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Linden Place Center for Nursing and Rehabilitation

1201 Carolina Street, Greensboro, NC 27401 · For profit - Corporation · 105 certified beds · (336) 522-5700 Medicare & Medicaid certified

Call the home — (336) 522-5700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2023Resident-funds citation (F0565)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 19% of its spending goes to commonly-owned related companies

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1103 N Elm St · (336) 271-3331 · Call to confirm hours
Pharmacy
1220 Magnolia Street, Suite 100
Grocery
1403 Yanceyville St · (336) 763-5007 · Call to confirm hours
Park
1145 Cridland Rd · (336) 373-5882 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%15.6%15.4%better
Long-stay residents who lose too much weight7.7%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection1.3%2.3%2.0%better
Long-stay residents with depressive symptoms4.4%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.2%3.5%3.3%typical
Long-stay residents whose ability to walk worsened17.6%18.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication22.6%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine88.6%94.1%95.3%typical
Long-stay residents with pressure ulcers8.7%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control24.0%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.2%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine32.1%78.1%79.4%worse

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.

34.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.7%U.S. median 51.5%
Got home and stayed home
0.33U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.7%CMS range 20.9–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified84.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.30
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.40
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.13
RN hoursweekends
36.0%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 105 beds and averages 89.1 residents a day — about 85% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.31 hrs/resident/day on weekends vs 3.80 on weekdays — 13% thinner on weekends. RN hours go from 0.37 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as 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

12
deficiencies at the latest standard inspection (2026-01-10)
3
at the previous standard inspection (2024-09-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2023-05-26 · 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, observations, interviews with residents and staff, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 1 resident investigated for abuse (Resident #13). Resident #13 had reported to the facility Nurse Aide (NA)#1 needed to feed her roommate correctly. Resident #13 alleged later the same evening NA #1 grabbed Resident #13's face very hard, squeezed her face, in a manner which scared the resident and after the incident the resident was found to have bruising on her right jawline and right cheek. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis following cerebrovascular accident (stroke), contracture of right hand and forearm, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE], indicated Resident #13's cognition was intact for daily decision making and she required total assistance with activities of daily living. The assessment indicated 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2026-01-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to maintain in good repair a resident's room door and bathroom sink in 1 of 11 resident rooms and 1 of 11 resident bathrooms on 1 of 2 halls whose room and/or bathroom was observed to have environmental concerns (Resident #48).The findings included:1) An initial observation of Resident #48's room was conducted on 1/5/26 at 1:10 PM. This observation revealed the door latch on the door to the resident's room did not secure the door so that it would remain closed. Accompanied by the facility's Maintenance Director, an observation of the door to Resident #48's room was conducted on 1/8/26 at 4:00 PM. When the Maintenance Director was shown the door latch and strike plate on the resident's door, he reported having worked on the door in the past. However, he acknowledged the repair did not appear to have fixed the problem. The Maintenance Director was observed as he attempted several times to close the door, but the door would not latch so that it would remain closed. The Director stated the door would likely need to be…

    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 · E2026-01-10 · 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 observations and staff interviews, the facility failed to: 1) Label a medication with the minimum required information (including the resident's name) stored on 1 of 2 medication (med) carts (North Hall Med Cart #2); 2) Discard expired medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom) and on 1 of 2 medication carts observed (North Hall Med Cart #2); and 3) Date medications as to when they were opened to allow for the determination of the shortened expiration date for medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom).The findings included:1. An observation was conducted on 1/5/25 at 2:45 PM with Medication (Med) Aide #1 of the North Hall Medication Storeroom. The observation revealed the following medications were stored in the Medication Storeroom:a. One (1) unopened, single-use vial of Arexy for injection (a vaccine for Respiratory Syncytial Virus or RSV) dispensed by the pharmacy on 4/4/25 for Resident #48 was stored in the medication storeroom refrigerator. The manufacturer's expiration date 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-10 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff and resident interviews, the facility failed to act upon group grievances, resolve repeat grievances, and/or communicate the facility's efforts to address grievances voiced during Resident Council meetings for 2 of 3 months reviewed (November 2025 and December 2025).The findings included:Resident Council minutes completed on 10/14/25 by the previous Activities Director, Activities Director #1, revealed the following grievances were expressed: staff had poor attitudes and used foul language, medications were dropped off and left in resident rooms, call lights not in reach, staff observed voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes. A review of the grievances for October 2025 revealed one grievance form completed by the Administrator on 10/14/25 that corresponded to the Resident Council minutes dated 10/14/25. This form revealed no mention of the grievances voiced by the Resident Council related to staff voicing confidential resident information in…

