Meridian Center
707 North Elm Street, High Point, NC 27262 · For profit - Corporation · 199 certified beds · (336) 885-0141 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 abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $88,566 in federal fines (most recent 2025-08-20)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 31% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 4 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 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 23.2% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.1% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 24.1% | 5.9% | 6.5% | worse |
| 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 | 3.4% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 17.1% | 18.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.6% | 21.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.8% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.8% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 21.6% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.2% | 22.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 12.9% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.2% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 31.8% 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 22 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 49.2%CMS range 37.6–62.8 | 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 | 11.5%CMS range 7.5–15.4 | 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 | 31.8% | 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 | 40.9% | 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 | 40.9% | 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 | 91.1% | 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 | 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 | 0.0% | 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 | 4.4% | 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 | 0.84 | 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 199 beds and averages 167.2 residents a day — about 84% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.77 hrs/resident/day on weekends vs 3.03 on weekdays — 9% thinner on weekends. RN hours go from 0.35 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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 14 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-08-20 · 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 observation, record reviews, and interviews with staff, resident, and the Medical Director, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. On 2/21/25, Resident #8 was being transferred to dialysis in the facility's transportation van. When Transportation Driver #1 made a left turn, Resident #8 and the wheelchair she was seated in tipped over onto the floor of the van. The Transportation Driver called 911. Resident #8 complained of pain to the right side of her neck and face and was transported to the hospital via Emergency Medical Services (EMS). Resident #8 was receiving a blood thinner which increased her risk of bleeding. While at the hospital, Resident #8 was found to not have sustained any injuries but was admitted for one day to receive her missed dialysis treatment before returning to the facility. This practice had a high likelihood of causing a serious adverse outcome, including death or serious injury. This deficient…
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.
- Immediate jeopardy · J2025-08-20 · 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 reviews, and staff and Medical Director interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 1 of 2 residents whose blood glucose levels were checked (Residents #135). This occurred while there was at least one resident with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer potentially exposes residents to the spread of blood borne infections. Care must also be taken by personnel handling glucometers to protect the glucometers against cross-contamination via contact with other surfaces. Immediate Jeopardy began on 8/14/25 when Nurse #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-09-04 · 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 observations, record review, and staff, resident, and Nurse Practitioner (NP) interviews the facility failed to transfer a resident safely from a shower to the resident's room. On 06/12/24 Resident #1 was being pushed in a shower chair down the hall by Nursing Assistant (NA) #1 and the resident fell forward out of the chair hitting the floor. The fall resulted in the resident being sent out to the hospital for complaints of severe pain. Resident #1 indicated from a 1-10 (10 being the most pain) her pain level was an 11 in her lower extremities and wanted to be sent out to the hospital immediately. Resident #1 was admitted to the hospital on [DATE] and was diagnosed with a left tibial plateau fracture (top part of the shin bone), right foot great toe fracture, and an acute displaced (bones are out of alignment) spiral (broken by twisting force) fracture of the right femur (thigh bone) requiring surgical repair. This was for 1 of 3 residents reviewed for providing supervision to prevent accidents…
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 · Gcited before2024-05-17 · 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, resident interview, staff interview and Nurse Practitioner interview, the facility failed to provide assistive devices to prevent accidents for 1 of 4 residents (Resident #110) reviewed for falls. Resident #110 fell out of bed, hit her head on the floor, yelled, and screamed of pain, sustaining a 36 centimeters [cm] full thickness curvilinear (crescent) wound to the lateral aspect of the right lower leg and the right first toenail was almost completely avulsed (torn off) with only attachments on the lateral proximal (from the side to the center) nail. Findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease (COPD) and hypertension (HTN). Resident #110's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and with no behaviors. The quarterly assessment further indicated Resident #110 required extensive assistance of two persons…
