O'Berry Neuro-Medical Treatment 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.

Staffing

How full it usually is: this home is certified for 144 beds and averages 122.6 residents a day — about 85% occupied, or roughly 21 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the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026.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 10.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.34 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 8.15 is at or above 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.

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

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.

29 citations, most serious first. The 18 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-02-07 · 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, and staff and physician interviews, the facility failed to consult with the physician immediately when Resident #2, who had a tracheostomy, experienced a medical emergency. On 1/16/25, Resident #2 exhibited signs of pain, and her oxygen saturation levels were at 69% on room air (normal range is 95%-100%). Nurse #1 was able to stabilize the resident's oxygen saturation through administration of oxygen and she medicated the resident for pain. Later in the shift, Nurse #1 was notified by Nurse Aide (NA) #1 Resident #2's oxygen saturation levels had dropped to 55% (a life threatening level), the resident was crying, and her tongue was blue. Emergency Medical Services (EMS) and the physician were not notified immediately. After notifying the physician and calling EMS Resident #2 was transferred to the hospital and was diagnosed with acute hypoxia (lack of oxygen in the body) respiratory failure (occurs when the body is unable to maintain adequate oxygen levels in the blood due to a sudden…

  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 · J2025-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and physician, the facility failed to provide nursing assessments and monitoring for Resident #2 following an acute change of condition. On 1/16/25 at approximately 3:30 AM, Resident #2 exhibited signs of pain and her oxygen saturation levels were at 69% (normal range is 95%-100%). Supplemental oxygen was applied, the physician ordered morphine 2 milligrams (mg) subcutaneously (under the skin), and instructed Nurse #1 to monitor the resident closely. Nurse #1 inadvertently administered 20 mg of morphine to Resident #2 at approximately 3:45 AM rather than the 2mg ordered by the physician. Nurse #1 nor any other nurse monitored or assessed on Resident #2 until approximately 4:40 AM when Nurse #1 was notified by Nurse Aide (NA) #1 that Resident #2's oxygen saturation levels dropped to 55%, she was crying, and her tongue was blue. Emergency Medical Services were not contacted until 4:58 AM. Resident #2 was transferred to the hospital and was diagnosed with acute…

  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 · J2025-02-07 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and the physician, the facility failed to prevent a significant medication error when Nurse #1 administered ten times the ordered amount of morphine (narcotic pain medication) to Resident #2. On 1/16/25, Resident #2 exhibited signs of pain and her oxygen saturation levels were at 69% (normal range is 95%-100%). Supplemental oxygen was applied and the physician ordered morphine 2 milligrams (mg) subcutaneously (under the skin). Nurse #1 obtained two vials of morphine and administered them to Resident #2. She believed each vial contained 1 mg of morphine rather than the actual content of 10 mg per vial resulting in the resident receiving 20 mg instead of the physician ordered 2 mg. Approximately one hour later the resident's tongue appeared blue and her oxygen saturation level dropped to 55% on 4 liters per minute of supplemental oxygen. She was transferred to the hospital and was diagnosed with acute hypoxia respiratory failure (occurs when the body is unable 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-12-16 · 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

  Based on record review, and staff and Medical Director interviews, the facility failed to notify the primary care physician when Resident #103 was not provided bolus tube feedings (a way to send formula through a tube directly into the stomach) per the physician order. On 9/28/24 Nurse #1 did not feed Resident #103 his bolus tube feeding because she believed he was full. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders without notifying the physician. Nurse #1 confirmed this was not a new practice for her and she had done this previously for an undetermined number of times and instances without notifying the physician. Deviating from the physician orders by not providing tube feeding formula without notifying the physician deprived Resident #103 of his assessed nutritional needs. When staff purposefully disregard physician's orders and make treatment decisions on their own, it places all residents at risk of serious harm and/or death. This deficient practice was identified…