    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 · D2026-01-10 · tag F0578 — failed to honor advance directives / code status — isolated
    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 observation, staff interviews and record review, the facility failed to maintain accurate and consistent advance directive information throughout both the electronic medical record and paper record kept at the nursing station for 1 of 32 residents reviewed for advance directives (Resident #96). The findings included:Resident #96 was admitted to the facility on [DATE] with cumulative diagnoses which included cancer and generalized muscle weakness.On [DATE] at 10:15 AM, a 3-ring binder containing paper copies of the residents' advance directives was observed at the nursing station. A review of Resident 96's record kept in this binder revealed it included a signed Do Not Resuscitate (DNR) form dated [DATE] and printed on bright yellow/orange-colored paper indicating the resident had a DNR status with No Expiration Date. Further review of the 3-ring advance directive binder revealed it also contained a Medical Order for Scope of Treatment (MOST) form dated [DATE] and signed by the resident's Nurse…

    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 · D2026-01-10 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR, a review to determine if the resident needs specialized services and nursing home care) Level II status (Resident #2) and Hospice services (Resident #17). This occurred for 2 of 32 residents whose MDS assessments were reviewed (Resident #2 and Resident #17).The findings included: 1. Resident #2's electronic medical record (EMR) included a PASRR Level II Determination Notification letter issued 11/22/23 which had no expiration date. Resident #2 was admitted to the facility on [DATE] with a cumulative diagnosis which included schizophrenia and major depressive disorder. The resident's care plan included an area of focus which reported the resident had a Level II PASRR status related to a serious mental illness and related condition due to schizophrenia (Initiated 3/25/25). Resident #2's most recent annual Minimum Data Set (MDS)…

    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 before2026-01-10 · 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 observations, record review, and resident interviews and staff interviews, the facility failed to develop a comprehensive care plan in the areas of use of a colostomy bag and urinary catheter (Resident #52), dialysis treatment (Resident #14), and discharge goal (Resident #65) for 3 of 32 residents whose care plans were reviewed. The findings included: 1.Resident #52 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, other specified soft tissue disorders, and rectal hemorrhage. The resident was admitted with a colostomy bag and a urinary catheter. A review of Resident #52's physician orders dated 10/27/2025 revealed orders for catheter care, including checking the placement of the catheter strap every shift and monitoring urinary catheter output every shift. Physician orders dated 10/29/2025 directed staff to check and empty the resident's colostomy bag every shift and replace it as needed. A review of Resident #52's care plan dated 10/28/2025 revealed that no care…

    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 · D2026-01-10 · 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

    Based on observations, record review, resident interview and staff interviews, the facility failed to shave facial hair for 1 of 4 residents reviewed for activities of daily living (ADL) (Resident #65). The findings included:Resident #65 was admitted to the facility 11/18/25 with diagnoses that included metabolic encephalopathy, needs assistance with personal care and muscle weakness.The admission Minimum Data Set (MDS) assessment completed on 11/24/25 documented Resident #65 was moderately cognitively impaired and required supervision or touching assistance with personal hygiene needs.A care plan developed on 12/4/25 documented Resident #65 required staff supervision/touching assistance with personal hygiene and included the goal that Resident #65 would improve current level of function in ADL through the next review. Interventions included Resident #65 required assistance by staff with personal hygiene. Resident #65 was observed on 1/5/26 at 12:26 PM. Resident #65 had a full beard that was approximately an inch in length and a mustache approximately 1/2 inch in length, which…