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 before2026-06-11 · 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 label and date food items stored for use in the reach-in refrigerator for 1 of 1 reach-in refrigerator and failed to use gloves when handling an unpeeled cucumber for 1 of 5 kitchen staff observed. These practices had the potential to affect food served to residents.Findings included:A.On 6/7/26 at 9:15 am the initial kitchen observation was completed with kitchen staff #1. The reach-in refrigerator had the following food items that were not in the original manufacturer's packaging and were not dated: Six applesauce cups no longer in the original package, One yellow pudding consistency food item in a large metal bowl with plastic wrap which was lying in the food and no longer covering. The food item appeared to be runny with water pooling on the edges, and Fourteen poured cups of thickened liquid were in plastic cups. On 6/7/26 at 10:45 am an interview was completed with the Dietary Manager (DM). The DM stated that all food items required an expired by date when placed in alternate packaging. B.On 6/9/26 at 12:32 pm…
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 · D2026-06-11 · 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, staff and resident interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #8) accepted a meal purchased by Resident #144 through an online food delivery service and failed to reimburse Resident #144 for the cost of the meal. The deficient practice was for 1 of 2 residents reviewed for misappropriate of resident property (Resident #144).Findings Included:Resident #144 was admitted to the facility on [DATE].Review of Resident #144's quarterly Minimum Data Set (MDS) Assessment indicated Resident #144 was cognitively intact.An initial allegation report dated 5/2/26 completed by the Administrator showed that Resident #144 made the Registered Nurse (RN) Weekend Supervisor aware on 5/2/26 that on 5/1/26, Nurse Aide #8 took his online food delivery service order and did not deliver it to him.A review of the 5-day investigation report dated 5/8/26 completed by the Administrator revealed that on 5/5/26 the Director…
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 before2026-06-11 · 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 resident and staff interviews, the facility failed to provide nail care for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #68). The findings included:Resident #68 was admitted to the facility on [DATE] with diagnoses including essential hypertension, communication deficit, unspecified visual loss, and chronic pain syndrome.A care plan dated 6/5/2026 indicated Resident #68 had an ADL self-care performance deficit with a goal that read Resident #68 would maintain his current level of function. The care plan revealed the resident was dependent on the assistance of one staff with personal hygiene.The significant change Minimum Data Set (MDS) assessment completed 5/22/2026 documented Resident #68 as cognitively intact, without refusal of care behavior, and dependent on others for personal hygiene.Resident #68 was observed on 6/7/2026 at 10:39 AM. The free edge of Resident #68's fingernails on both hands were either jagged or broken,…
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 · D2026-06-11 · 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 observations, record review, and resident, resident representative, staff, Neurosurgery Staff Nurse, Wound Care Physician, and Medical Director interviews, the facility failed to follow up with the neurosurgeon's office regarding a follow up appointment to address resident's staples. The deficient practice affected 1 of 1 resident reviewed for quality of care (Resident #1).The findings included:A review of Resident #1's hospital Discharge summary dated [DATE], it was noted that the resident underwent a C4-T2 (4th cervical vertebra through 2nd thoracic vertebra) posterior fusion on 4/30/26. It was also noted that there were no follow-up visits scheduled for Neurosurgery or guidance provided regarding the 15 staples present in her surgical incision.Resident #1 was admitted to the facility on [DATE]. Her diagnoses included a non-displaced cervical fracture C6 and C7 (cervical spine in neck) acute 3-column fracture of C6 (a severe and unstable cervical spine injury in which all three structural columns 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 · Dcited before2026-06-11 · 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 observation, record review, resident and staff interviews, the facility failed to provide personal care in a safe manner when Resident # 44 was left unattended in shower room with the side rails on shower stretcher left in down position. Resident #44 rolled off the right side of shower stretcher and required transfer to the hospital for medical evaluation. This was for 1 of 4 residents reviewed for accidents (Resident #44).Findings included: Resident #44 was admitted to the facility on [DATE]. The residents' diagnoses included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body) following Cerebral infarction (ischemic stroke) affecting left non-dominant side, and contractures of left wrist and hand. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #44 was cognitively intact and had range of motion impairment on one side of his upper and lower extremities. The MDS also indicated Resident #44 was dependent rolling left and right.Resident #44's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-11 · 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 secure a bottle of prescription eye drops that was left unattended on top of the second-floor medication cart for 1 of 5 medication carts reviewed for medication storage (second floor medication cart).The findings included:A continuous observation was conducted on 6/9/26 from 9:15 AM to 9:18 AM. During that time, the second-floor medication cart parked outside of room [ROOM NUMBER], contained a bottle of prescription eye drops (timolol, used to reduce high pressure in the eye) that were sitting on top of the cart. The cart was unattended and an observation of the hallway revealed the nurse for this cart (Nurse #7) was not present in the hallway. Also, at 9:15 AM Unit Manager #1 walked past the medication cart but did not acknowledge or remove the prescription eye drops. There were 2 residents observed sitting in the hallway in the vicinity of the medication cart during the observation. On 6/9/26 at 9:19 AM Nurse #7 returned to the medication cart…
