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Maple Grove Health and Rehabilitation Center

308 West Meadowview Road, Greensboro, NC 27406 · For profit - Limited Liability company · 210 certified beds · (336) 230-0534 Medicare & Medicaid certified

Call the home — (336) 230-0534 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2025Resident-funds citation (F0565)1 actual-harm citation$50,310 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • 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)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $50,310 in federal fines (most recent 2024-03-06)
  • about 25% 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
433 W Meadowview Rd · (336) 333-3007 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
2416 Randleman Rd · (336) 274-0983 · Call to confirm hours
Grocery
Food Lion0.2 mi
120 W Meadowview Rd · (336) 379-7253 · Call to confirm hours
Park
Owls Roost Trl · Typically dawn to dusk
Place of worship
2401 Randleman Rd · (336) 235-0880

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 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased8.4%15.6%15.4%better
Long-stay residents who lose too much weight3.5%7.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.8%2.3%2.0%better
Long-stay residents with depressive symptoms0.3%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 injury2.7%3.5%3.3%better
Long-stay residents whose ability to walk worsened15.2%18.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication23.2%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine97.8%94.1%95.3%typical
Long-stay residents with pressure ulcers2.3%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control9.0%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table21.9%14.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine58.8%78.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.081.781.67better
Long-stay outpatient ER visits per 1,000 resident days0.971.801.80better

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.

0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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 SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.83
RN hours/ resident / day
0.45
LPN hours/ resident / day
2.33
Aide hours/ resident / day
3.61
Total nurse hours/ resident / day
0.59
RN hoursweekends
48.4%
Total nursing turnover
38.5%
RN turnover

How full it usually is: this home is certified for 210 beds and averages 111.9 residents a day — about 53% occupied, or roughly 98 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.25 hrs/resident/day on weekends vs 3.76 on weekdays — 13% thinner on weekends. RN hours go from 0.93 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

0
deficiencies at the latest standard inspection (2025-06-05)
5
at the previous standard inspection (2024-03-06)

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.

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2024-03-06 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews with the resident and staff, the facility failed to provide a cognitively dependent resident with access to a hearing amplifier to accommodate a hearing deficit. This deficient practice occurred for 1 of 1 resident reviewed for accommodation of needs (Resident #96). The reasonable person concept was applied for Resident #96 due to his inability to hear what was happening around him. A reasonable person would feel social isolation, loneliness, and frustration. Findings included: Resident #96 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's disease. A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #96 had moderately impaired cognition and moderately impaired hearing with the use of a hearing device. Resident #96's care plan revised on 12/14/23 revealed a focus area for inability to express emotion, listen and share information; auditory alteration/deficit characterized by decreased lack 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 · D2025-11-19 · 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, and interviews with the resident's Responsible Party, staff, Nurse Practitioner (NP), Medical Director, law enforcement, and the hospital physician, the facility failed to protect Resident #1's right to be free from injury of an unknown origin. Resident # 1 sustained facial swelling, hematoma and contusion extending from the right eye to the corner of his right lip. The source of the injury to Resident #1 was not observed by anyone, the source of injury could not be explained by the resident, and the injury was suspicious. On 10/09/25, Resident #1's was observed by Nurse Aide (NA) #2 to have swelling to the residents' right side of face. The resident was transferred to the hospital via Emergency Medical Services (EMS) who noted the resident had been assaulted by a facility staff member. Observations of Resident #1 during the investigation showed swelling to the residents' right side of the face and soreness was reported by the resident. This deficient practice affected 1 of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each 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 Responsible Party, dental provider Chief Operating Officer, Medical Director, staff and hospital physician interviews, the facility failed to provide the necessary assistance to obtain dental services for 1 of 3 residents reviewed for routine and emergency dental services (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included seizures, osteoarthritis, and cognitive communication deficit.Review of physician order dated 10/31/23 revealed Resident #1 was ordered Eliquis (anticoagulant medication) 5mg (milligrams) twice a day.Review of the in-house dental list provided by the facility revealed 07/09/25 was the last time the dentist was in the facility. Resident #1 was not seen by the dentist on 07/09/25. Review of a notice sent by the in-house dentist office on 08/22/25 revealed the notice had been emailed to Social Worker (SW) #1 and SW #2 and indicated Resident #1 required a medical consultation for medication adjustment…

