Senior Citizens Home
2275 Ruin Creek Road, Henderson, NC 27537 · For profit - Limited Liability company · 60 certified beds · (252) 492-0066 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $55,760 in federal fines (most recent 2023-09-27)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 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 improved from 2 to 3 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 | 24.1% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.8% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.8% | 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 | 0.0% | 3.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 38.4% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.5% | 21.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.9% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.5% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.0% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.1% | 78.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.8% | 22.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 24.7% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.68 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.68 | 1.80 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
45.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 30.4% 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 23 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 0.11 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 45.0%CMS range 30.5–59.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 5.8–14.8 | 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 | 30.4% | 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 | 21.7% | 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 | 13.0% | 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 | 88.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 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 | 8.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 60 beds and averages 55.6 residents a day — about 93% occupied, or roughly 4 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.
Weekend coverage: total nurse staffing is 2.76 hrs/resident/day on weekends vs 3.25 on weekdays — 15% thinner on weekends. RN hours go from 0.75 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 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2023-09-27 · 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 Based on record review, observations, staff, and Physician interview, the facility failed to safely transfer a dependent resident from wheelchair to bed which resulted in the fracture of the right humeral head (shoulder joint) and injury to the toenail of the right great toe with bleeding for 1 of 1 Residents (Resident #27) reviewed for accidents The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke that resulted in right sided weakness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #27 was severely cognitively impaired. The MDS indicated the Resident was dependent on 2 staff members for transfers and was coded as having impairment on 1 side of his upper and lower extremities. A care plan for an activities of daily living (adl) self-care performance deficit was last revised on 3/21/23. The interventions included assistance from 2 staff members and a mechanical lift for transfers, extensive to total…
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.
- Actual harm · G2023-09-27 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and Physician, resident, Responsible Party (RP), and staff interviews the facility failed to provide a pest free living environment for 1 of 1 resident residing in the facility (Resident #42). The facility's failure contributed to Resident #42 sustaining a rash to her arms and legs due to ant bites resulting in itching and discomfort. The Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive 1-2 staff member assistance with all activities of daily living including bed mobility. Resident #42 was coded as having no limitations in her range of motion, clear speech, and had the ability to understand others. A review of the Pest Control Commercial Services Agreement dated 7/11/23 stated services would be provided weekly specifically targeting roaches, ants,…
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 before2026-03-12 · 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 keep food service equipment free of debris and corrosion by failing to clean 2 of 3 HVAC (heating and air conditioning system) filters observed. This practice had the potential to affect food served to the residents who resided in the facility.The findings included:During the tour of the kitchen with the Certified Food Manager on 3/10/26 at 11:56 AM the kitchen preparation table was observed. Two feet above the food preparation table where wrapped silverware was stacked ready for lunch service, 2 of the 3 HVAC vents were observed with dark debris on the metal vents. The air filter system was off at the time. A second observation on 03/11/2026 11:08 AM the kitchen filters were observed in the same condition with dark debris on the metal vents. The air filter system was on and blowing towards the tray line, 6 feet away. The tray line was not in use at the time.In an interview on 3/11/26 at 11:10 AM the Certified Food Manger stated the HVAC filters were not on a kitchen cleaning schedule as Maintenance came in every 1-2…
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 before2026-03-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Director of Nursing, Nurse Practitioner, Pharmacy Technician, and Pharmacist, the facility failed to provide services to ensure the acquiring, dispensing, and administration of medications for 1 of 5 sampled residents whose medications were reviewed (Resident #59). The facility failed to have an anticonvulsant, antipsychotic, and a triple-therapy bronchodilator available for administration to Resident #59.The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included COPD, depression and bipolar disorder.a. Resident #59 had a physician order initiated on 2/5/26 for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligrams(mg) (an anticonvulsant medication sometimes used for mood stabilization)- Give 1000 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/6/26 by Nurse #1,…
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 before2026-03-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Nurse Practitioner, Pharmacist, Assistant Director of Nursing, and Director of Nursing, the facility failed to prevent a significant medication error for 1 of 5 residents whose medications were reviewed (Resident #59). The facility failed to administer prescribed antipsychotic medication, anticonvulsant medication and triple therapy bronchodilator to Resident #59. The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), depression and bipolar disorder. a. Resident #59 had a physician order initiated on 2/5/26 for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligrams(mg) (an anticonvulsant medication sometimes used for mood stabilization) Give 1000 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/6/26 by Nurse #1, with…
