Margate Health and Rehabilitation, LLC

Location & what’s nearby

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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

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.

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.

60.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 250 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 62.9% 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 124 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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.

Staffing

How full it usually is: this home is certified for 210 beds and averages 115.0 residents a day — about 55% occupied, or roughly 95 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.83 hrs/resident/day on weekends vs 3.80 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.75 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 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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.

23 citations, most serious first. The 14 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · J2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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, staff, Nurse Practitioner, Funeral Home Representative and Hospitalist interviews the facility failed to provide care in a safe manner. On [DATE] Nurse Aide (NA) #1 was performing incontinence care for Resident #195 who was resting on an air mattress raised to waist height and rolled Resident #195 on her side away from NA #1 who proceeded to walk around to the other side of the bed at which time the air mattress decompressed. Resident #195 rolled off the side of the bed to the floor and was wedged between the bed and the wall. Resident #195 was transferred to the hospital where she was diagnosed with a right femur fracture, right inferior and superior pubic rami (pelvic) fractures, questionable nondisplaced sacral alar (lower spine) fracture. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice affected 1 of 6 residents (Resident #195) reviewed for accidents. The findings 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-11-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 verify that a Nurse Aide (NA) was competent in providing care for a dependent resident. Resident #195 rolled out of bed and sustained a right femur (long bone of the upper leg), right inferior and superior pubic rami (pelvic) fractures and questionable nondisplaced sacral alar (lower spine) fracture during care. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice occurred for 1 of 6 NAs (NA #1) reviewed for competencies. Immediate jeopardy began on [DATE] when NA #1 performed care without competencies being verified Resident #195 rolled off the side of the bed. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-25 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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, staff, family, and Medical Director interviews the facility failed to protect Resident #1 from being physically restrained by Nurse Aide (NA) #1. NA #1 grabbed Resident #1's left forearm and held it when the resident became combative during incontinent care and Resident #1 was trying to hit NA #1 and NA #2. Resident #1 received a large purple bruise on her left forearm. This deficient practice affected 1 of 3 residents reviewed for dignity. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, delirium, anxiety, and chronic atrial fibrillation (irregular heart rhythm). Review of a physician order dated 04/14/23 read Apixaban (also known as Eliquis) (blood thinner) 2.5 milligrams (mg) by mouth twice a day for atrial fibrillation. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was moderately cognitively impaired and required extensive assistance with toileting…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-25 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, and staff interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after NA #2 witnessed the NA grab Resident #1's left forearm to prevent her from hitting NA #1 and NA #2 when the resident became combative during incontinent care. In addition, the facility failed to identify, thoroughly investigate, and report the incident to the state agency, Adult Protect Services, and local Law Enforcement for 1 of 3 residents reviewed for dignity. The findings included: Review of the facility Abuse/Neglect/Misappropriation of Resident Property policy revised 07/2022 read in part, All allegations of resident abuse, neglect, misappropriation of resident property, involuntary seclusion, and injuries of unknown origins will be promptly reported and thoroughly investigated, and facility must prevent further potential abuse while investigation is in progress. Any suspicion of a crime will be reported to law enforcement. Employees of the facility…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-13 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect 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 observations, record reviews and staff, resident, manufacturer customer service representative, Pharmacy Manager and Nurse Practitioner interviews, the facility failed to protect a resident's right to be free from misappropriation of medication. This failure occurred for 1 of 1 resident reviewed for misappropriation. The findings included:Resident #24 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #24 was cognitively intact and had a diagnosis of diabetes mellitus.Review of Resident #24's physician orders revealed an order dated 09/11/25 for tirzepatide (Monjaro) 5 milligrams (mg) per 0.5 milliliters (ml) administer one syringe subcutaneously once a day on Friday for Type 2 Diabetes Mellitus.Review of a pharmacy delivery sheet dated 12/12/25 and signed by Nurse #4 at 10:00 PM indicated 2 ml of tirzepatide (which equals 4 injections) were delivered from the pharmacy for 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating an allegation of misappropriation. Upon the discovery of misappropriation, the facility did not submit a report to the State Agency or conduct a thorough investigation of the misappropriation. This failure occurred for 1 of 1 resident reviewed for misappropriation (Resident #24).The findings included:The facility's policy titled, Abuse, Neglect and Exploitation, revised 06/01/25 read in part, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent . and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The facility will implement policies and procedures…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0880 — failed to prevent and control infections — isolated