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 · D2026-06-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 resident and staff interviews, the facility failed to provide food that was palatable in taste and temperature. The deficient practice affected 3 of 3 residents reviewed for food (Resident #14, #83, and #139). Findings included:1a. On 6/7/26 at 9:10 am during the initial kitchen observation, there were two carts of breakfast trays returned to the kitchen for washing. Several of the plates had what appeared to be French toast that was dark brown with shriveled edges that was not eaten or had bites taken. The toast felt hard when touched.On 6/7/26 at 9:12 am kitchen staff #1 was interviewed. She stated the carts were breakfast trays returned from this morning. She had no comment regarding the French toast that was not eaten and returned on the tray nor its consistency. On 6/7/26 at 9:15 am the cook was interviewed. The cook stated she prepared the breakfast which included French toast and had no comment about the toast. Resident #14 was admitted to the facility on [DATE]. Resident #14's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-20 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, residents, and the dialysis center Nurse Manager, the facility failed to provide transportation back to the facility after hemodialysis was completed which caused the residents to wait up to 2 hours to return. The residents requested they be transported back to the facility and not wait, which made one resident late for dinner. This deficient practice affected 2 of 3 residents reviewed for dialysis (Residents #22 and #8). The findings included:1a.Resident #22 was admitted to the facility on [DATE] with the diagnosis of end stage renal disease (ESRD) dependent on hemodialysis. Resident #22's quarterly Minimum Data Set, dated [DATE] documented the resident had intact cognition. The care plan for Resident #22 dated 7/14/25 documented he had impaired renal function and was at risk for complications of hemodialysis. The interventions were hemodialysis on Monday, Wednesday and Friday and to watch for complications. On 08/12/25 at 9:41 am Resident #22 was interviewed.…
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 · E2025-08-20 · tag F0646 — patternNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), that is the State Mental Health or Intellectual Disability Authority, when a significant change in condition was identified for a resident with a mental disorder or intellectual disability (Resident #39) and failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for PASRR Level II residents identified to have a significant change in his or her physical or mental status (Resident #11 and Resident # 179). This deficient practice affected 3 of 3 residents reviewed who had a significant change in condition. The findings included: 1.Resident #39 was admitted to the facility on [DATE]. His cumulative diagnoses included a diagnosis of schizoaffective disorder. The resident's electronic medical record (EMR) included information from the North Carolina Medicaid Uniform Screening Tool (NC MUST). This record revealed Resident #39 was evaluated and found 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 before2025-08-20 · 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 ensure 1 of 2 kitchen icemakers was free from black and gray debris and wet mixing bowls were not stacked together before they were fully dry. This had the potential to affect all residents who received ice and/or food that came into contact with the mixing bowls. An observation completed on 08/11/25 at 9:38 AM revealed 1 of the facility's 2 icemakers in the kitchen had black and gray debris running down the ice divider inside of the ice maker and then along the top ridge of the icemaker where the door opened and closed. The black and gray debris was wet in nature and appeared to be running down the divider and potentially dripping onto the ice. Additional observations at this time revealed 3 large metal mixing bowls that had recently been washed, nested together on a storage shelf. When pulled apart visible liquid drained from each of the bowls and onto the floor.An interview with the Dietary Manager on 08/11/25 at 9:46 AM revealed the ice maker was scheduled to be cleaned monthly by the maintenance department. 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.
Show the remaining 11 citations
- Potential for harm · D2025-08-20 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete an admission Minimum Data Set (MDS) assessment in the 14-day timeframe for 1 of 33 residents (Resident #190) reviewed for MDS assessments.Findings included:Resident #190 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 2 diabetes, and hypertension.During the record review for Resident #190 it was noted the MDS admission assessment had an assessment reference date of 08/06/25, however it was not complete.An interview was conducted on 08/15/25 at 10:13 am with the MDS Coordinator and she verified Resident #190's MDS admission assessment was not completed and should have been completed by 08/12/25. She indicated she was running behind and would get it done.On 08/15/25 at 12:22 pm an interview was conducted with the Administrator, and he indicated that his expectation was for all MDS assessments to be completed on time.
