quetiapine Fumarate (an antipsychotic medication) half of a 25 milligram tablet twice a day for dementia with agitation. The quarterly Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #14 was severely cognitively impaired and was receiving antipsychotics on a routine basis. Resident #14's care plan last reviewed 9/25/2024 did not include a focus for the use of antipsychotic medications. A review of Resident #14's Medication Administration Record from 9/3/2024 to 11/26/2024 recorded Resident #14 received Quetiapine Fumarate half of a 25 milligram tablet twice a day. In a phone interview with the MDS Nurse #1 on 11/27/2024 at 12:14 pm, she explained she worked part-time on weekends and she had been working as the MDS nurse since the last full time MDS Nurse left the facility in September 2024. She stated as the MDS Nurse, she was responsible for developing the initial…
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.
- Potential for harm · D2024-11-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, interviews with staff, and record review, the facility failed to ensure an oxygen filter was clean of dust and debris for 1 of 2 residents (Resident #5) reviewed for oxygen use. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia and respiratory failure. Resident #5's physician's orders revealed an order dated 9/4/24 for oxygen supplementation as needed for shortness of breath, hypoxia, and comfort at 2 liters per minute (Lpm) by nasal canula as needed to maintain oxygen saturation levels above 90%. Resident #5's Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, had shortness of breath or trouble breathing with exertion, while sitting at rest, and while lying flat. The MDS indicated she used oxygen therapy. Observation on 11/25/24 at 10:06 a.m. revealed Resident #5 asleep in low bed. She had a nasal cannula on and oxygen was running from her concentrator at 2 Lpm. The external air filter had 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.
- Potential for harm · D2024-11-27 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to ensure 2 of 5 staff reviewed who were assigned nurse aide tasks met the minimum qualifications for working as a nurse aide when Staff #1 and Staff #2 were performing nurse aide tasks without having completed a training and competency evaluation program, or a competency evaluation program approved by the State and were not in a state approved training and competency evaluation program. The findings included: The North Carolina (NC) Department of Health and Human Services (DHHS) Health Care Personnel Education and Credentialing Section's website indicated under the section of Nurse Aide I, last updated 1/24/24, that in accordance with federal law, a facility may employ a nurse aide (NA) for a period of up to 4 months under the following conditions: -During the 4-month grace period, an individual must be deemed competent to provide nursing or nursing-related services by a Registered Nurse and work toward meeting the training and testing requirements by participating in a state-approved Nurse Aide I training 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.
- Potential for harm · F2023-10-26 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the facility arbitration agreement and staff interview, the facility failed to allow residents/resident representatives the right to choose whether or not to enter into a binding arbitration agreement when they required a binding arbitration agreement to be signed as a condition of admission to the facility and as a requirement to continue to receive care. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. The findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. The arbitration agreement read in part, In the event either party wishes to seek the enforcement of any remedy or bring any claim arising from or otherwise related to this Agreement of to the [Facility], the parties shall submit the matter to binding arbitration . During the entrance conference on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-26 · tag F0848 — widespreadProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review of the facility arbitration agreement and staff interviews, the facility failed to provide an arbitration agreement that provided for 1) a selection of a neutral arbitrator agreed upon by both parties and 2) the selection of a venue that was convenient to both parties. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. Findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. The arbitration agreement read in part, In the event either party wishes to seek remedy or bring any claim arising from or otherwise related to this Agreement or to [Facility], the parties shall submit the matter to binding arbitration . It further read in part, Should arbitration between the parties become necessary or ensue, the parties agree that Wake County, North Carolina is 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.
- Potential for harm · F2023-10-26 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews the facility failed to electronically submit complete and accurate Registered Nurses hours based on payroll data to the Centers for Medicare and Medicaid (CMS) for the third quarter of 2023. Findings included: The payroll-based journal staffing report triggered for no Registered Nurses hours on four or more days. A review of the staffing sheets did not include Registered Nurses who were in the building 16 out of 92 days reviewed. A review of the payroll for those days revealed that there were Registered Nurses in the building for 8 consecutive hours on those days. An interview with the Director of Nursing on 10/26/23 at 10:40 AM revealed that she used to input the information into the payroll-based journal but that she no longer did the Administrator now completed that task, she was unable to state as to when the Administrator started inputting the data. She further revealed that she had used the staffing sheets to input the data. An interview with the Administrator on 10/26/23 at 11:25 AM indicated that she now puts in the data 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.
- Potential for harm · Dcited before2023-10-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 record reviews and staff interviews the facility failed to follow a resident's care plan for transfers for 1 out of 22 residents reviewed (Resident #19). Findings included: Resident # 19 was admitted into the facility on [DATE] with diagnoses that included Alzheimer's dementia. A review of Resident #19's most recent comprehensive care plan dated 9/20/23 stated that she was a 1 person assist with transfers via mechanical lift. Resident #19's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired and was totally dependent on one staff member for transfers. On 10/25/23 at 9:28 AM an interview with Nursing Assistant #3, who was caring for Resident #19 that day, revealed that she transferred Resident #19 using a stand pivot transfer. When asked if she knew that it was care planned for a mechanical lift, she stated yes but that Resident #19 did not like the mechanical lift and Resident # 19 was able to stand long enough to complete a stand-pivot transfer. 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.