    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 · D2026-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 and Nurse Practitioner interviews, the facility failed to obtain a physician order for the treatment of a stage 3 pressure ulcer and failed to set a pressure relieving air mattress to the correct setting for 1 of 3 residents reviewed for pressure ulcers (Resident #17). The findings included:Resident #17 was admitted to the facility on [DATE] with diagnosis that included cerebral vascular disease, type 2 diabetes, hypertension, pressure ulcer of sacral region, and peripheral vascular disease.The care plan revised on 08/29/25 revealed Resident #17 had a pressure ulcer on her coccyx and was at risk for further breakdown related to failure to thrive and disease process. The goal was Resident #17's pressure ulcer would show signs of healing and remain free from infection. Interventions included assessing resident for risk of skin breakdown, keeping skin clean and dry as possible, and skin assessments as indicated. Weekly treatment documentation to include measurement of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record reviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen was in use for 1 of 1 resident reviewed for respiratory care (Resident #88).The findings included:Resident #88 was admitted to the facility on [DATE] with a diagnosis of systolic (congestive) heart failure.The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #88 had severely impaired cognition. Review of the resident's electronic medical record (EMR) census revealed the resident was sent out to the hospital on [DATE] with re-entry to the facility on [DATE].Resident #88's Physician's Orders included an order received on 12/11/25 for supplemental oxygen to be provided via nasal cannula at 2 liters per minute as needed for shortness of breath to maintain an oxygen saturation rate greater than 90%. During an observation conducted on 1/5/26 at 10:15 AM of Resident #88, the resident 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 · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 6 residents observed during the medication administration observations (Resident #11 and Resident #33).The findings included:1. Breo Ellipta is an aerosol powder for inhalation used for the management of chronic obstructive pulmonary disease (COPD) and/or asthma. The manufacturer's Full Prescribing Information for the Breo Ellipta inhaled medication included Administration Information. These instructions read, in part: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis [a superficial yeast infection of the mouth, also known as oral thrush].On 1/7/26 at 8:33 AM, Medication Aide (Med Aide) #2 was observed as she prepared and administered ten (10) medications to Resident #11. The medications administered to the resident included 200 - 25 micrograms (mcg) per…

    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
Show the remaining 19 citations
  • Potential for harm · D2024-09-12 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident and staff interviews, the facility failed to honor a residents' request to have medications administered at a time that was desired for 1 of 4 residents (Resident #64) reviewed for choices. The findings included: Resident # 64 admitted to facility on 7/16/24 with diagnoses that included chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 was cognitively intact. On 09/10/24 at 12:51 PM an interview was conducted with Resident #64 and he indicated he was concerned with the time he was getting his medications. He indicated he would sometimes receive his morning medications close to lunch time. Resident #64 stated, I have talked numerous times to someone here about my medications and getting them on time, and nothing has changed A review of Resident#64's September electronic medication administration record revealed morning medication times scheduled for 7:00 AM, 8:00 AM, and 9:00 AM. On 09/11/24…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · 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 interviews of the staff, physician, and nurse practitioner, the facility failed to notify the on-call nurse practitioner when a resident had a change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization. Findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. On 6/12/24 at 7:30 pm Nurse #1 documented in the neurological assessment form Resident #95 had blood pressure (BP) 135/95, pulse (P) 91, respirations (R) 13, and temperature (T) 97.0. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. There was no headache, seizure, drainage from the ear or nose, or vomiting. On 9/11/24 at 2:49 pm Nurse #1 was interviewed. Nurse #1 stated she had not informed the on-call nurse practitioner (NP) on 6/12/24 at 11:30 pm when…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · 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 of the staff, physician, and nurse practitioner, the facility failed to identify a resident's change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization. Findings included: The resident had medical orders for scope of treatment (MOST) form dated 3/21/22 signed by a representative. Section A was for do not resuscitate. Section B was limited additional interventions: Do not intubate or mechanical ventilate but may consider less invasive airway support such as BiPAP or CPAP (oxygen mask with positive pressure), transfer to hospital if indicated, and avoid intensive care. Sections C and D were to provide antibiotics and intravenous fluids. Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. Resident #95's care plan dated 5/23/24 documented she had an impaired cognitive function and thought process, 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 · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · 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 that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Findings Included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included multiple fractures and pressure ulcers. He was discharged to the hospital on [DATE] and did not return to the facility. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Care Area Assessment (CAA) summary identified care plans would be developed for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 5/28/21 and 5/26/23 and the current complaint investigation survey of 5/6/24. This failure occurred for a repeat deficiency originally cited in the area of comprehensive resident centered care plans that was subsequently recited on the current complaint investigation survey of 5/6/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI Program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive…