    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 · D2024-03-06 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 medical record review and staff interviews the facility failed to complete a significant change in status assessment for 1 of 1 resident reviewed for significant change (Resident #70). Findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses of dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #70 required supervision with eating, upper body dressing, lower body dressing partial /moderate staff assistance for oral hygiene, toileting hygiene, putting on/taking off footwear, and personal hygiene. Resident #70 was independent in the mobility areas of roll left and right, sit to lying, lying to sit, sit to stand, chair and bed transfer. Resident #70 had no weight loss. Review of the quarterly MDS dated [DATE] revealed Resident #70 was dependent on staff in the following areas of mobility: eating, oral hygiene, toileting, shower/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, and personally hygiene. 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 · Dcited before2024-03-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with resident and staff, the facility failed to provide nail care to a resident who needed extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice affected 1 of 7 residents (Resident # 90) reviewed for ADLs. Findings included: Resident #90 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body). Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #90 was cognitively intact and required extensive assistance with personal hygiene. Review of Resident #90's care plan revised 01/25/24 revealed a need for Activities of Daily Living (ADL)/Personal Care with the following intervention including the resident required assistance for personal hygiene, and grooming. During observation and interview on 02/26/24 at 12:03 pm, Resident #90 was observed lying in bed with fingernails on both hands that were about ½ inch long. Resident #90 stated he wanted his nails…

    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 before2024-03-06 · 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 observations, resident and staff interviews and record review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint surveys dated 1/18/22 and current survey 3/06/24 in the area of accurately coding Minimum Date Set (MDS). The facility also failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 1/18/22, 1/27/23 and the current survey 03/06/24, in the area of Activity of Daily Living (ADL) care provided for dependent residents. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This citation is cross referenced to: 1 F 641 Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area hearing, speech, and vision for…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interviews, the facility failed to implement their policy for immediately notifying the Administrator of an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #4). Findings included: The facility abuse policy, last revised 10/15/22, read in part, Any employee who witnesses or suspects that abuse, neglect, exploitation, or misappropriate of property has occurred will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. The Administrator will ensure for all allegation that involves abuse or results in serious bodily injury, the Division of Health Service Regulation, Health Care Personnel Section, and Adult Protective Services are notified immediately but no later than 2 hours after the allegation is received, and determination of alleged abuse is made. Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, mild with other behavioral disturbances.…

