Premier Nursing and Rehabilitation Center
225 White Street, Jacksonville, NC 28546 · For profit - Limited Liability company · 239 certified beds · (910) 353-7222 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $51,984 in federal fines (most recent 2024-03-27)
- about 23% 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 1 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 | 16.9% | 15.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.4% | 7.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.4% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.6% | 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 | 4.3% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.0% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.0% | 21.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 90.2% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.7% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.9% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.5% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.5% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.0% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.33 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.19 | 1.80 | 1.80 | better |
‡ 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.
53.0% 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 248 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.9% 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 136 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 53.0%CMS range 46.1–60.0 | 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 | 12.4%CMS range 9.5–14.7 | 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 | 55.9% | 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 | 59.6% | 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 | 47.1% | 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 | 98.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 85.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 6.0% | 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 | 7.6%CMS range 5.1–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 239 beds and averages 141.7 residents a day — about 59% occupied, or roughly 97 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.84 hrs/resident/day on weekends vs 3.37 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2024-03-27 · 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 record review, staff, and Psychiatric Nurse Practitioner interviews, the facility failed to protect 2 of 5 residents' rights to be free from physical abuse (Residents #114 and #29). All residents involved resided in the memory care unit. Resident #99 struck the back of Resident #114's head on 9/8/23 and hit Resident #114's left jaw twice on 10/11/23. Both incidents occurred after Resident #114 wandered into Resident #99's room. Resident #114 had redness and a small amount of swelling to the left side of face after the second incident. Resident #99 slapped Resident #29 on the cheek after Resident #29 touched Resident #99's pants in the activity room. Resident #29 sustained no injuries. A reasonable person would not expect to be physically abused in their home and would experience feelings such as intimidation, fear, humiliation, embarrassment, and anxiety. This was for 2 of 5 residents reviewed for abuse. 1. Resident #99 was admitted to the facility on [DATE]. Resident #99's diagnoses included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to treat a resident with dignity when a nurse aide did not sit while feeding a resident who needed assistance with meals for 1 of 2 dining observations (Resident #51). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want staff to stand over them while assisting with meals. Findings included: Resident #51 was admitted to the facility on [DATE]. Her active diagnoses included dysphagia. Review of Resident #51's Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired and totally dependent on staff for eating. Review of Resident #51's care plan dated 4/21/25 revealed she was dependent on staff for eating. During observation on 4/23/25 at 1:06 PM Nurse Aide #4 was observed assisting Resident #51 with lunch. The nurse aide was standing next to Resident #51 who was seated in her specialized wheelchair with her bedside table in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · 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 review, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of swallowing/nutritional status (Resident #39) and hospitalization (Resident #138). This was for 2 of 24 residents reviewed for accuracy of assessments. Findings included: 1. Resident #39 was admitted to the facility on [DATE]. A review of an admission nursing progress note for Resident #39 dated 10/2/24 at 6:45 PM revealed in part he had a percutaneous endoscopic gastrostomy feeding tube (a PEG tube is a feeding tube placed into the stomach through the abdominal wall). A review of a physician's order for Resident #39 dated 10/2/24 revealed to flush his tube every 4 hours with 100 cubic centimeters (cc) of water (H2O). A review of Resident #39's March 2025 Medication Administration Record (MAR) revealed documentation indicating 100 cc of H2O was administered