    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 · Ecited before2023-05-26 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and/or respond to concerns voiced by residents during Resident Council meetings for 9 of 10 months (July 2022, August 2022, October through, December 2022, and January, February, March, and April 2023). Findings included: The Resident Council meeting minutes for July, August, October, November, and December 2022 revealed no concerns or grievances were documented from residents. The minutes indicated Resident #38, Resident #29, Resident #2, and Resident #55 attended these meetings. During an interview with the current Activities Director on 05/12/23 at 12:00pm, she stated she began working at the facility in April 2023. She indicated she oversaw the Resident Council meetings and documented the minutes, but no concerns or grievances were brought up in the April 2023 Resident Council meeting. The Activities Director was not able to locate resident council minutes from January 2023 to present. A telephone interview was attempted on 05/12/23 at 12:32pm with the previous…

    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 · Ecited before2023-05-26 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 5/12/23. This was for a deficiency that was cited in the area of Development/implement a Comprehensive Care plan on 5/28/21 and recited on the current recertification and complaint survey on 5/12/23. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 6/16/22. This was evident by the deficiency in the areas of maintain an effective pest control program originally cited on the recertification and recited on the current recertification and complaint survey of 5/12/23. The repeated citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included The tags were cross referenced 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-26 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, resident and staff interview the facility failed to provide a pest free living environment for 4 of 4 residents residing in the facility. (Resident #243, Resident #38, Resident #2, and Resident #18). Findings Included: a. During the facility tour on 5/8/23 at 10:00 AM, an observation was made of a roach crawling on the 100 hallway. b. During a Resident Council meeting on 5/10/23 at 10:00 AM, residents who attended the meeting (Residents #38, Resident #18, and Resident #2) reported that the facility had issues with pests in their room. There were roaches in their rooms and in the hallways. Resident #38 (President of Resident Council) was interviewed on 5/10/23, at 4:00 PM. The resident indicated that the facility had issues with pests. Resident #38 stated she saw a roach crawling on the wall beside the bathroom door in her room last night (on 5/9/23). Resident #38 indicated she had been complaining in the Resident Council meeting for months and that concerns had not been addressed. c. On 5/8/23 at 11:39 AM, Resident #243 was interviewed, and 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · 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

    Based on record review, resident and staff interviews the staff failed to report an allegation of employee to resident abuse to the Administrator immediately. This was evident for 1 of 3 residents reviewed for allegations of abuse. (Resident #13). Findings included: The facility's Abuse, Neglect and Exploitation Policy dated 11/1/22 read in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan included: The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-26 · 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 interview, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for 1 of 25 residents (Resident # 24). Findings included: Resident #24 was readmitted on [DATE] with diagnoses that included end stage renal disease, and dependence on Hemodialysis. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE]. Resident was assessed as cognitively intact and needed extensive assistance with one-person physical assistance for activities of daily living (ADL). Assessment indicated Resident #24 was receiving dialysis. Review of the Care Area Assessment (CAA) revealed the resident was triggered for Nutrition and Nutrition status to be addressed in care plan. Review of Resident #24's care plan revealed the resident was not care planned for nutrition. During an interview on 5/10/23 at 11:28 AM, the Dietitian (RD) stated the resident was on renal diet and was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 2). The findings included: Resident #2 was readmitted on [DATE] with diagnoses in part, paraplegia, liver carcinoma and heart failure. A record review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was admitted to the facility on [DATE]. The resident was assessed as cognitively intact and was dependent on staff for most of the activity of daily living. Review of the resident's care plan revealed it was reviewed by staff on 3/9/23, but there was no indication that the resident or resident's family participated in the care plan meeting or in the development of Resident #2's plan of care. During an interview on 5/8/23 at 12:39 PM, Resident #2 stated the facility had not invited the resident to any care plan meeting or to participate in…