    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 · D2023-09-01 · 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 reviews and interviews with the consultant pharmacist, Nurse Practitioner, Medical Director, and a representative of the facility's contracted pharmacy, the facility failed to ensure there was an appropriate indication for prescribing an oral antibiotic shown to be ineffective against systemic infections for a resident with a surgical wound infection. This occurred for 1 of 4 residents (Resident #2) reviewed for the provision of care according to professional standards. The findings included: Resident #2 was admitted to the facility on [DATE] from another skilled nursing facility. His cumulative diagnoses included a history of a myocardial infarction (heart attack) and status post coronary artery bypass graft (a surgical procedure used to treat coronary artery disease). The resident's electronic medical record (EMR) included a Nursing Progress Note dated 4/28/23 which reported Resident #2 was being seen by a wound clinic for treatment of a surgical wound to his sternum (breastbone). A culture 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to ensure dishware was stored and stacked clean and dry; The facility also failed to ensure the food items not provided by the facility were dated and labeled with the residents' names, dates and room numbers when stored in the snack/nourishment refrigerators; and food items served to but refused by residents were not stored in 1 of 3 residents' nourishment rooms. These practices had the potential to affect food served to residents. Findings included: 1. On 1/25/23 at 11:40 a.m., during an observation of the meal service tray line preparation, 44-food stained and/or greasy plates were stacked in the plate warmer located ready for use next to steamtable. There were also 3-sectioned/divided plates with dried food stains, one of which was also chipped stacked on the meal service trayline. There were 4-large muffin tins with dried food debris and greasy stains and 1-large (6deep) steamtable pan with dried food stains stacked on the storage rack next to clean and dry pots and pans. The Dietary Consultant removed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-27 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on an observation and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from standing water and refuse. These unsanitary practices had the potential to affect the environment of the residents. Findings included: During an observation, accompanied by the Dietary Manager (DM) on 1/23/23 at 10:05 a.m., there was a mattress with puddles of water floating on top, lying on the ground next to the trash compactor. Also, there was a large pool of standing water and leaves beneath and surrounding the trash compactor. On 1/23/23 at 10:06 a.m., the DM stated the leaves should have been raked from beneath the trash compactor so the rainwater could drain. The DM indicated she had no knowledge why a mattress was placed on the ground next to the compactor. During an interview on 1/27/23 at 11:10 a.m., the Administrator stated that his expectation was for the facility's environmental and dietary staff to check and ensure the trash compactor and the surrounding area were free from debris when they disposed of trash from the facility.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-27 · 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 record review, resident and staff interviews, and review of the Resident Council Minutes, the facility failed to record and respond to concerns voiced by residents during Resident Council meetings for 8 of 12 months (April, May, July, August, September, October, November and December 2022). Findings included: The Resident Council minutes were reviewed for April, May, July, August, September, October, November and December 2022 and revealed no concerns or grievances were documented from residents. The minutes indicated Resident #18, Resident #32, Resident #47, Resident # 48, Resident#52, Resident #67, Resident #73, Resident #87 and Resident # 392 attended these meetings. The identified Residents were interviewable with a BIMS (brief interview mental status) greater than 11. On 01/24/23 at 10:30 am a Resident Council meeting was held and attended by Resident #67, Resident #48, Resident # 86, Resident #392, Resident #18, Resident #47, Resident #52, Resident #50, Resident #65 and Resident #73. During the meeting the residents were notified that based on review of the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2023-01-27 · tag F0760 — failed to prevent significant medication errors — pattern
    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 observation, record reviews, psychiatric nurse practitioner and staff interviews, the facility failed to administer duloxetine hydrochloride (an antidepressant medication) for eleven days as ordered by the psychiatric nurse practitioner for 1 of 5 sampled residents (Resident# 27) reviewed for unnecessary drugs. Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included: major depressive disorder, disorganized schizophrenia, and bipolar disorder. The quarterly assessment dated [DATE] indicated Resident #27 was severely, cognitively impaired; had no behaviors; and, received antipsychotic and antidepressant medications. The care plan dated 12/17/22 revealed Resident #27's use of psychotropic drugs (antipsychotic, antidepressant) with the potential for side effects of cardiac, neuromuscular, gastrointestinal systems related to his psychological diagnoses. Interventions included: evaluate effectiveness and side effects of medications for possible reduction 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-27 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident representative interviews and staff interviews, the facility failed to explain to resident representatives that the binding arbitration agreement was not a condition of admission for 3 of 3 residents who entered into an Arbitration Agreement with the facility. (Resident #89, Resident #492, and Resident #493). The findings included: The Resident and Facility Arbitration Agreement, last revised on 08/01/22, included a statement that executing this agreement is not a precondition of admission. a. Resident #89 was readmitted to the facility on [DATE]. A review of Resident #89's admission assessment dated [DATE] indicated that Resident #89 had severe cognitive impairment. During an interview with the resident representative on 1/27/23 at 1:20pm she indicated that the admission coordinator explained the process of arbitration and that this needed to be signed to admit Resident #89. b. Resident #492 was admitted to the facility on [DATE] with a diagnosis of dementia. During an interview…