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 · F2024-12-05 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in developing the Facility Assessment, failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies, and failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, which had the potential to affect 49 of 49 residents. The findings include: Review of the Facility Assessment revealed it was revised 8/13/24 and updated on 9/24/24 and 11/01/24. The persons involved in completing the assessment were listed as the Administrator, the Director of Nursing (DON), the Medical Director, Social Service Director, Food Service Director, Environmental Operations Director, Therapy Director, and a Governing Board Member. There was no indication that direct care staff were involved in completing the assessment or that the facility solicited and considered input from residents, resident representatives and family members. The Facility…
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 · F2024-12-05 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 3 2024). Findings included: Review of the PBJ for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed there were no Registered Nurse (RN) hours for 4/13/24, 4/14/24, 4/27/24, 4/28/24, and 6/15/24. The PBJ report also noted the facility failed to have licensed nursing coverage 24 hours per day for 4/13/24, 4/14/24, 4/28/24, 6/15/24, and 6/16/24. Review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 4/13/24, 4/14/24, 4/27/24, 4/28/24, and 6/15/24 revealed there were RN hours for the 3rd quarter of the fiscal year 2024. The Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 4/13/24, 4/14/24, 4/28/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-05 · 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 and staff interviews, the facility failed to conduct quarterly reviews of resident care plans for 5 of 23 resident care plans that were reviewed (Resident #23, Resident #6, Resident #9, Resident #8, and Resident #45). The findings included: 1. Resident #23 was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD) and osteoarthritis. A review of Resident #23's care plan revealed the most recent review date of 7/30/24 and no further reviews or updates had been completed. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact. An interview was completed on 12/3/24 at 10:03 am with the Director of Nursing (DON) who revealed she was both the MDS Nurse and the DON for the facility. She stated she was responsible for reviewing resident care plans. The DON verified Resident #23's care plan review was overdue. The DON stated she was aware the resident care plans were behind, and she was working on getting them…
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 · D2024-12-05 · tag F0641 — isolatedEnsure 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 observations, record reviews, resident interview, and staff interviews the facility failed to correctly code the Minimum Data Set (MDS) assessment in the areas of falls and restraints for 2 of 23 residents whose MDS assessments were reviewed for accuracy (Residents #45 and #23). The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, dementia, and a history of a stroke. An incident report dated 8/5/24 at 5:37pm stated Resident #45 was observed laying on the floor in front of her personal recliner. The note stated Resident #45's lower extremities had normal range of motion and were without pain. The facility Nurse Practitioner (NP) was notified and an order for an x-ray of the Resident's left hip was received. The quarterly MDS dated [DATE] revealed Resident #45 was severely cognitively impaired and was coded no for any falls since admission/entry, reentry, or prior assessment. The review further revealed the questions regarding 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 · D2024-12-05 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such 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 record review and staff interviews, the facility failed to have a physician order for dialysis in the medical record for 1 of 1 resident reviewed for dialysis (Resident #204). Findings included: Resident #204's hospital Discharge summary dated [DATE] included instructions that included the name, address and telephone number of the dialysis center and indicated Resident #204's chair time was Monday, Wednesday, and Friday at 12:00 PM. Resident #204 was admitted to the facility on [DATE] with diagnosis including end stage renal disease stage 5. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #204 was coded for dialysis. During an interview with the Unit Manager on 12/3/2024 at 2:51 p.m. she revealed she was responsible for admitting Resident #204 to the facility. She stated she reviewed the hospital discharge summary for Resident #204, and she did not remember how she omitted entering the physician order for dialysis in his medical record. In an interview with Nurse #2 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, pharmacy director interview, physician assistant interview, and resident interview the facility failed to provide medications upon admission for 18 hours for 1 (Resident #1) of 3 residents reviewed for provision of medication upon admission. Findings included: Resident #1 had cumulative diagnoses some of which included Type 2 diabetes, Hypertension, Bipolar disorder, congestive heart failure, anxiety disorder, status post orthopedic surgery, and post-traumatic stress disorder. Documentation in the electronic medical record of Physician orders listed as entered on 10/30/2023 by Nurse #2 at 12:57 PM for Resident #1 included the following medications: - Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 60 units of insulin to be injected subcutaneously every morning for Type 2 diabetes. 15 units of insulin were to be injected subcutaneously if Resident #1 was not eating breakfast. - Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 30 units of insulin…
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 before2023-11-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, Physician Assistant interview, Pharmacy Director interview, Surgical Physician interview and resident interview the facility failed to provide antibiotic, diabetic, hypertension, antiepileptic, and pain medication as ordered resulting in significant errors by omission of high alert medications for one (Resident #1) of one resident reviewed for significant medication errors. Antibiotic medications were delayed after admission to the facility due to a transcription error for Resident #1. Diabetic, hypertension, antiepileptic, and pain medication were omitted initially upon admission due to a delay obtaining required medications from the pharmacy for Resident #1. Findings included: 1.Documentation on a hospital Discharge summary dated [DATE] revealed Resident #1 was to be discharged to the facility post operation for an amputation. The problem list on the discharge summary revealed Resident #1 had a diabetic infection of his left foot. The surgical wound was cultured 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.