via Resident #39's PEG tube every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 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 · Dcited before2025-04-24 · 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 observation, record review, and resident, Responsible Party (RP) and staff interviews, the facility failed to implement the comprehensive care plan in the area of activities of daily living (Resident #27), and failed to develop an individualized, person-centered comprehensive care plan to include the use of a percutaneous endoscopic gastrostomy feeding tube (a PEG tube is a feeding tube placed into the stomach through the abdominal wall) (Resident #39), and the use of a noninvasive mechanical ventilator (a device to help with nighttime breathing for people with respiratory issues) (Resident #290 and Resident #71). This was for 1 of 5 residents reviewed for activities of daily living, 1 of 2 residents reviewed for tube feeding, and 2 of 4 residents reviewed for respiratory services. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of intracerebral hemorrhage (bleeding in the brain). A review of Resident #27's annual Minimum Data Set (MDS) assessment dated [DATE]…
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 before2025-04-24 · 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 observations, record review, and resident, staff and Medical Director interviews the facility failed to obtain a physician's order for the use of a BiPAP machine (a device that delivers two levels of air pressure during inhalation and exhalation to help people with breathing difficulties) (Resident #290) and a physician's order for use of a CPAP machine (a machine that used mild air pressure to keep breathing airways open while sleeping) (Resident #71). The facility also failed to administer oxygen by tracheostomy (a surgical opening in the neck for breathing) in accordance with the Physicians order (Resident #39). This was for 3 of 4 residents reviewed for respiratory care (Resident #290, Resident #71 and Resident #39). Findings included: 1. Resident #290 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. The hospital discharge summary for Resident #290 dated 4/3/25 stated she needed to wear a BiPAP machine (a device that delivers two levels of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews the facility failed to attempt alternatives, assess entrapment risk, review risks and benefits and obtain informed consent prior to installing and utilizing bilateral quarter length side rails for 1 of 1 resident reviewed for side rails (Resident #290). Findings included: Resident #290 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. Resident #290's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and had impairment to bilateral upper and lower extremities. The MDS further revealed she needed substantial to maximum assistance with bed mobility. Resident #290 was observed lying in her bed with bilateral quarter length side rails in the raised position on 4/21/25 at 11:15 AM. In an interview with Resident #290 on 4/21/25 at 11:15 AM she stated she needed the side rails for bed mobility and positioning. A review of Resident #290's electronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to maintain an accurate medical record with regards to documentation of actual oxygen (O2) administration rate and route. This was for 1 of 4 residents (Resident #39) reviewed for the accuracy of medical records related to respiratory care. Findings included: Resident #39 was admitted to the facility on [DATE] with a diagnosis of tracheostomy status. A review of a current physician's order for Resident #39 dated as initiated on 12/12/24 revealed to administer 4 liters (L) of oxygen (O2) per minute via tracheostomy to maintain Resident #39's O2 saturations above 90 percent (%). On 4/21/25 at 2:44 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/22/25 at 2:12 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/23/24 at 11:02 AM an observation 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 before2025-04-24 · 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 policy for enhanced barrier precautions (EPB) when Nurse #4 failed to wear a gown when providing tracheostomy (a surgical opening in the neck for breathing) care for Resident #27 and when Nurse #5 and Nurse #6 failed to wear a gown during a high contact care activity that included transfer and the provision skin care and hygiene for Resident #39 who had a tracheostomy. This was for 3 of 8 staff members observed for infection control practices. This had the potential to result in the risk of multidrug-resistant organism (MDRO) transmission. Findings included: A review of the facility's policy titled Enhanced Barrier Precautions dated last revised on 6/13/24 revealed in part the following: Enhanced Barrier Precautions are used in conjunction with standard precautions to reduce the risk of MDRO transmission during high-contact resident care activities. It includes the use of both gown and gloves. Enhanced Barrier Precautions apply to residents with any of the following: Presence of an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · 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 