  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 before2024-12-16 · 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, and staff and Medical Director interviews, the facility failed to protect the residents' right to be free from neglect when Nurse #1 did not provide the necessary care and services as assessed and ordered by the physician to Resident #103. On 9/28/24 Nurse #1 did not provide Resident #103 his bolus tube feeding (a way to send formula through a tube directly into the stomach) because she thought he was full. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders and deprive the resident of his assessed nutritional needs. Nurse #1 revealed this was not a new practice for her and she had done this previously for the resident an undetermined number of times. When staff purposefully disregard physician's orders and make treatment decisions on their own, it places all residents at risk of serious harm and/or death. This deficient practice affected 1 of 7 residents reviewed for tube feedings…

  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 · Kcited before2024-04-21 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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

  Based on observation, record review, Responsible Party interview, staff interviews and a Physician interview, the facility failed to protect Resident #1 from neglect by not implementing effective interventions to prevent a resident with a known diagnosis of PICA disorder (a mental health condition where a person compulsively eats non-food items that are harmful or toxic) from repeated incidents of accessing and ingesting medical examination gloves. On 2/21/2024, Resident #1 vomited two medical examination gloves. On 2/24/2024, a dime size object resembling a part of a medical examination glove was observed in Resident #1's enteral feeding (nutrition delivered through a tube placed into the stomach or small intestine) residual (enteral feeding not digested from the stomach). On 3/24/2024, Resident #1 vomited two medical examination gloves. On 4/5/2024, Resident #1 was found lying in bed with a medical examination glove in emesis under her pillow. The ingestion and vomiting of examination gloves created a high likelihood of serious harm such as a blockage of Resident #1's airway,…

  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 · Kcited before2024-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 observation, record review, Responsible Party interview, staff interviews and a Physician interview, the facility failed to provide supervision to prevent a resident with a known diagnosis of PICA disorder (a mental health condition where a person compulsively eats non-food items that are harmful or toxic) from engaging in PICA behaviors. On 2/21/2024, Resident #1 vomited two medical examination gloves. On 2/24/2024 a dime size object resembling a part of a medical examination glove was observed in Resident #1's enteral feeding (nutrition delivered through a tube placed into the stomach or small intestine) residual (enteral feeding not digested from the stomach area). On 3/24/2024, Resident #1 vomited two medical examination gloves. On 4/5/2024 Resident #1 was found lying in bed with a medical examination glove in vomit under the edge of her pillow. The ingestion and vomiting of examination gloves created a high likelihood of serious harm such as a blockage of the resident's airway, choking, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-02-23 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 interviews, and review of the facility's video footage the facility failed to protect the resident's right to be free from abuse when Resident #1 physically abused by Nurse Aide (NA) #1. On 2/8/24 Resident #1 was attempting to leave a common area of the facility when NA #1 stopped him from leaving by blocking the resident's exit, physically turning the resident around with her hands on his arms, and then proceeded to use the resident's ambulatory assistance device (gait vest) to forcefully move the resident 14 feet to the couch. NA #1 attempted to get Resident #1 to sit on the couch by using both hands to push on Resident #1's torso. Resident #1 resisted the seated position and attempted to stand back up twice. On the first instance, NA #1 again pushed the resident with both hands on the front of his torso to a seated position. On the second instance, Resident #1 stood up with his feet crossed resulting in the resident falling to the floor and sustaining a laceration…