Show the remaining 14 citations
- Potential for harm · F2023-09-27 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. The findings included: During an interview with the Interim Director of Nursing (DON) on 9/24/23 at 11:30 am she revealed the Infection Preventionist (IP) was responsible for the facility's Infection Prevention and Control Program. The DON stated the IP was new to the position and had not completed any of the required training programs for the IP position yet. The DON stated the facility did not have any staff members with specialized training to meet the qualifications for the IP role. An interview was conducted with the IP on 9/25/23 at 11:29 am who revealed she was new to the position and the facility planned for her to attend the next training session to complete the required specialized training. She stated she was shown how to monitor infections in the facility but had not had any other education regarding 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 · E2023-09-27 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days week for 8 of 62 days reviewed (7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23). Findings include: The nursing staff schedule and the staff posting was reviewed from 5/1/223 through 9/15/23. The daily staffing sheet indicated a Registered Nurse (RN) was not scheduled for at least eight consecutive hours a day on the following dates: 7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23. In an interview with the Nurse Manager (NM) on 9/25/23 at 8:37 A.M. she stated she was the scheduler for the facility. She revealed the staffing agency was contracted by her facility to assign an RN to the facility on 7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23 but failed to do so. During an interview with the prior DON on 9/25/2023 2:33 P.M. she stated she was the RN on weekdays. She revealed they relied on an agency for weekend RN coverage, and the agency was unable to provide RN…
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 · E2023-09-27 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a lunch meal tray line observation, staff interviews and record review the facility failed to provide pureed food items with a smooth consistency. This failure had the potential to affect 7 of 45 residents with diet orders for a pureed diet texture. The findings included: A review of the Diet Order Report dated 9/27/23 revealed 7 residents with diet orders for a pureed diet texture. Review of the menus revealed the facility followed the National Dysphagia Diet (NDD) for residents with diet orders for a pureed diet texture. The NDD recorded a dysphagia pureed diet required all foods pureed and thickened, if necessary, to a pudding-like consistency, lump free, requiring little to no chewing. An observation was conducted on 9/25/23 at 12:46 pm of Resident #27 eating his lunch meal in the dining room. Resident #27's meal ticket indicated he was on a pureed diet. The observation revealed no issues with the consistency of the pureed meal. A continuous observation of the lunch meal tray line on 9/26/23 from 11:45 AM - 12:01 PM revealed the Certified Dietary Manager (CDM) recorded…
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 before2023-09-27 · 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 observation and staff interviews, the facility failed to 1) maintain the temperature of potentially hazardous cold foods at 41 degrees Fahrenheit or below (yogurt and milk) prior to delivery 2) label/date, store, and discard perishable foods beyond the use date in one of two kitchen refrigerators and failed to 3) allow plates to air dry prior to assemblage and stacking for one of two observations. These practices had the potential to affect all residents. The findings included: 1. An observation of the lunch meal dining service occurred on 9/26/23 at 12:01 PM. Perishable dairy products for the lunch meal were displayed on a meal tray adjacent to the tray line. The following temperatures were obtained at the request of the surveyor by the District Manager and these foods were ready for service: - single serve yogurt container: 59.8 degrees Fahrenheit - whole milk carton: 49 degrees Fahrenheit As a result, all perishable dairy products were discarded by the District Manager and Certified Dietary Manager (CDM). During an interview with the CDM on 9/26/23 at 2:58 PM, she…
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 · E2023-09-27 · 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 observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 5/12/22. This was for two deficiencies cited in the areas of food procurement store/prepare/serve sanitation (F812) and infection prevention/control (F880). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. F812: Based on observation and staff interviews, the facility failed to 1) maintain the temperature of potentially hazardous cold foods at 41 degrees Fahrenheit or below (yogurt and milk) prior to delivery 2) label/date, store, and discard perishable foods beyond the use date in one of two kitchen refrigerators and failed to 3) allow plates to air dry prior to assemblage and stacking for one of two observations. These practices had the potential…