    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 · D2023-05-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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, staff, Nurse Practitioner, and Medical Director interview the facility failed to follow physician orders to obtain a hemoglobin A1c (HbA1c) every three months as ordered for Resident #33 for 1 of 24 residents reviewed. Findings included: Resident #33 was admitted to facility 3/11/22 and had a diagnosis of type 2 diabetes. Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. A review of Resident #33's care plan dated 3/14/22 revealed Resident had diabetes. Goal was Resident would have no complications related to diabetes. A review of Resident #33's physician orders revealed the following: order dated 9/28/22 Trulicity Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 milligram subcutaneously one time a day every Thursday. order dated 10/10/22 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 units subcutaneously every morning and at bedtime. order dated 12/21/22 Humalog KwikPen 100 UNIT/ML Solution pen-injector Inject subcutaneously…

    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 · D2023-05-26 · 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 facility staff and record reviews, the facility failed to accurately document a sedative medication for a resident 1 of 6 nights during the stay in the facility. This occurred for 1 of 22 residents (Resident # 245) whose medications were reviewed. The findings included: Review of admission orders dated 9/23/22 revealed Zolpidem Tartrate (Ambien) Tablet 10 milligrams (mg); Give 1 tablet by mouth at bedtime for difficulty sleeping Take 5 to10 mg by mouth at bedtime. It was due to be administered at 9:00 PM. The Electronic Medication Administration Record (EMAR) for Resident # 245 revealed Ambien did not have administration documented on 9/23/22, 9/24/22, 9/26/22, 9/27/22, 9/28/22, and 9/29/22. There were chart codes on the EMAR with the number '9' that indicated 'see nurse note' for 9/23/22, 9/24/22, 9/26/22, 9/27/22, and 9/28/22. On 9/29/22 there was blank medication administration on the EMAR indicating Ambien was not given. Ambien was documented as given on 9/25/22. An interview on 05/09/23 at 11:25 AM…

    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
  • No harm found · B2026-01-10 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 Ombudsman and staff interviews, the facility failed to notify the Ombudsman in writing of residents transfer to the hospital for 2 of 2 emergency hospitalization transfers reviewed for hospitalization (Resident #99 and Resident #88). The findings included:1. Resident #99 was admitted to the facility on [DATE].The nursing progress note dated 12/10/25 revealed Resident #99's was out of the facility at an appointment and was transferred to the hospital for further evaluation due to chest pain.The medical record indicated Resident #99 was discharged from the facility on 12/10/25 and did not return to the facility.The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #99's transfer to the hospital.An interview was conducted with the Social Worker on 1/9/26 at 10:37 AM and revealed she was hired in October of 2025, and she had not sent the Ombudsman office any notifications regarding emergency transfers as it was not her responsibility. The…

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

    Resident Rights Deficiencies · No revisit needed
  • No harm found · B2026-01-10 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 transmit Minimum Data Set (MDS) assessments within the regulated timeframe for 2 of 32 residents reviewed for MDS assessments (Resident # 1 and # 30).Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and hypertension. Resident #1's quarterly MDS with an assessment reference date (ARD, the last day of the look back period) of 11/14/25 was completed on 11/26/25 and had not been transmitted. The MDS coordinator was not available for interview. An interview was conducted on 01/10/26 at 11:34 a.m. with the Director of Nursing (DON). She verified Resident #1's MDS quarterly MDS dated [DATE] had not been transmitted. The DON indicated there was a glitch in the system and it should have automatically transmitted when the assessment was completed. On 01/10/26 at 11:40 a.m. an interview was conducted with the Administrator. He indicated it was his expectation for all MDS assessments to be…