  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 · D2026-06-23 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff the facility failed to ensure a resident, whose care plan noted she should be allowed to sit on the floor if the resident chose to do so, was treated with dignity when a Nurse Aide lifted the resisting resident to her feet and dragged her to her room. This was for 1 (Resident # 1) of 3 residents reviewed for staff treatment.The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE]. Resident # 1 had diagnoses which included profound intellectually disability and blindness in the right eye.Resident # 1's Minimum Data Set assessment, dated 4/26/26, coded Resident #1 as severely cognitively impaired and ambulatory with supervision. Additionally, Resident # 1 was coded as having behaviors that were not directed at others.Resident # 1's care plan, dated 5/15/26, revealed the following information. Resident # 1 was identified to at times have self-injurious behavior, loud vocalizations, mouthing inedible objects, 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide a safe transfer and failed to provide supervision to a resident, left unattended on the commode for 2 of 5 residents reviewed for accidents (Residents #114 and #85).The findings included: 1.Resident #114 was admitted to the facility on [DATE] with diagnoses that included dementia, profound intellectual disabilities, stroke and osteoporosis. Review of Minimum Data Set (MDS) dated [DATE] revealed the Resident was severely cognitively impaired, had impairment of upper extremities on one side and was dependent on staff for transfers. Resident #114's care plan initiated on 7/16/21 revealed a care plan was in place for assistance for safe transfers. Staff were to provide 2 people assisting with stand/pivot transfers and assistive devices / gait belt for all transfers. Review of HCT (Heath Care Technician) #2's a (contract staff) written statement provided to the facility on 4/24/25 revealed that on 4/24/25 she brought Resident…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2025-02-07 · 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 reviews and staff interviews, the facility failed to have a complete and accurate medication administration record for 1 of 3 residents reviewed for medical record accuracy (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (low oxygen level). Resident #2's physician orders dated 1/14/25 noted an order for Tramadol (narcotic pain medication) 50 milligrams (mg) per feeding tube every 8 hours for 3 days for pain after surgery. Resident #2's physician progress notes dated 1/15/25 noted the resident returned to the facility the previous day (1/14/25) after surgery to remove kidney stones and to place an indwelling ureteral stent (a tube inserted to help urine drain from the kidney to the bladder). Resident #2's nursing progress note dated 1/16/25 at 3:30 AM written by Nurse #1 noted she had given Resident #2 a dose of Tramadol at 12 midnight. Resident #2's January 2025 Medication Administration Record…

  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 · E2024-12-16 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 document written advance directive information and/or an opportunity to formulate an advance directive was provided for 16 of 19 residents reviewed for advance directives. (Resident's #'s 19, 30, 40, 42, 48, 59, 63, 71, 72, 73, 83, 87, 88, 97, 99 and 125). Findings included: The Advance-Care Directives and Right for a Nature Death policy dated [DATE] read in part: (1) that patients/residents who have the capacity to receive the advance care directive information and to articulate whether they have made an advance care directive be given the information upon admission or when they gain/regain such capacity, (2) the facility should periodically review the capacity status of patients/residents, (3) designated appropriate staff at each facility shall have resource information of organizations that have agreed to assist facility patients/residents in making advance care directives, and (4) facilities shall regularly review advance care directives 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-12-16 · 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

  Based on record review and staff interviews, the facility failed to document on residents' controlled medication records that two different nurses ensured accurate reconciliation and accounting of controlled medications for 1 of 1 medication cart reviewed for controlled medication records (Cluster 1 Hall 2 medication cart). Findings included: The facility's Diversion Prevention Policy dated last reviewed 9/9/2020 stated documentation of access and inventory was performed by both off going and ongoing personal during shift change by use of an ancillary form, a controlled substance shift change accountability record. A review of residents' controlled medication records for Cluster1 Hall 2 medication cart on 12/11/2024 indicated there was no nurse signature for an oncoming shift, an off going shift or the same nurse signed as the oncoming and off going nurse for a shift on the following dates on the residents' controlled medication record: - Resident #81's Phenobarbital 64.8 milligrams (mg) controlled medication record on December 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. - Resident #123's…