    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 before2023-01-27 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 2/4/20 and 1/18/22 and for complaint survey on 8/18/21 in order to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 1/27/23. The deficiencies were in the area of notice requirements before transfer/ discharge, Activity of Daily Living (ADL) care provided for dependent residents and residents free of significant medication errors. The continued failure during four federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: 1. F623 -Based on record review and staff interviews, the facility failed to provide the resident and/or Responsible Party (RP) written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization (Residents #342, #442…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-27 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 review, the facility failed to offer a pneumococcal (pneumonia) vaccine for 1 of 5 residents (Resident #69) reviewed for immunizations. Findings included: Resident #69 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was severely cognitively impaired. Further review revealed the MDS coded the pneumonia vaccine as not up to date and that the pneumonia vaccine was not offered. Review of the policy titled Infection Control Guidelines, which had a revision date of 03/10/20, read in part; There are two pneumococcal (Pneumonia) vaccines recommended for adults. These vaccines are the pneumococcal conjugate 13 vaccine (PCV 13) and the pneumococcal polysaccharide 23 vaccine (PPSV23). These vaccine recommendations are established by the Centers for Disease and Control (CDC) and the Advisory Committee on Immunization Practices (ACIP). Pneumonia vaccines are given on admission unless contraindicated was noted on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-27 · 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 record review, observation resident and staff interviews the facility failed to treat Resident #392, 1 of 1 resident reviewed for catheter care, with dignity. The facility failed to have Resident #239's catheter bag covered for privacy and dignity. The findings included: Review of Resident #392's medical record revealed she was originally admitted to the facility on [DATE] with most recent readmission on [DATE]. Her diagnoses included chronic kidney disease, sepsis, urinary tract infection. Review of Resident #392's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required supervision to extensive assistance with all activities of daily living, such as, turning in bed, transferring, eating, toileting, bathing, and personal hygiene. Resident #392 also required an indwelling urinary catheter. On 01/23/23 at 12:04 PM Resident #392 was observed sitting in her wheelchair in the doorway of her room. Her catheter bag was hanging from the side of her wheelchair with the bag…

    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 before2023-01-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interview ' s the facility failed to provide showers, nail care, and mouth care to residents who needed extensive and/or were dependent on staff for Activities of Daily Living (ADL). This was for 2 of 2 residents (Resident #79 and #80) reviewed for ADL ' s. The findings include: 1. Resident #80 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis) and hemiparesis (partial weakness) to one side of the body following a cerebral infarction (stroke), contractor (a fixed tightening of muscle, tendons, ligaments, or skin) of left hand, and Parkinson ' s Disease. Review of Significant Change Minimum Data Set (MDS) assessment, dated 01/13/23, revealed Resident #80 ' s cognition was severely impaired. The resident required extensive assist of one person for bed mobility and toilet use, and she was totally dependent of one person for personal hygiene and bathing. Resident #80 had functional limitations in range 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 · D2023-01-27 · 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 record review, observations, and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 1 of 2 residents reviewed for pressure ulcers (Resident #80). The findings include: Resident #80 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) and a stage IV coccyx pressure ulcer. Resident #80's active physician orders included an order dated 12/18/22 for an alternating pressure air mattress to the bed. Nursing to check setting every day and night shift. Settings: Weight 90-150lbs, Medium firm, 10 minutes cycle time, Alternate. Review of Significant Change Minimum Data Set (MDS) assessment, dated 01/13/23, revealed Resident #80 ' s cognition was severely impaired, one stage 4 pressure ulcer, one Deep Tissue Injury (DTI), and a pressure reducing device to the bed. Resident #80's weight on 1/2/2023 was 133.0 pounds (lbs). Review of Resident #80 ' s care plan dated 11/08/22, last…

