Macgregor Downs Health Center by Harborview
2910 Macgregor Downs Road, Greenville, NC 27834 · For profit - Corporation · 152 certified beds · (252) 758-4121 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Dec 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,023 in federal fines (most recent 2024-08-02)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.2% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.7% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.1% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.0% | 5.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 23.0% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.6% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 89.2% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.5% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 59.7% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.9% | 22.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.0% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 1.80 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 527 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 209 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.9%CMS range 54.1–62.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 9.2–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 39.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 43.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 24.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 97.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.1%CMS range 7.1–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 152 beds and averages 143.3 residents a day — about 94% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 2.75 hrs/resident/day on weekends vs 3.65 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · K2024-08-02 · tag F0925 — failed to control pests — patternMake 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 observation, record review and interviews with pest control staff, resident and facility staff, the facility failed to maintain an effective pest control program to prevent an infestation of mice and to protect a vulnerable resident from mice. On 7/1/24 Resident #18 was in bed when she felt something touch her foot. She pressed her call bell for assistance and when Nurse Aide (NA) #7 responded the NA pulled the blankets off the bed and a mouse jumped out of the bed and onto the floor. On 7/7/24 Resident #18 was in bed when NA #7 pulled the covers down to provide care and a mouse jumped out of the bed and onto the floor. On 7/26/24 Resident #18 saw a mouse running across the floor of her room. Resident #18 was shocked when the mouse was in her bed, and she was afraid of being bitten by a mouse. Mice are known to carry multiple diseases that can be life threatening. Diseases can spread by rodent bites and contact with their feces, urine, and saliva. This deficient practice affected 1 of 3 residents and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, the facility failed to honor a resident's right to attend care plan meetings for 1 of 28 residents reviewed for care planning (Resident #53).Findings included:Resident #53 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 was moderately cognitively impaired. The care plan for Resident #53 was initiated on 2/12/24 and last revised on 3/26/26.Record review revealed a late entry note written by Social Worker #1 on 3/31/26 stated a care plan meeting was held with only the Interdisciplinary Team (IDT) (the facility Social Worker and the MDS Nurse) in attendance. The Responsible Party (RP) was invited but did not attend. The record also revealed advanced directives and code status were reviewed. An interview with Resident #53 was conducted on 4/27/26 at 11:26 AM. Resident #53 stated she did not get invited to care planning meetings. She went on to say she feels her RP is not acting in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, record review, and staff interviews, the facility failed to clean and maintain window curtains, the flooring underneath medical equipment, and the packaged terminal air conditioner (PTAC) in a resident's room for 1 of 28 resident rooms (Resident #6) on 1 of 6 halls observed for environment. The findings included: Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she was severely cognitively impaired. An observation of Resident #6's room on 4/27/26 at 1:45 PM revealed both (two in total) window curtains had scattered red stains on them. There were also two pools of brown liquid underneath the tube feeding pole to the right of the head of the bed. It was also observed that dust like black bits, fragments, and pieces were on top of and inside the PTAC near the insertion site of the filter. Additional observations of Resident #6's room were conducted on 4/28/26 at 8:13 AM and 4/29/26 at 9:07 AM both observations revealed the two window curtains had scattered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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, Nurse Practitioner, Physician, Responsible Party (RP), and Hospital Case Manager, the facility failed to allow Resident #129 to return the facility after being transferred to the hospital for evaluation for 1 of 4 residents reviewed for discharge (Resident #129).Finding included:Resident #129 was admitted to the facility on [DATE]. His active