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 · D2023-09-27 · 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, resident, and staff interviews the facility failed to invite the resident to participate in the development of care planning for 1 of 14 Residents care plans reviewed (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE], and recently readmitted on [DATE] with diagnoses that included Anemia, Type 2 Diabetes Mellitus, Chronic Kidney disease and Hyperlipidemia. A review of Resident #41's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #41's care plan revealed it was updated on 7/23/2023. A review of Resident #41's nursing progress notes revealed there was a care plan meeting on 4/13/23 and 7/19/23. There was no documentation to indicate Resident # 41 was included in her care plan development and/or invited to participate in her care plan meeting. During an interview with Resident #41 on 9/24/2023 at 12:00 P.M. Resident #41 stated she has not participated in any care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 staff interviews, the facility failed to provide nail care to 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included stroke with hemiplegia (paralysis one side of body) on the right side and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #27 had severe cognitive impairment and required staff assistance for personal hygiene and bathing. Resident #27 was not coded for behaviors and had impaired range of motion on one side for the upper and lower extremities. Resident #27's care plan, last revised on 9/09/23, revealed he had an activities of daily living (ADL) self-care performance deficit related to history of stroke with hemiplegia and was dependent on staff for personal care and bathing. Review of Resident #27's care guide (no date) revealed he was scheduled for showers on Monday and Thursday…
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 · D2023-09-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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, staff interviews, Physician interview, and Pharmacy Consultant interview, the facility failed to ensure Physician's orders for PRN (as needed) psychotropic medications were time limited in duration for 1 of 7 Residents (Resident #24) reviewed for unnecessary medications. The findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses that included Lewy Body dementia, anxiety disorder, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively impaired. She was coded as not having any behaviors during the assessment period. A Physician order dated 8/10/23 indicated Lorazepam 0.5 milligrams (mg) 1 tab by mouth every 12 hours as needed (PRN) was ordered without a stop date. The Note to Attending Physician/Prescriber dated 8/15/23 revealed the facility was notified by the Pharmacy Consultant that Resident #24's PRN lorazepam medication did not have a stop date. A care plan was last revised on 8/20/23 for impaired…
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 · D2023-09-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to ensure 1 of 1 wound treatment carts and 1 of 2 medication carts (Hall 2) were not secured while unattended. The findings included: 1. A continuous observation on 9/25/23 at 8:22 am through 8:38 am of the wound treatment cart revealed the cart was unlocked with the lock in the outward position and the key hanging from the lock. The wound treatment cart was located outside room [ROOM NUMBER], without staff present. At 8:38 am the Infection Preventionist (IP) came from another hall and removed the key from the cart and pushed the lock in to secure the wound treatment cart and entered room [ROOM NUMBER]. The IP and the Minimum Data Set (MDS) Nurse exited the room. An interview was conducted with the MDS Nurse on 9/25/23 at 9:22 am who revealed she was told by the IP that she left the wound treatment cart unlocked with the key in the lock when she entered room [ROOM NUMBER]. The MDS Nurse stated she was trying to help with wound treatments and 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 · D2023-09-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and staff interviews, the facility failed to implement their infection control policy and policy for handling soiled linen. Laundry Aide #1 was observed having soiled linens come in contact with her clothing while sorting them into the washing machine and transporting soiled linens from a resident hall to the laundry room in a wire laundry basket with no lid for 1 of 2 laundry aides observed (Laundry Aide #1). The findings included: Review of the facility policy titled Infection Prevention and Control Program last reviewed/revised in January 2023 revealed was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy further read laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. The environmental services staff shall not handle soiled linen unless it was properly bagged. Review of the facility policy titled Handling Soiled Linen…