  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 · D2024-12-16 · 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 for the use of anticoagulants (medications that increased the time it takes for blood to clot) for 1 of 31 residents whose MDS assessments were reviewed (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE] and diagnoses included coronary artery (heart) disease. Physician orders dated 10/17/2024 included Apixaban (an anticoagulant used to reduce the risk of forming blood clots) 5 milligrams (mg) every twelve hours. The October 2024 Medication Administration Record (MAR) recorded Resident #63 received Apixaban 5 mg every twelve hours from 10/17/24 to 10/31/24. The November 2024 MAR recorded Resident #63 received Apixaban 5 mg every twelve hours from 11/1/2024 to 11/30/2024. The quarterly MDS assessment dated [DATE] indicated Resident #63 was receiving an antiplatelet (a medication to prevent platelets from sticking together and forming blood clots). In an…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2024-12-16 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of the use of blood thinner and/or anticoagulants (a medication that increases the time it takes for blood to clot) (Resident #63) and in the area for seizures and the use of antiepileptic medications (Resident #101) for 2 of 31 residents whose comprehensive care plan was reviewed. Findings included: 1. Resident #63 was admitted to the facility on [DATE] and diagnoses included coronary artery (heart) disease. Physician orders dated 10/17/2024 included Apixaban (an anticoagulant used to reduce the risk of forming blood clots) 5 milligrams (mg) every twelve hours. The October 2024, November 2024 and December 2024 Medication Administration Record (MAR) recorded Resident #63 received Apixaban 5 mg every twelve hours from 10/17/24 to 12/11/2024. The quarterly MDS assessment dated [DATE] indicated Resident #63 was receiving an antiplatelet (a medication to prevent platelets from sticking together 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, and Registered Dietician (RD) interviews, the facility failed to administer tube feedings via a gastrostomy tube (a tube to provide formula directly to the stomach) as ordered by the physician for 1 of 7 residents reviewed with tube feeding orders (Resident #103). The findings included: Resident #103 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that included esophageal dysmotility (esophagus did not move in a coordinated way), recurrent aspiration pneumonia, dysphagia (difficulty swallowing), a gastric tube, and history of weight loss. Resident #103 quarterly Minimum Data Set (MDS) dated [DATE] indicated he had no speech, rarely or never understood others and was rarely or never understood. He had severe cognitive impairment. He required the use of a feeding tube for nutrition and consumed more than half his calories through the feeding tube daily. The MDS indicated he had not had any significant weight…

  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 before2024-12-16 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to secure medications in an unlocked medication room and unlocked medication cart (Building 1 Hall 4 medication room and medication cart), failed to dispose of an expired medication (Building 2 Hall 2 medication cart), failed to maintain a temperature range of 36 to 46 degrees Fahrenheit (F) for refrigerated medications and monitor the internal temperature of medication refrigerators (Building 2 Hall 2 and Building 4 Hall 3 medication rooms) for 3 of 6 medication rooms and medication carts reviewed for medication storage. Findings included: 1. On [DATE] at 12:47 pm, Building 1 Hall 4 medication room was observed unlocked with no staff observed in the medication room, and the medication cart located inside the unlocked Building 1 Hall 4 medication room was observed unlocked when a resident's medication drawer on the medication cart was able to be pulled open. A continuous observation of the Building 1 hall 4 medication room began until…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-16 · 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 have a complete and accurate medication and treatment administration record for 1 of 7 residents reviewed for medical record accuracy (Resident #103). The findings included: Resident #103's physician order dated 4/11/24 revealed he was to receive a 2-Calorie formula bolus (poured directly into the gastric tube)1 carton 4 times a day at midnight, 6:00 AM, noon, and 6:00 PM and to check residuals before accessing the gastric tube and hold the bolus for 1 hour if residuals were greater than 30 cc (cubic centimeters). Resident #103's Treatment Administration Record (TAR) for September 28-30, 2024 revealed Nurse #1 signed she provided Resident #103 his ordered tube feeding at midnight and 6:00 AM. There were no notes on the TAR to indicate the resident had to have his feeding held for any reason by Nurse #1. In a statement written by Nurse #1 on 9/30/24, she said she did not provide Resident #103 with his ordered formula on the night of 9/29/24 at midnight because she thought he was full. She wrote she would not give…

  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

“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

$167,242 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $167,242 — penalty dated 2024-02-23
• Medicare payment denial — starting 2024-03-28 for 50 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.

Who owns this facility

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

What families pay in NC