diagnoses included Parkinson's disease, bilateral sensorineural hearing loss (a permanent type of hearing loss caused by inner ear damage), bilateral unqualified visual loss (significant vision reduction in both eyes that has not been specifically categorized as either low vision or blindness), hypertension, diabetes mellitus, hyperlipidemia, dementia, anxiety disorder, depression, and asthma.Medical record review from admission on [DATE] through 4/18/26 revealed no evidence of behaviors for Resident #129. A late entry progress note dated 4/20/26 completed by Nurse #1 revealed Resident #129 was observed kneeling on the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 store a sugar scoop in a manner that prevented the potential for cross contamination by storing the scoop in the bulk sugar bin with the scoop handle touching the sugar. This was for 1 of 3 pantry's observed. This had the potential to affect food served to residents. Findings included: On 2/11/25 at 4:05 PM an observation of the bulk sugar bin in Hall 2 pantry revealed the sugar scoop was stored directly in the bulk sugar bin with the handle of the scoop in contact with the sugar. In an interview with Dietary Aide #1 at that time she stated she was assigned to the Hall 2 pantry that day. She reported that when she had gone on her break a little after 3:00 PM that day the scoop had not been in the sugar. She stated the sugar scoop should always be stored separately and not in contact with the sugar in the bin for sanitary reasons to prevent the potential for cross contamination. She reported this had probably been done by [NAME] #1. On 2/11/25 at 4:13 PM an interview with the Dietary Manager indicated a scoop should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #57 active diagnoses included influenza. Review of the signage on the door to Resident #57's room read in part, Droplet Contact Precautions. Everyone must: Clean hands before entering and when leaving room. Wear a gown when entering the room and remove before leaving. Wear surgical/procedure mask when entering the room. Remove immediately before leaving room. Wear gloves when entering room. Perform hand hygiene after removing gloves. During observation on 2/9/25 at 10:56 AM the Director of Nursing entered Resident #57's room with no gown or gloves and a surgical/procedure mask, touched the privacy curtain while speaking with Resident #57, washed her hands, and left the room. During an interview on 2/9/25 at 10:57 AM the Director of Nursing, upon looking at the signage on the door, stated she thought it was enhanced barrier precautions room instead of droplet precautions room and she should have put on a gown and gloves prior to entering the room. During an interview on 2/9/25 at 11:03 AM the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications and vitamins for 1 of 1 resident with medications observed at bedside (Resident #42). Findings included: Resident #42 was admitted to the facility on [DATE]. Her active diagnoses included anemia, heart failure, hypertension, diabetes, and respiratory failure. Review of Resident #42's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. Review of Resident #42's electronic health record on 2/10/25 at 1:06 PM revealed there was no physician's order for self-administration of medications and no self-administration of medication assessment. During observation on 2/9/25 at 11:24 AM two medication cups with pills were observed in Resident #42's room on the resident's bedside table. There were no facility staff members in the resident's room. Resident #42 was in bed and the bedside table with the medication placed in front of her. Review 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.
- Potential for harm · D2025-02-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, family and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #105 and #114). This was for 2 of 4 residents reviewed for advance directive. The findings included: A review of the facility's policy titled Residents' rights Regarding Treatment and Advance Directives dated 3/1/22 and reviewed/revised on 3/1/24 revealed it is the policy of this facility to support and facilitate a residents' right to formulate an advance directive. On admission the facility will determine if the resident has executed an advance directive, and if not determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 1. Resident # 105 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.
- Potential for harm · D2025-02-13 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident #89). Findings included: Resident #89 was admitted to the facility on [DATE]. Review of Resident #89's electronic health record revealed Medicare part A services began on 1/6/25. The resident's last covered day of Medicare Part A was 1/19/25. Resident #89 remained in the facility following her discharge from Medicare Part A. There was no evidence a SNF/ABN form was provided to the resident or resident representative. During an interview on 2/11/25 at 11:19 AM Social Worker #3 stated Resident #89's last covered date was 1/19/25 for Medicare part A. A SNF/ABN was missed and not provided to Resident #89 and it should have been. The SNF/ABN was used to provide the resident or representative information regarding what costs they would 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.