complete and submit an initial report for an abuse allegation within 2 hours of discovery to the state regulatory agency. The facility also failed to notify the police department, or Adult Protective Services (APS) for staff to resident abuse (resident #350) for 1 of 3 residents investigated for facility reported incidents. Findings included: A facility grievance form dated 10/10/23 was filed by SW#1 on behalf of resident #350. A review of the form revealed the resident stated her hair was pulled and that a bruise on her right hand was caused by NA #5 because the resident did not want to go to bed. Resident #350 further stated that her parents were outside the locked door, and no one would let them in. The form further revealed SW #1 reported the incident to the Assistant Director of Nursing (ADON) and Administrator #2 immediately after taking the report from the resident. An interview with SW #1 on 3/20/24 at 11:10 AM revealed she visited Resident #350 on 10/10/23 and noticed a bruise on her right hand. SW #1 asked…
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 before2024-03-27 · 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 2. Resident #68 was admitted to the facility on [DATE] with diagnoses which included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A review of Resident #68's significant change Minimum Data Set (MDS), dated [DATE], indicated that Resident #68 was severely cognitively impaired. Hospice Care was not indicated. A review of Resident #68's Care Plan, last revised 12/13/23, revealed a problem of has advanced directives with an intervention of resident/responsible party elected hospice. This intervention was initiated on 09/28/23. A review of Resident #68's Physician orders revealed an order, dated 12/22/23, which read, admit to hospice services effective 09/21/23. An interview was conducted with the MDS Coordinator nurse on 03/21/24 at 1:37 p.m. The nurse stated he completed the significant change MDS, dated [DATE], because Resident #68 was placed on hospice services. The nurse explained that he missed marking Hospice Care due to human error. A telephone interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to develop a person-centered care plan for 1 of 1 resident reviewed for respiratory services (Resident #37). The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses that included heart failure and shortness of breath. A review of Resident #37's physician orders revealed an order dated 2/16/24 for supplemental oxygen at 2 liters per minute by nasal cannula to keep the oxygen saturation above 90%. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 received continuous supplemental oxygen. A review of Resident #37's comprehensive care plan revealed no care plan was developed related to oxygen use from admission through 3/21/24. Interview with Nurse #6 (MDS nurse) on 3/21/24 at 9:05 AM revealed supplemental oxygen use was triggered on the admission MDS and should have been part of the care plan. She stated the mistake was made by human error. An interview with Director of Nursing (DON) on 3/21/24 at…
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 20 citations
- Potential for harm · D2024-03-27 · 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 keep a dependent resident's fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #69). Findings included: Resident #69 was admitted to the facility on [DATE]. Her active diagnoses included contracture of left wrist, reduced mobility, lack of coordination, and diabetes mellitus. Review of Resident #69's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had no rejection of care documented in the assessment. She required maximal assistance with bathing, and moderate assistance with personal hygiene. Review of Resident #69's care plan dated 2/22/24 revealed she was care planned for activities of daily living care. The interventions included providing extensive physical assistance with personal hygiene and grooming. During observation on 3/19/23 at 3:54 PM Resident #69's left hand fingernails were observed to be long. During an interview on 3/20/24 at…
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 before2024-03-27 · 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 and staff interview, the facility failed to investigate and analyze falls to determine causative factors and implement targeted interventions to reduce risk of further falls for 1 of 3 residents (Resident #348) reviewed for accidents. The findings included: Resident #348 was admitted to the facility on [DATE] with diagnoses that included abnormality of gait and mobility. A fall risk assessment dated [DATE] indicated Resident #348 was not at risk for falls. A review of Resident #348's admission Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired and had no fall history. He required extensive assistance with bed mobility and transfers, total assist with toileting, used a wheelchair for mobility and had no impairment in range of motion. The Care Area Assessment (CAA) dated 7/3/23 for the 6/20/23 MDS revealed Resident #348 was coded as at risk for falls due to having received antidepressant medication one or more of the last 7 days since 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.