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 · D2023-09-27 · 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 staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccine upon admittance to the facility for 2 of 5 residents reviewed for immunizations (Resident #12 and Resident #33). The findings included: The facility policy for Pneumococcal Vaccine last reviewed on 8/31/22 read in part to encourage qualifying residents to have a pneumococcal vaccine appropriate to their age and medical conditions. Upon admission the resident and/or their responsible party will be educated about and offered the pneumococcal vaccine. The resident/responsible party will sign a consent and the facility will maintain an immunization record. a. Resident #12 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #12 was not up to date with the pneumococcal vaccine and that it was not offered. Review of Resident #12's immunization record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-12-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to post accurate licensed nurse staffing data for 18 of 30 days reviewed for sufficient staffing (11/02/24, 11/03/24, 11/05/24, 11/06/24, 11/09/24, 11/10/24, 11/13/24, 11/15/24, 11/16/24, 11/17/24, 11/18/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/27/24, 11/28/24, 11/30/24). The findings included: A review of the posted Daily Nursing Staffing Forms from 11/01/24 through 11/30/24 revealed the following: a. A review of the Daily Nursing Staffing Form for the 7:00 am-3:00 pm shift revealed the licensed nursing staff was not recorded accurately for the following days: 11/02/24-Daily Nursing Staffing Form recorded 3 Licensed Practical Nurses (LPNs); the Daily Staffing Sheet recorded 1 LPN. 11/03/24- Daily Nursing Staffing Form recorded 1 Registered Nurse (RN) and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/09/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/10/24-Daily Nursing Staffing Form recorded 3 LPNs; the Daily Staffing Sheet recorded 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-09-27 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, the facility failed to provide mail delivery to the residents on Saturdays. This had the potential to affect all 45 of 45 residents residing in the facility. The findings included: An interview with members of the Resident Council on 9/26/23 at 11:22 am revealed the facility did not deliver any mail on Saturdays. The members present for the meeting were Resident #41, Resident #28, Resident #11, Resident #35, Resident #6, and Resident #2. The Resident Council members stated the mail was only delivered during the week by the Activities Director and they had to wait until Monday to have Saturday's mail delivered. An interview was conducted with the Activities Director on 9/26/23 at 11:40 am who revealed she did not collect or hand out mail to residents on Saturday because she did not work on the weekend. The Activities Director stated when she returned to work on Monday, she would pass out Saturday's mail to the residents. During an interview on 9/27/23 at 1:11 pm with the Administrator he revealed the Activities Director delivered resident mail…
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 · Ccited before2023-09-27 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews the facility failed to post nurse staffing in a location that was readily accessible to residents and visitors on 3 of 4 days during the survey (9/24/23, 9/25/23, and 9/26/23). The findings included: An observation on 9/24/23 at 9:30 am revealed the daily nurse staff posting was hung on the wall behind the nursing station, which was accessible for staff only. The daily nurse staffing sheet was a white, 8 X 10-inch piece of paper with both sides of the posting curled toward the center of the paper. The daily nurse staff posting was not visible or accessible for residents or visitors to view. Additional observations on 9/25/23 at 12:15 pm, and 9/26/23 at 1:05 pm of the facility's daily nurse staff posting revealed it was hung on the back wall behind the nursing station, which was restricted for staff only per the signage. The daily nurse staffing sheet was a white, 8 x 10-inch piece of paper and was not visible or accessible for residents or visitors to view. An interview was conducted on 9/26/23 at 2:33 pm with the Interim Director 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.
“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
$55,760 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $55,760 — penalty dated 2023-09-27
- Medicare payment denial — starting 2023-10-25 for 22 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ALLIANCE HEALTH GROUP — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 1.8 | +1.2 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 1 of 5 | 2.2 | -1.2 vs chain |
The other 11 homes this chain runs (chain average 1.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HENDERSON EMAC LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 01/01/2023 |
| KLEIN, ELIEZER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 01/01/2023 |
| BORNSTEIN, YISROEL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2023 |
| HIRSCH, NISSON | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2023 |
| HENDERSON SCH OPERATING LLC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $303K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 345316. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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.