- Potential for harm · D2025-02-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop the comprehensive care plan in the area of pain for 1 of 28 residents (Resident #114) whose comprehensive care plans were reviewed. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had been on a scheduled pain medication regime. He had pain almost constantly. His pain affected his sleep and interfered with his daily activities almost constantly. Resident #114 rated his pain as a 10 on a zero to 10 scale with zero being no pain and 10 being the greatest pain. The Care Area Assessment (CAA) for pain was triggered. A review of Resident #114's comprehensive care plan dated as initiated on 1/27/25 did not reveal a focus area for pain. On 2/11/25 at 10:11 AM in an interview the MDS Director stated Resident #114's comprehensive care plan should have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and physician interviews, the facility failed to follow a physician's order for placement of a lidocaine (topical pain medication) patch on a resident's left hip when the patch was applied to the resident's back. This was for 1 of 2 residents (Resident #114) reviewed for professional standards of practice. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had been on a scheduled pain medication regime. He had pain almost constantly. His pain affected his sleep and interfered with his daily activities almost constantly. Resident #114 rated his pain as a 10 on a zero to 10 scale with zero being no pain and 10 being the greatest pain. Resident #114's active physician's orders as of 2/10/25 revealed a physician's order dated 1/16/25 for a lidocaine (topical pain medication) 5…
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.
Show the remaining 14 citations
- Potential for harm · Dcited before2025-02-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident and physician interview, the facility failed to clarify orders for blood sugar monitoring and insulin administration for short and long-acting insulins (insulin is a medication injected into the skin to control blood sugar) from the hospital discharge summary for a resident with a diagnosis of diabetes (Resident #81). This was for 1 of 2 residents reviewed for professional standards of practice. The findings included: The hospital discharge summary for Resident #281 dated 2/7/25 stated in part: - Monitor blood sugars closely - Sliding scale insulin (short acting insulin) - Continue Lantus (long-acting insulin) The hospital discharge summary revealed that upon Resident #281's arrival in the emergency department on 1/17/25 he told hospital staff that he had not been taking his diabetic medication for some time as he did not believe it would help him. Resident #281 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus II, osteomyelitis (bone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #92 was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident #92's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had functional impairment in range of motion on one side of her upper extremities and both sides of her lower extremities. She required substantial assistance to roll from left to right in bed. She was always incontinent of bladder. She had no falls since her prior assessment. A review of a nursing progress note for Resident #92 dated 12/5/24 at 8:11 PM written by Nurse #1 indicated Resident #92 experienced a fall from bed at 6:00 PM that day. Nurse Aide (NA) #1 was present during the fall and provided Nurse #1 with a full statement of the incident. NA #1 had been attempting to change Resident #92's bed sheets, turned Resident #92 away from herself, pulled on the bed sheets, and Resident #92 fell off the bed onto her right side. Resident #92 had not hit her head. A full body assessment and vital signs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and family interviews, the facility failed to attempt alternatives to bed rail use and document how these alternatives failed to meet the resident's needs prior to the installation of bed rails. This was for 1 of 6 residents (Resident #114) reviewed for accidents. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's medical record revealed an informed consent for the use of bed rails dated 1/7/25 that indicated the risks versus the benefits of bed rail use. This was signed by Resident #114's family member indicating she consented to the use of bed rails for Resident #114. A review of Resident #114's nursing admission assessment dated [DATE] at 4:51 PM completed by Admissions Nurse #2 revealed Resident #114 would have quarter (1/4) length rails on his bed to assist with bed mobility and positioning and to provide a handhold area for support by staff. Resident #114's family member…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews the facility failed to assess for food preferences for 1 of 1 resident reviewed for food preferences (Resident #280). Findings included: Resident #280 was admitted to the facility on [DATE]. Resident #280's 5-day Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired. An interview with Resident #280 was conducted on 2/9/25 at 12:41 PM. Resident #280 stated she wished the kitchen would stop sending pork products on her tray because she doesn't like pork. She further stated no one had asked her about her food preferences. An interview was conducted on 2/10/25 at 11:18 AM with the Dietary Manager. The Dietary Manager stated food preference assessments were conducted upon admission. A record review by the Dietary Manager was observed at this time that revealed no food preferences had been documented in the computer for Resident #280 and the Dietary Manager was not able to locate the paper assessment for the resident's food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews the facility failed to maintain an indwelling urinary catheter drainage tubing from touching the floor for 1 of 1 resident reviewed for indwelling urinary catheter use (Resident #14). This deficient practice placed the resident at increased risk for infection of the urinary system. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked and can cause urine to back up and injure one or both kidneys). Review of the care plan dated 6/17/24 indicated Resident #14 was at risk for alteration of elimination of bladder with a goal of no complications related to indwelling urinary catheter use. Interventions included to check catheter tubing for proper drainage and positioning. A review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. He required partial 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.