- Potential for harm · D2025-08-20 · 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 staff interviews and record review, the facility failed to develop a comprehensive care plan to address a resident's needs as identified in the admission assessment for 1 of 36 residents (Resident #4) whose care plans were reviewed.The findings included: Resident #4 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included diabetes and unspecified convulsions (seizure disorder).The resident's most recent Minimum Data Set (MDS) assessment was a comprehensive admission assessment dated [DATE]. A review of the MDS revealed the resident had intact cognition. She had impairment of range of motion of her upper and lower extremities on both sides of her body and utilized a walker for mobility. The resident required set-up or clean-up assistance for eating and personal hygiene; partial/moderate assistance for bed mobility and sit to stand; substantial/maximum assistance for bathing and dressing her upper body; and was dependent on staff for toileting and transfers. Resident #4 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 · Ecited before2024-05-17 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and record review, the facility failed to honor a resident's choice to receive showers as scheduled or requested. This was for 1 (Resident #88) of 3 residents reviewed for choices. The findings included: Resident #88 was admitted on [DATE] with cumulative diagnoses of atrial fibrillation, cerebral vascular accident with left sided paralysis and chronic obstructive pulmonary disease (COPD). Review of the facility's Recreation Comprehensive assessment dated [DATE] read choosing between and bath or shower was very important to him. Resident #88 quarterly Minimum Data Set, dated [DATE] indicated he had moderate cognitive impairment, exhibited no behaviors, coded for impairment on one side for his upper and lower extremities and set up only for bathing. He was also coded with occasional bladder incontinence and always continent of bowels. Review of Resident #88's care plan last revised on 5/9/24 read he required extensive staff assistance for bathing. There was no…
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 · D2024-05-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record and staff interviews the facility failed to protect a resident's right to be free from abuse when Resident #420 struck Resident #133 with a cane. This affected 1 of 9 residents reviewed for abuse. The findings included: Resident #420 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, insomnia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #420 was cognitively intact with no behaviors. Resident #420's Care Plan dated 4/1/20 included the focus area of risk for distressed/fluctuating mood symptoms related to: neurocognitive disorder, encephalopathy, new environment, anxiety, PTSD, new roommate. Interventions included observe for signs of delirium, including delusions/hallucinations; notify physician/advance practitioner as needed; encourage Resident #420 to seek staff support for distressed…
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 · D2024-05-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report allegations of abuse to Adult Protective Services (APS). This deficient practice was for 3 of 3 residents reviewed for abuse. (Resident # 11, Resident #319, Resident #133). Finding included: a. A review of the Initial Allegation Report for an allegation of misappropriation of property submitted on 5/12/2024 at 2:17 p.m. indicated the facility became aware of an incident on 5/12/2024 at 6:42 a.m. for Resident #11. The allegation details revealed Resident #11 alleged that a staff member took Resident #11's earphones one day last week without permission. The initial report indicated local law enforcement was notified on 5/12/24 at 10:00 am. The initial report did not indicate whether APS was notified. The Investigation Report completed on 5/16/24 for the 5/12/24 incident concerning Resident #11 indicated APS was notified on 5/15/24. During an interview on 5/16/24 at 2:30 PM with the Regional Director of Clinical Services, he indicated that he assisted with a mock survey on 5/9/24 and they identified an issue…
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 before2024-05-17 · 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 record review, observations, resident, and staff interviews the facility failed to provide nail care to 1 of 7 residents who were dependent on staff for assistance with activities of daily living (Resident #102). Findings included: Resident #102 was admitted to the facility on [DATE] with diagnoses that included a stroke, compressed spinal cord, and contracture of right elbow. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #102 was cognitively intact and was assessed as being dependent on staff for personal hygiene. Resident #102's care plan dated 4/2/24 showed he needed assistance with activities of daily living related to quadriparesis from compressed spinal cord. Interventions included provide extensive assistance from one staff member for personal hygiene. An observation was made on 5/13/24 at 1:08 P.M. of Resident #102's fingernails. Resident #102 had a finger nail on his right fourth finger that was approximately 1 inch longer than the tip of his finger, 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 · D2024-05-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff, resident and the Medical Director interviews and record review, the facility failed to obtain Physician orders for continuous oxygen for a resident with a diagnoses of chronic obstructive pulmonary disease (COPD) and Emphysema. The facility also failed to adminster oxygen at the ordered rate for Resident #86. This was for 2 (Resident #16 and Resident #86) of 3 residents reviewed for respiratory care. The findings included: 1. Resident #16 was admitted on [DATE] with cumulative diagnoses of COPD, Emphysema, shortness of breath and chronic pain syndrome. Review of Resident #16's admission orders dated 1/9/24 on hospice services with orders for continuous oxygen at 2 liters per minute (2L/M) Resident #16 care plan was revised on 2/13/24 for her COPD, bronchitis and Emphysema. An intervention dated 4/11/24 read to administer oxygen as ordered/indicated. She was also care planned revised on 3/5/24 for noncompliance with wearing her oxygen as ordered. The quarterly Minimum Data Set, dated…
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 · D2024-05-17 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 staff interviews and record review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented effective procedures and monitor the interventions the committee put into place following the recertification and complaint survey dated 07/19/21 and on complaint survey on 04/14/22 for F 677. An F 677 was subsequently recited during the recertification and complaint survey dated 05/17/24. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F 677:Based on record review, observations, resident, and staff interviews the facility failed to provide nail care to 1 of 7 residents who were dependent on staff for assistance with activities of daily living (Resident #102). During a complaint investigation on 04/14/22, the facility failed to provide personal grooming for hair, face, and nails for 1 of 3 dependent residents. During a recertification and complaint investigation 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.