- Potential for harm · Dcited before2024-03-27 · 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 observations, record review, and resident and staff interviews the facility failed to administer oxygen (O2) in accordance with the physician's order for 1 of 3 residents (Resident #44) reviewed for respiratory care. Findings included: Resident #44 was admitted to the facility on [DATE] with a diagnosis of dependence on supplemental oxygen. A review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was dependent for personal hygiene and required moderate assistance to go from lying to sitting. He received continuous oxygen therapy on admission and while a resident. A review of Resident #44's medical record revealed in part a physician's order dated 3/15/24 for O2 3 liters (L) per minute via nasal cannula (NC). On 3/19/24 at 3:13 PM an observation of Resident #44 revealed he was in bed. He was receiving O2 at 4L per minute via NC from an O2 concentrator that was positioned on his left side at the head of his bed. An interview with Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-27 · 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
Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended medication cart (the 700-hall medication cart) for 1 of 7 medication carts. The findings included: a. A continuous observation of the 700-hall medication cart was conducted on 03/21/24 from 8:32 AM to 9:01 AM. The 700-hall medication cart was located two resident doors away from the end of the 700-hall section where it transitioned to the 800 hall. The medication cart was observed with the lock not engaged as evidenced by the red dot on the lock being visible. There was no staff member at the medication cart. Several staff members, residents, and visitors were observed walking past the medication cart. Nurse #7 came out of a resident room and returned to the medication cart at 8:44 AM. Nurse #7 was asked to open the top drawer and realized she had left the medication cart unlocked. Nurse #7 stated she usually locks her cart. b. A continuous observation of the 700-hall medication cart was conducted on 3/22/24 from 8:45 AM to 8:54 AM. The 700-hall medication cart 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 · Dcited before2024-03-27 · 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 observations, record review and staff interview the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 1/7/22 and 3/3/23, and the complaint survey of 10/27/22. This was for 5 recited deficiencies in the areas of Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plans (F656), ADL Care Provided For Dependent Residents (F677), Free Of Accident/Hazards/Supervision/Devices (F689), Label/Store Drugs & Biologicals (F761) and Infection Control (F880). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The tag is cross-referenced to: F641 - Based on staff interviews and record review the facility failed to accurately code the Preadmission Screening Resident Review (PASRR) status, falls, and hospice status the Minimum Data Set (MDS) assessment for 3 of 29 minimum data set…
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 before2024-03-27 · 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 hand washing and alcohol-based hand sanitizer procedures as part of their infection control policies when Nurse Aide (NA) #4 failed to perform hand hygiene during meal delivery service after moving an overbed table and handling a bed control during 1 of 6 meal delivery service observations. This had the potential to result in cross contamination of microorganisms between residents. Findings included: A review of the facility's procedures titled Handwashing Procedure and Alcohol Hand Sanitizer Procedure dated 4/2023 revealed in part the following, You should wash your hands before and after contact with residents [and] After handling contaminated items (soiled incontinent briefs, linens, trash etc.) An alcohol-based hand sanitizer may be used unless hands are visibly soiled. During a continuous observation of meal delivery service beginning on 3/19/24 at 12:33 PM on the 100 Hall NA #4 was observed to remove a meal from the meal cart, enter Resident #20's room and place his meal on his…
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 · D2024-03-27 · 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 and resident interviews the facility failed to offer the flu vaccine during the flu season for 2 of 5 residents reviewed for immunizations (Resident #56, Resident #69). Findings included: 1. Resident #56 was admitted to the facility on [DATE]. Review of Resident #56's minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He was documented to have not been offered the flu vaccine. Review of Resident #56's health record on 3/19/24 revealed there was no documentation of the flu vaccine being offered to Resident #56. During an interview on 3/21/24 at 12:25 PM the Director of Nursing stated when she reviewed Resident #56's vaccine record on 3/20/24 she noted that Resident #56 had not been documented to have been offered the flu vaccine during the current flu season. She stated Nurse #8 was responsible for offering the flu vaccines this flu season for Resident #56's hall as the Infection Control Nurse was new to the position and was not involved. 