- Potential for harm · Ecited before2023-12-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 prevent the potential for cross-contamination by storing plastic scoops inside dry ingredient bins allowing the handles to touch the dry ingredients for 2 of 2 observations. Findings included: During an observation of the kitchen on 12/17/23 at 10:35 AM the flour and sugar scoops were observed in the flour and sugar bins and the handles were visibly touching the flower and sugar. During observation of the kitchen on 12/18/23 at 12:43 PM the flour and sugar scoops were again observed in the flour and sugar bins and the handles were visibly touching the flower and sugar. During an interview on 12/18/23 at 12:46 PM the Kitchen Supervisor stated scoops were not to be stored inside the storage bin due to sanitation concerns with the handle. The scoops would normally be put on a container on top of the storage bin. He concluded he was unsure why they were all stored in the storage bins, and they should not have been stored in that way. During an interview on 12/18/23 at 10:55 AM the Dietary Manager stated the scoops for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0867 — failed to act on quality-improvement findings — patternSet 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 observation and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) originally cited on 5/14/21 during a recertification and complaint investigation survey and subsequently cited on 12/22/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. This tag is cross referenced to: F812: Based on observations and staff interviews the facility failed to prevent the potential for cross-contamination by storing plastic scoops inside dry ingredient bins allowing the handles to touch the dry ingredients for 2 of 2 observations. During the recertification and complaint investigation survey of 5/14/21 the facility was cited for failing to keep food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 observation, record review and staff, resident, nurse practitioner, and podiatrist interviews, the facility failed to notify the resident's physician of a change in condition for 1 of 1 resident (Resident #118) reviewed for Notification of Changes. Resident #118 experienced bleeding following the debridement of her right great toenail. This change in condition was not reported to the resident's attending Physician or the Podiatrist. Findings included: Resident # 118 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes with neuropathy, and chronic kidney disease (CKD) stage 3. Review of podiatry visit summary and progress notes dated 12/6/23 revealed that Resident #118 had a podiatric diagnosis of atherosclerosis (a thickening or hardening of the arteries) of the extremities, onychomycosis (fungal infection of the nail unit); type 2 diabetes mellitus with peripheral circulation disorders. Resident #118 was evaluated, examined, and treated at bedside. The note further the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-22 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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, staff, family, responsible party, and police detective interviews the facility failed to prevent misappropriation of resident property when a nurse aide (NA #8) took resident's credit cards and used them without permission to make purchases. This was for 2 of 2 residents (Resident #286 and Resident #12) reviewed for misappropriation. Findings included: 1. Resident #286 was admitted to the facility on [DATE] with a diagnosis of right femur (leg bone) fracture. A review of Resident #286's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of the facility's initial allegation report dated 4/25/23 revealed in part Resident #286's Responsible Party (RP) notified the Administrator on 4/25/23 at 2:00 PM that when he was paying Resident #286's credit card bill he noticed fraudulent charges. The RP reported the fraudulent charges began on 4/15/23 and the most recent one on the billing statement was on 4/19/23. He further reported…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-22 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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, family, responsible party, and police detective interviews the facility failed to implement their abuse policy and procedure by failing to maintain evidence of proof of preemployment screening and failing to maintain documentation of a complete and thorough investigation of allegations of misappropriation. This was for 2 of 2 residents (Resident #286 and Resident #12) reviewed for misappropriation. Findings included: A review of the facility policy titled Abuse, Neglect and Exploitation last revised 6/1/23 revealed in part, It is the policy of this facility to provide protection 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 are discussed herein: 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, record review and staff, and resident interviews the facility failed to complete an accurate assessment for 1 of 1 resident reviewed. Resident #118 experienced bleeding following the debridement of her right great toenail. Findings included: Resident # 118 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes with neuropathy, and chronic kidney disease (CKD) stage 3. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #118 was cognitively intact. Review of care plan dated 5/5/23 and revised 10/16/23 revealed a problem that Resident #118 was at risk for altered non pressure related skin integrity related to fragile skin. With Interventions that included staff would manage factors that increased risks for altered skin integrity, skin would be observed during activities of daily living care for any changes in skin condition and the nurse would be notified, and weekly skin assessments would be done by the treatment nurse. Review 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.