- No harm found · B2024-11-27 · tag F0641 — patternEnsure 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) in the areas of Gradual Dose Reduction (Residents #16 and #13) and Restraints (Resident #8) for 3 of 12 residents reviewed. Findings included: 1. Resident #13 was admitted on [DATE] with diagnoses including dementia and major depressive disorder. A psychiatric Nurse Practitioner progress note dated 10/03/24 recorded Resident #13 was to continue taking quetiapine (an antipsychotic medication used to treat mental health conditions) 25 milligrams (mg) and apriprazole 2.5 mg. Her medications were reviewed for possible Gradual Dose Reduction (GDR- to reduce the dose or discontinue the medication) of psychotropics (includes several classifications of medications used to treat mental illness), and it was noted a GDR was not recommended at that time. Review of Resident #13's October 2024 Medication Administration Record revealed she had received quetiapine and aripiprazole daily. Resident #13's significant…
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.
- No harm found · C2023-10-26 · tag F0655 — widespreadCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 provide a written summary of the baseline care plan to the resident or family in 2 out of 2 residents (Resident # 21 and Resident #7). Findings included: 1a. Resident #21 was admitted into the facility on 8/16/23 with diagnoses including: dementia and anxiety. A review of Resident 21's admission Minimum Data Set (MDS) dated [DATE] revealed she had severe cognitive impairment. An interview conducted on 10/25/23 at 11:25 AM with her Family Member indicated the Family Member had not received a copy or a summary of the base line care plan, she was informed of and did attend the comprehensive care plan meeting. 1b. Resident #7 was admitted into the facility on 8/15/23. A review of Resident #7's admission MDS dated [DATE] revealed he was cognitively intact. An interview conducted with Resident #7 on 10/25/23 at 10:45 AM indicated he went to the comprehensive care plan meeting but he had not received a copy or summary of his baseline care plan.…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVANS, TONI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | 6% | since 07/07/1995 |
| MILLER, WILLIAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | 6% | since 07/07/1995 |
| SHERRILL, DEBBIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | 6% | since 07/07/1995 |
| EVANS, RILEY | Individual | DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; CORPORATE DIRECTOR | — | since 07/07/1995 |
| EVANS, ROBERT | Individual | DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/07/1995 |
| JONHSON, FLORENCE | Individual | DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/07/1995 |
| MILLER, ROSEMARY | Individual | DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 07/07/1995 |
| STAN JOHNSON AND ASSOCIATE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 07/07/1995 |
| JONES, SHARON | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2008 |
| EVANS, KISA | Individual | CORPORATE OFFICER | — | since 01/01/2020 |
| BUIE, KATHYRN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/06/2025 |
| DEVINE, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/10/2021 |
| LANZETTA, SHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2025 |
| MAYS, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/10/2021 |
| POPE, TAMMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2002 |
| SEAVERSON, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/14/2025 |
| MILLER, ZACHARY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/12/2026 |
| MOORE, FALON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/12/2026 |
| RODERICK, MAEGAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/12/2026 |
| EVENTUS WHOLEHEALTH PLLC | Organization | ADP OF THE SNF | — | since 03/28/1998 |
| GREENBRIER LLC | Organization | ADP OF THE SNF | — | since 12/22/2012 |
| LEGACY HEALTHCARE SERVICES INC | Organization | ADP OF THE SNF | — | since 07/01/2011 |
| NUTRITION PLUS OF GREENVILLE INC | Organization | ADP OF THE SNF | — | since 02/01/2006 |
| SETH A WARD CPA PLLC | Organization | ADP OF THE SNF | — | since 01/01/2010 |
| SHERRILL INVESTMENT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/22/2012 |
| WINDSOR POINT PHARMACY, INC. | Organization | ADP OF THE SNF | — | since 03/28/1998 |
| BHAGALIA-PATEL, PARUL | Individual | ADP OF THE SNF | — | since 01/01/2022 |
| JOHNSON, ETHAN | Individual | ADP OF THE SNF | — | since 12/22/2012 |
| JOHNSON, JOSH | Individual | ADP OF THE SNF | — | since 12/22/2012 |
| MCDOUGALD, ANNA | Individual | ADP OF THE SNF | — | since 12/22/2012 |
| MCDOUGALD, JR., ANDREW | Individual | ADP OF THE SNF | — | since 12/22/2012 |
| PENDERGRASS, KELLY | Individual | ADP OF THE SNF | — | since 10/01/2010 |
| PICKFORD, SARAH | Individual | ADP OF THE SNF | — | since 02/01/2006 |
| ROBINSON, BETH | Individual | ADP OF THE SNF | — | since 05/06/2017 |
CMS files one row per role, so the 65 rows in the source record cover these 34 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
This home reported $315K 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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the North Carolina Medicaid page for homes that do.
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 345500. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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.