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 · E2023-03-03 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to: 1a) ensure the residents rooms were free from damaged drywall in 10 of 10 resident rooms noted to have drywall wall damage (101, 104, 114, 116, 203, 214, 217,303, 815, and 817), 1b) replace 1 of 1 missing privacy curtains in 1 of 4 shower rooms (300-Hall), and 1c) failed to replace broken or missing floor tiles next to shower drain in 1 of 4 shower rooms (100-Hall); 2a) clean and disinfect dried feces off a resident's room floor, and 2b) tell housekeeping staff to clean and disinfect the hallway area where Nursing Aide (NA) dropped soiled linen, for 2 of 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) that were observed for environment. Findings included: An initial tour of the facility was conducted on 02/20/23 at 10:30 AM., revealed damaged drywall in 10 of 10 resident rooms observed to have drywall wall damage (101, 104, 114, 116, 203, 214, 217,303, 815, and 817). 1a. An observation on 02/21/23 at 10:35 AM revealed 10 of 10…
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 before2023-03-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observation, record review and staff interviews the facility failed to develop and implement a comprehensive person-centered care plan that addressed measurable goals and interventions for 4 of 6 residents (#8, #77 #123, #127) reviewed for care planning. Findings included: 1). Resident #8 was admitted to the facility on [DATE] with diagnoses which included in part: congestive heart failure, anxiety, depression, and dementia with behaviors. Resident #8's 12/25/22 admission Minimum Data Set (MDS) revealed resident with severe cognitive impairment, was sometimes able to make self understood and usually understands others. Resident #8 had the following behaviors coded: physical behaviors, other behavioral symptoms, behavioral symptoms which significantly interfered with care, put others at risk of physical injury, intruded on privacy or activities of others, significantly disrupted the care or living environment, and rejection of care. Resident #8 was coded as had one fall since admission and received…
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 · E2023-03-03 · tag F0687 — failed to care for feet properly — patternProvide appropriate foot 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, observations, and resident, staff, and physician interviews the facility failed to follow up on a Podiatrist (foot doctor) order from June 2022 for diabetic shoes to help with protecting the resident's feet secondary to loss of sensation, weakness, and deformity which caused the resident frustration and the inability for the resident to get out of his room and ambulate with his walker for 1 of 1 resident (Resident #36) reviewed for diabetic foot care. Findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus with diabetic polyneuropathy (numbness, pain, burning in feet due to peripheral nerve damage), depression, and generalized anxiety disorder. Review of the electronic medical record (EMR) for Resident #36 revealed a Podiatrist exam report dated and signed on 06/20/2022. The report read in part, Reason for Visit: Diabetic foot care. Patient presents for at risk foot care. Patient footwear evaluation was performed. Order written…
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 before2023-03-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and staff and physician interviews the facility failed to: 1) comprehensively assess residents for fall risk, thoroughly investigate falls and implement interventions to reduce the risk of falls for residents with a history of falls for 2 of 2 residents (Resident #8 and Resident #77) reviewed for falls; 2) ensure Resident #22, who was assessed as an unsafe smoker, had interventions implemented for safe smoking to include nursing staff to assist the resident to the designated smoking area, not leaving the resident unattended while smoking, and the use of a smoking apron; 3) secure smoking materials (Residents #22, #104, and #127); and 4) assess the safety of a resident who was a known smoker (Resident #127) for 3 of 4 residents reviewed for smoking. Findings included: 1). Resident #8 was admitted to the facility on [DATE] with diagnoses which included in part dementia with behaviors. Resident #8's 11/23/22 admission Fall Risk Evaluation was incomplete with predisposing…
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 · E2023-03-03 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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, Nurse Practitioner, Pharmacist Consultant, and staff interviews the facility failed to implement a pharmacy recommendation which resulted in a resident (Resident #55) not receiving her daily dose of Victoza (a non-insulin medication to treat diabetes) for 21 days for 1 of 5 residents reviewed for unnecessary medications. Findings included: Resident #55 was admitted to the facility on [DATE]. Diagnoses included, in part, insulin dependent diabetes mellitus. The Minimum Data Set annual assessment dated [DATE] revealed the resident was cognitively intact and received 7 days of insulin during this assessment. Review of the physician orders revealed orders written on 12/19/22 to include Glargine Solution (long acting basal insulin) Pen Injector 100 units/milliliter (ml), inject 45 units subcutaneously every 12 hours and Humalog (short acting insulin) KwickPen Solution Pen Injector 100 units/ml, inject per sliding scale subcutaneously three times daily for diabetes mellitus. A…