- Potential for harm · D2023-12-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 record review and resident, staff, Responsible Party and the Vaccine Distribution and Help Desk Supervisor at the North Carolina Immunization Registry interviews the facility failed to provide education regarding the benefits and possible side effects of a pneumococcal vaccine, offer a pneumococcal vaccine, and then document either a refusal or the administration of a pneumococcal vaccine for 1 of 5 residents (Resident #19) reviewed for immunizations. Findings included: A review of the facility policy titled Vaccination of Residents last revised October 2019 read in part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. All new residents shall be assessed for current vaccination status on admission. Certain vaccines (e.g., influenza and pneumococcal vaccines) may be administered per the physician-approved facility protocol (standing orders) after the resident has been assessed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-02-13 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to have a complete and accurate Medication Administration Record (MAR) for 1 of 2 residents who received enteral formula (a method of providing nutrition directly into the gastrointestinal tract through a tube) who were reviewed for medical record accuracy (Resident #333). Findings included: Resident #333 was admitted to the facility on [DATE]. Resident #333 Physician's orders included an order dated 11/12/24 for enteral formula Osmolite 1.5, 237 milliliters (ml) to be administered every 6 hours. In a telephone interview with Nurse #4 on 2/11/24 at 8:20 AM she revealed when she started to pour the enteral formula into the tube Resident #333 stated he did not want the formula, she then stopped pouring the enteral formula. She went on to say Resident #333 had not refused his enteral formula to her in times past. Attempts made to reach Nurse #4 for further investigation were not successful. Review of the MAR for 11/27/24 revealed the midnight dose 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.
- No harm found · B2023-12-22 · tag F0657 — failed to keep the care plan current — patternDevelop 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 review, resident, and staff interviews, the facility failed to have care plan meetings for 1 of 2 residents reviewed for care plan meetings (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and neurogenic bladder. The annual Minimum Data Set, dated [DATE] indicated that Resident #2 was cognitively intact. An interview on 12/17/23 at 2:33 PM with Resident #2 revealed they had not been invited to a care plan meeting since February 15, 2023. An interview on 12/19/23 at 9:00 AM with the Social Worker (SW) #1 revealed that Resident #2 had not had a care plan meeting since 2/15/23. She stated she was aware of the requirement to have a care plan meeting quarterly but had not done so for Resident #2. She stated that it was not a priority for her and it had not been done. An interview on 12/20/23 at 8:30 AM with the Administrator revealed she was unaware that Resident #2 had not had a care plan meeting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,023 in federal fines across 1 penalty.
- $10,023 — penalty dated 2024-08-02
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 HARBORVIEW HEALTH SYSTEMS — 22 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.3 | -0.3 vs chain |
The other 21 homes this chain runs (chain average 1.9★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GA NC 14, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2022 |
| CARLONE, JAMES | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2022 |
| ENGLANDER, DAVID | Individual | CORPORATE OFFICER | — | since 03/01/2022 |
| LEIBOWITZ, CHAIM | Individual | CORPORATE OFFICER | — | since 03/01/2022 |
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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
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.
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 345168. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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 →
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