    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 · No revisit needed
  • No harm found · Bcited before2024-06-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 and staff interviews the facility failed to maintain clean and sanitary floors, ensure baseboards were in good repair and ensure the toilet was clean and in good repair in 2 of 3 rooms (rooms [ROOM NUMBERS]), ensure the light fixture was clean and a sink was in good repair in 1 of 3 rooms (room [ROOM NUMBER]), and maintain cleanliness and sanitation in 1 of 2 linen closets and 1of 1 dining room observed for maintenance of a sanitary and orderly interior. The findings included: Review of the Perfomance Improvement Project (PIP) worksheet dated 5/6/24 revealed the facility had decluttered resident's rooms and transitioned from contracted housekeeping services to in house. The facility documented results of their interventions as clean building, decreased pests, consistent housekeeping, deep cleaning and decluttering. To sustain improvement, the facility wrote consistent housekeeping and focus on being clutter-free, and constant contact with local pest exterminator for any pest seen. The PIP…

    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 plan of correction
  • No harm found · Bcited before2024-06-18 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by pests observed in 1 of 3 hallways (the hallway leading into the dining room) and in 2 of 3 residents' rooms (rooms [ROOM NUMBERS]) reviewed for pest activity. The findings included: Review of the facility's Performance Improvement Project (PIP) dated 3/3/24 in Environmental Services revealed a problem with pest control. Interventions included decluttering residents' rooms, scheduling deep cleaning of rooms, weekly exterminator rounds, care planning for residents who hoarded and daily rounding by the administrator, social worker, maintenance and environmental services. This PIP did not have a date of completion. Review of the facility's invoices from a local pest control company as follows: 4/5/24 read in part: Treated kitchen area corner tile broke with roaches, treated side exit door therapy and hallway restroom for German Roaches. 4/12/24 read in part: Kitchen…

    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.

    Environmental Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2023-05-26 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review and staff interview the facility failed to provide written notice of discharge to the ombudsman for 1 of 1 resident (Resident #246) reviewed for discharge to the hospital. This practice had the potential to impact other residents. The findings included: Resident #246 was admitted on [DATE]. Review of nursing note dated 12/8/22, revealed Resident #246 was sent to the hospital on [DATE] and did not return to facility. During an interview with the Social Worker on 5/12/23 at 12:32 pm it was revealed she was responsible for sending the notification to the ombudsman of discharges. The Social Worker stated she notified the ombudsman of discharges that facility initiated but was not aware that she was supposed to send notification for residents that were transferred to the hospital. An interview was conducted on 5/12/23 at 1:22 pm with the Regional Nurse Consultant (who was covering for the Administrator), and she indicated the facility was expected to send facility-initiated discharges 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 plan of correction
  • No harm found · B2023-05-26 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 provide the bed hold policy to 1 of 1 residents discharged to the hospital (Resident #246). This practice had the potential to impact other residents. The findings included: Resident #246 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #246 had a diagnosis including Alzheimer's disease. The significant change in status Minimum Data Set (MDS) dated [DATE], indicated Resident #246 cognition was impaired. A review of nursing note written by Nurse # 9 dated 12/8/22 at 12:58 pm revealed Resident #246 was sent out to the emergency department (ED) per hospice. The family was made aware. Attempts to contact Nurse #9 for an interview were unsuccessful. An interview was conducted on 5/12/23 at 12:32 pm with the Social Worker (SW) and she indicated she was not aware that she was responsible for follow up on of the bed hold policy and had not done so. During an interview on 5/12/23 at 1:22 pm with the Regional Nurse…

    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 plan of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ALLIANCE HEALTH GROUP — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.5+0.5 vs chain
Health inspection 2 of 51.8+0.2 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 4 of 52.2+1.8 vs chain
The other 11 homes this chain runs (chain average 1.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
EMANUEL, YOSEFIndividualCORPORATE OFFICERsince 08/01/2024
ALLIANCE HEALTH GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
SIMPSON, MALIKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/01/2024
COALITION GROUP LLCOrganizationADP OF THE SNFsince 01/16/2025

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 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.

$10.2M
Net patient revenuemost recent cost report
-5.1%
Operating marginrevenue minus expenses
$2.0M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 3%Other / private 22%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$337per resident / day
operating cost
$10,251per month
≈ monthly operating cost
$321per day
avg. revenue, all payers

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

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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