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 · E2023-03-03 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to accurately transcribe and administer a medication used to treat depression resulting in 23 doses administered at a higher dose than ordered for 1 of 3 residents (Resident #8) reviewed for psychotropic medication (a medication used to treat behavior, mood, thoughts, or perception). Findings included: Resident #8 was readmitted to the facility on [DATE] with diagnoses which included in part dementia with behaviors, depression, and anxiety. The 1/30/23 discharge summary medication list for Resident #8 included an order for sertraline 50 milligrams (mg.) give 25 mg daily. A physician order dated 1/30/23 was entered by Quality Improvement (QI) Nurse #2 for sertraline 50 milligrams (mg.) give 1 tablet by mouth one time a day for depression admission Drug Regimen Review on 1/31/23 indicated the order for sertraline required clarification and noted the order on the discharge summary read sertraline 50 mg. 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 · E2023-03-03 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to accurately transcribe and administer a medication used to treat hypertension (high blood pressure) resulting in 8 doses administered in error for 1 of 1 residents (Resident #8) reviewed for medication error. Findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses which included in part hypertension (high blood pressure), atrial fibrillation, congestive heart failure and coronary artery disease. Discharge Summary 11/23/22 indicated Resident #8 was to receive metoprolol succinate (a long acting medication to treat high blood pressure)100 milligrams (mg) every morning. A physician order dated 11/23/22 was entered by Unit Manager #1 for metoprolol tartrate (a short acting form of the medication used to treat high blood pressure) 100 mg. for hypertension. Pharmacy admission Drug Regimen Review for Resident #8 on 11/25/22 revealed no hospital discharge summary was received in 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 · Ecited before2023-03-03 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, staff interviews, and review of the manufacturers guidelines the facility failed to label multi dose oral inhalers with resident names and failed to record opened dates on multi dose oral inhalers and on an insulin pen on 2 of 3 medication carts (300 and 400 hall medication carts) reviewed for medication storage. Findings included: 1. Review of the manufacturer's guidelines revealed to discard the Stiolto Respimat, the Striverdi Respimat, and the Combivent Respimat 3 months after the first use. The guidelines revealed the Trelegy oral inhaler should be discarded 6 weeks after opening and to record the opened date on the label of the inhaler. The Advair Diskus was to be discarded 30 days after removal from the protective foil pouch, and to discard Incruse 6 weeks after opening and to record the opened date on the inhaler. An observation of the 300-hall medication cart conducted on 02/19/23 at 4:15 PM with Nurse #3 revealed: two Stioloto Respimat oral inhalers (prescribed for treatment of chronic lung disease) that were not labeled with resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-03 · 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 discard milk cartons and nutritional supplements that were stored for use past the use by dates in 1 of 1 walk in refrigerators observed for food storage. This practice had the potential to affect all residents who consumed these products. The facility also failed to repair broken floor tiles in the kitchen adjacent to the dishwasher, and repair cracked, peeling paint hanging from the ceiling tiles above 2 of 3 the food preparation tables reviewed for sanitation. Findings included. 1)The initial tour of the kitchen conducted on 02/19/23 at 11:30 AM revealed 3 crates of milk cartons. One crate contained 32 milk cartons and each carton had a use by date of 02/17/23, a second crate contained 15 milk cartons each with a use by date of 02/18/23, a 3rd crate contained 50 milk cartons each with a use by date of 02/18/23. This was observed in the walk-in refrigerator. There was no label on the crates indicating the milk cartons had expired. Further observations conducted on 02/19/23 at 11:30 AM revealed 4 cases 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 · Ecited before2023-03-03 · 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, and staff interviews, the facility's Quality Assurance & Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a recertification and complaint investigation of 01/07/22 and complaint investigations of 06/30/22 and 12/23/20. This was for 3 deficiencies that were originally cited in the areas of accurate coding of the Minimum Data Set assessments (F641), developing/implementing comprehensive care plans (F656), and drug regimen reviews/report irregularities (F756) and were subsequently recited on the current recertification survey of 03/03/23. The continued failure during 2 or more federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program. Findings included: This tag is cross referenced to: a. F641: Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 31 residents (Resident #127) reviewed for MDS accuracy.…