- No harm found · B2025-08-20 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to submit a quarterly Minimum Data Set (MDS) assessment within the required time limit for 1 of 4 residents (Resident #75) reviewed for the Resident Assessment facility task.The findings included:Resident #75 was admitted to the facility on [DATE]. The resident's electronic medical record (EMR) revealed her history of Minimum Data Set (MDS) assessments included the following, in part:--A quarterly MDS dated [DATE] was reported as electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) database and accepted;--However, a quarterly MDS dated [DATE] was reported only as completed in Resident #75's EMR.An interview was conducted on 8/13/25 at 11:02 AM with the facility's MDS Coordinator. During the interview, the nurse reviewed Resident #75's history of MDS submissions. Upon this review, the MDS Coordinator noted the 6/11/25 quarterly MDS completed for Resident #75 should have been sent to CMS but was not. She stated, That's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-08-20 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect whether anticonvulsant and anticoagulant medications were administered for 1 of 36 residents (Resident #4) whose MDS assessment was reviewed.The findings included:Resident #4 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included diabetes and unspecified convulsions (seizure disorder).The resident's electronic medical record (EMR) included her Physician's Orders. These orders included, in part:--25 milligrams (mg) lamotrigine (an anticonvulsant medication) given as one tablet by mouth in the evening (Initiated 6/4/25). --75 mg pregabalin (an anticonvulsant medication) to be given as one capsule by mouth two times a day (Initiated 6/4/25). Further review of Resident #4's Physician's Orders and Medication Administration Record (MAR) did not reveal the resident received an anticoagulant at any time during the month of June 2025.The resident's admission…
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 · B2024-05-17 · 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 staff interviews and record review, the facility failed to revise the comprehensive care plan in the area of staff assistance with dressing and bathing for 1 (Resident #88) of 15 residents reviewed for activities of daily living (ADLs). The findings included: Resident #88 was admitted on [DATE] with diagnoses including cerebral vascular accident with left sided paralysis. Resident #88 quarterly Minimum Data Set (MDS) dated [DATE] indicated he had moderate cognitive impairment, coded for set-up only assistance with bathing and independence with dressing his upper and lower extremities. Review of Resident #88's ADL care plan last revised on 5/9/24 read he required extensive staff assistance for dressing and bathing. An interview was completed on 5/15/24 at 10:20 AM with Resident #88. He stated he was able to dress himself and independently washed himself up in the sink in the room. An interview was completed on 5/15/24 at 2:35 PM with Nursing Assistant (NA) #1. She stated Resident #88 was able to wash up…
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
$88,566 in federal fines across 5 penalties.
- $54,964 — penalty dated 2025-08-20
- $16,801 — penalty dated 2024-09-04
- $4,017 — penalty dated 2024-05-17
- $4,766 — penalty dated 2024-05-17
- $8,018 — penalty dated 2024-05-17
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 GENESIS HEALTHCARE — 184 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 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 2 of 5 | 3.5 | -1.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
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 |
|---|---|---|---|---|
| REGENCY HEALTH SERVICES, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2009 |
| FC GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| SUN HEALTHCARE GROUP, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2022 |
| SUNBRIDGE HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2019 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 12/01/2012 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| BERNARDINI, HOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/27/2026 |
| JOHS, LANCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/29/2025 |
| MOHAMMED, AMINU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/29/2025 |
| MORRIS, DIANE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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.
About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $6.1M paid to related parties — landlords or management companies under common ownership — equal to about 31% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 345172. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, 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 →
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