    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 · D2023-01-27 · tag F0729 — isolated
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    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, review of the Nurse Aide Registry forms and staff interviews the facility failed to verify with the North Carolina (NC) Nurse Aide Registry a Nursing Assistant's (NA#12) certification for 1 of 3 employees reviewed (NA #12). The findings included: NA #12 was hired by the facility on [DATE] to work with residents in need of care and treatment. A review of NA #12's personal file indicated that NA #12's Nurse Aide Certification had expired on [DATE]. A review of the staffing schedule sheet from [DATE], to [DATE], revealed NA #12 had worked during the timeframe of the schedules reviewed. On [DATE] at 4:00 PM an interview was conducted with the Senior Administrator, and she presented the NC Nurse Aide Registry form dated [DATE] and it verified NA #12's Nurse Aide Certification had expired on [DATE]. The Senior Administrator indicated that the facility contacted NC Nurse Aide Registry and was informed that NA#12's certification had expired. The Senior Administrator indicated that on [DATE], 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-27 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 the facility failed to maintain a resident's record of refusal or if contraindicated for the vaccine for COVID-19 for 2 of 5 residents reviewed for COVID-19 vaccination status (Resident #44 and #242). Findings included: Review of the policy, Principle Covid-19 Guidelines, last revised 10/2022, revealed in part, that residents are encouraged to remain up to date with all recommended COVID-19 vaccinations. 1. Resident #44 was admitted to the facility on [DATE]. Review of Resident #44's medical records revealed no documentation that the COVID-19 vaccine was contraindicated, administered, or refused. An interview was conducted on 01/26/23 at 10:02 AM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She stated if a resident refused a vaccine she would add refused under immunizations in the electronic record. She also stated that the facility does not currently have a consent/refusal form for the COVID-19 vaccine. An interview 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-03-06 · tag F0641 — pattern
    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 reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area hearing, speech and vision for 1 of 1 resident reviewed for communication. (Resident #96). The findings included: Resident #96 was admitted to the facility on [DATE] with diagnosis of hearing deficit. A review of Resident #96's electronic medical record (EMR) included Pace of the Triad Primary Comprehensive Assessment progress note dated 11/9/23. This assessment revealed a chronic medical condition of severe hard hearing. The Pace Nurse Practitioner (Pace NP #1) indicated in this note that Resident #96's was severely hard of hearing, and the hearing loss was chronic and ongoing. Resident #96's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and coded the resident as not having a hearing deficit. Resident #96's care plan revised on 12/14/23 by MDS Nurse #1 revealed a focus area for inability to express emotion,…

    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
  • No harm found · B2023-01-27 · 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 interviews, the facility failed to provide the resident and/or Responsible Party (RP) written notification of the reason for a hospital transfer for 3 of 3 residents reviewed for hospitalization (Residents #342, #442 and #80). The findings included: 1. Resident #342 was admitted to the facility on [DATE]. A Modification of admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #342 was cognitively intact. A review of Resident #342's medical record revealed she was transferred to the hospital on [DATE] for nausea and vomiting and was expected to return to the facility. There was no documentation that a written notice of transfer was provided to the resident and/or the RP for the reason of the transfer. On 01/26/23 at 11:36 AM an interview was conducted with Unit Manager #1. She stated it was the nurses ' responsibility to send the notification in writing to the resident and family for the reason of the discharge to the hospital. On 01/26/23 at 11:37 AM 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 Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2023-01-27 · 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 staff interviews and record review, the facility failed to provide notice of the bed hold policy prior to transfer for 3 of 3 resident reviewed for hospitalizations (Residents #342, #442, #80). The findings included: 1. Resident #342 was admitted to the facility on [DATE]. A Modification of admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #342 was cognitively intact. A review of Resident #342's medical record revealed she was transferred to the hospital on [DATE] for nausea and vomiting and was expected to return to the facility. There was no documentation that the bed hold policy was given to the resident and/or the Responsible Party. On 01/26/23 at 11:36 AM an interview was conducted with Unit Manager #1. She stated it was the nurses ' responsibility to send the bed hold policy to the hospital with the resident at time of transfer. On 01/26/23 at 11:37 AM an interview was conducted with Assistant Director of Nursing/Infection Control Preventionist (ADON/ICP). She stated it…

    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

$50,310 in federal fines across 1 penalty.