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 · D2023-03-03 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews the facility failed to provide a resident with privacy when Resident #29 was observed lying in bed with his naked body exposed when door to the hallway was opened and the privacy curtain not pulled around the bed in a semi-private room. The deficient practice affected 1 of 1 resident reviewed for privacy. The reasonable person concept was applied to Resident #29 as residents have an expectation of privacy in their home environment. Findings included: Resident #29 was admitted to the facility on [DATE] with medical diagnoses which included in part intracerebral hemorrhage with and hemiparesis. Resident's 01/27/23 annual Minimum Data Set (MDS) assessment revealed that resident had severe cognitive impairments and needed extensive assistance with bed mobility, transfers, bathing, and toileting. Observation on 02/21/23 at 10:55 AM revealed upon knocking and entering Resident #29's room, resident was lying in bed naked with full frontal exposure. The privacy…
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 before2023-03-03 · 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 record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 31 residents reviewed for MDS accuracy (Resident #127). Findings included: Resident #127 was admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis and weakness. Review Resident #127's admission Minimum Data Set (MDS) assessment dated [DATE] revealed tobacco use was coded as no. Review of Resident 127's care plan revealed a plan of care for Safe and Independent Smoker was added on 02/19/2023. An interview and observation of Resident #127 smoking outside in the designated area occurred on 02/21/2023 at 01:25 PM. Resident #127 stated that she has been smoking since she was admitted to the facility in October. She further stated that she kept her cigarettes and lighter in her purse and the facility had never her asked her to turn her cigarettes in for safe keeping. An interview was conducted with the MDS Coordinator #1 on 02/23/2023 at 09:15 A.M. MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-03 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff, Consultant Pharmacist and Nurse Practitioner interviews, the facility failed to order and administer a diabetes medication as prescribed by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #62). Findings included: Resident #62 was admitted to the facility 10/30/21 with medical diagnosis which included stroke with hemiplegia and diabetes. Resident#62's 11/18/22 quarterly care Minimum Data Set (MDS) revealed resident was cognitively intact, had diagnoses of diabetes and received insulin injections two days during the look back period. Resident #62 exhibited no rejection of care. Resident #62's 11/29/22 care plan revealed a focus of diabetes with potential for complications of hyper/hypoglycemia. Goal was Resident #62 would be free from any signs/symptoms of hyper/hypoglycemia through next review. Interventions included fingerstick blood sugar monitoring and medication as ordered by the physician. Review of the 1/24/23 consultant pharmacist Medication Regimen Review for Resident #62 indicated a recommendation 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.
“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
$51,984 in federal fines across 1 penalty.
- $51,984 — penalty dated 2024-03-27
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRINCIPLE LONG TERM CARE — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 39 homes this chain runs (chain average 3.0★, 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 | Since |
|---|---|---|---|
| HILL, RAYMOND | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2011 |
| HILL, ROBERT | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2011 |
| HILL, STEPHEN | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2011 |
| SCHMIDT, MELISSA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/06/2024 |
| SCHMOKE, RAYMOND | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 11/01/2024 |
| BOICE, GALE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/05/2018 |
| JOHNSON, DIANNE | Individual | CORPORATE OFFICER | since 01/01/2011 |
| PRINCIPLE LONG TERM CARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2011 |
CMS files one row per role, so the 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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 345217. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, 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.