  • $50,310 — penalty dated 2024-03-06

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

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 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 5 of 53.0+2.0 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 39 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Ayden Court Nursing and Rehabilitation CenterAyden, NC 1 of 5Greendale Forest Nursing and Rehabilitation CenterSnow Hill, NC 1 of 5River Trace Nursing and Rehabilitation CenterWashington, NC 1 of 5Somerwoods Rehabilitation and Healthcare CenterSomerset, KY 1 of 5University Place Nursing and Rehabilitation CenterCharlotte, NC 2 of 5Cherry Point Bay Nursing and Rehabilitation CenterHavelock, NC 2 of 5Clear Creek Nursing & Rehabilitation CenterMint Hill, NC 2 of 5Graham Healthcare and Rehabilitation CenterRobbinsville, NC 2 of 5Greenwood Rehabilitation and Healthcare CenterBowling Green, KY 2 of 5Macon Valley Nursing and Rehabilitation CenterFranklin, NC 2 of 5Magnolia Lane Nursing and Rehabilitation CenterMorganton, NC 2 of 5Northchase Nursing and Rehabilitation CenterWilmington, NC 2 of 5Tower Nursing and Rehabilitation CenterRaleigh, NC 2 of 5Westwood Hills Nursing and Rehabilitation CenterWilkesboro, NC 2 of 5Willow Creek Nursing and Rehabilitation CenterGoldsboro, NC 3 of 5Bethany Woods Nursing and Rehabilitation CenterAlbemarle, NC 3 of 5Franklin Oaks Nursing and Rehabilitation CenterLouisburg, NC 3 of 5Greenhaven Health and Rehabilitation CenterGreensboro, NC 3 of 5Harmony Hall Nursing and Rehabilitation CenterKinston, NC 3 of 5Pine Ridge Health and Rehabilitation CenterThomasville, NC 3 of 5Piney Grove Nursing and Rehabilitation CenterKernersville, NC 3 of 5Premier Nursing and Rehabilitation CenterJacksonville, NC 3 of 5Richmond Pines Healthcare and Rehabilitation CenteHamlet, NC 3 of 5Riverpoint Crest Nursing and Rehabilitation CenterNew Bern, NC 3 of 5Smoky Mountain Health and Rehabilitation CenterWaynesville, NC 3 of 5Springbrook Nursing and Rehabilitation CenterClayton, NC 4 of 5Barbour Court Nursing and Rehabilitation CenterSmithfield, NC 4 of 5Carolina Rivers Nursing and Rehabilitation CenterJacksonville, NC 4 of 5Chowan River Nursing and Rehabilitation CenterEdenton, NC 4 of 5Croatan Ridge Nursing and Rehabilitation CenterNewport, NC 4 of 5Kerr Lake Nursing and Rehabilitation CenterHenderson, NC 4 of 5Lake Park Nursing and Rehabilitation CenterIndian Trail, NC 4 of 5Lake Way Rehabilitation and Healthcare CenterBenton, KY 4 of 5Northampton Nursing and Rehabilitation CenterJackson, NC 4 of 5Wayland Nursing And Rehabilitation CenterKeysville, VA 4 of 5Wilson Pines Nursing and Rehabilitation CenterWilson, NC 5 of 5Grantsbrook Nursing and Rehabilitation CenterGrantsboro, NC 5 of 5Harnett Woods Nursing and Rehabilitation CenterDunn, NC 5 of 5Jacob's Creek Nursing and Rehabilitation CenterMadison, NC

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
BOICE, GALEIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/05/2018
JOHNSON, DIANNEIndividualCORPORATE OFFICERsince 01/01/2011
PRINCIPLE LONG TERM CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2011
ARMIJO, OLIVIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
BERNARDINI, HOLLYIndividualADP OF THE SNFsince 01/01/2004
HILL, RAYMONDIndividualADP OF THE SNFsince 01/01/2011
HILL, ROBERTIndividualADP OF THE SNFsince 01/01/2011
HILL, STEPHENIndividualADP OF THE SNFsince 01/01/2011

CMS files one row per role, so the 11 rows in the source record cover these 8 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.

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

Follow the money — this home’s finances

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

$11.6M
Net patient revenuemost recent cost report
-23.7%
Operating marginrevenue minus expenses
$3.6M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 1%Other / private 24%

About 75% 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 $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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

$377per resident / day
operating cost
$11,466per month
≈ monthly operating cost
$305per 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 345448. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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