  Provide 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 interviews, the facility failed to follow their Hand Hygiene Policy when the Wound Nurse performed pressure ulcer treatments on Resident #10 and did not wash or sanitize her hands before applying clean gloves. This deficient practice occurred for 1 of 7 staff members observed for infection control practices (Wound Nurse).The findings included:Review of the facility's Hand Hygiene policy read in part:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Review of the facility's Basics of Hand Hygiene policy read in part:You should always perform hand hygiene: before applying and after removing personal protective equipment (e.g., gloves), before and after providing any type of care and after contact with bodily fluids or other potentially contaminated surfaces.Wound care observations were made on 02/10/26 at 2:15 PM on Resident #10 by the Wound Nurse. The Wound Nurse gathered the supplies…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-06 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for the use of oxygen for 1 of 3 residents (Resident #1) reviewed for respiratory care. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, coronary artery disease and pneumonia. Review of Resident #1's admission physician orders initiated on 05/07/25 for continuous oxygen at 2 liters per minute. Review of Resident #1's baseline care plan dated 05/07/25 indicated oxygen therapy at 2 liters per minute. Review of Resident #1's Medication Administration Record (MAR) for 05/2025 indicated Resident #1 received continuous oxygen and the order was set up for all three shifts (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, 11:00 PM-7:00 AM). The MAR was signed off as being done for all three shifts. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 was cognitively intact and did not receive oxygen…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide 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 record reviews, staff, admission Clerk, emergency room (ER) Nurse, ER Physician, and Nurse Practitioner (NP) interviews, the facility failed to implement continuous oxygen as ordered during transport to the ER. This practice affected 1 of 3 residents (Resident #1) reviewed for respiratory care. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease (CAD) and pneumonia. Review of Resident #1's physician orders initiated on [DATE] for continuous oxygen at 2 liters per minute. Review of Resident #1's baseline care plan dated [DATE] indicated oxygen therapy at 2 liters per minute. Review of Resident #1's Medication Administration Record (MAR) for 05/2025 indicated Resident #1 received continuous oxygen and the order was set up for all three shifts (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, 11:00 PM-7:00 AM). The MAR was signed off as being completed for all three shifts. Review of the admission Minimum Data Set assessment dated [DATE] revealed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-20 · tag F0561 — failed to honor residents' choices — pattern
  Honor 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, record review, and staff and family interviews, the facility failed to honor a resident's choice to have a communal dining experience for 1 of 1 resident reviewed for choices (Resident #87). This had the potential to affect all residents who wish to have a communal dining experience. The findings included: Resident #87 was admitted to the facility on [DATE]. A review of Resident #87's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #87 to be severely cognitively impaired. She was coded as requiring supervision with eating. A review of Resident #87's annual Minimum Data Set assessment dated [DATE] revealed it was very important to Resident #87 to do things with groups of people. An interview with Resident #87's Family Member on 11/04/24 at 12:20 PM, revealed approximately 3 months ago the facility abruptly stopped communal dining in the dining room. Resident #87's Family Member stated Resident #87 enjoyed eating and the main dining room with other residents and felt 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-20 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 5 of 8 months reviewed (January 2024, February 2024, May 2024, June 2024, July 2024, August 2024, September 2024, and October 2024). Findings included: Review of the Resident Council Minutes for the period 01/30/24 through 10/29/24 revealed the following: a. The Resident Council meeting minutes dated 01/30/24 noted a concern was voiced that menus were not being provided for them to choose their meals for the following day. It was noted that the Director of Nursing (DON) was made aware of the issues and stated that she had scheduled a meeting with Dietary to discuss the issues. b. The Resident Council meeting minutes dated 02/27/24 revealed the last meeting's minutes were reviewed and residents stated that everything was documented correctly. There was no indication that the facility's efforts (response, action and/or rationale) to address the concern(s) voiced during the 01/30/24 meeting 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-20 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff, the facility failed to follow their infection control policy and procedures regarding Enhanced Barrier Precautions during high-contact care activities for residents with a feeding tube (Resident #126) and wounds (Resident #68 and Resident #49). This failure occurred for 4 of 4 nursing staff observed for infection control practices (Nurse #4, Nurse Aide #1, Nurse Aide #2 and Infection Preventionist). Findings included: Review of the facility's Enhanced Barrier Precautions (EBP) policy and procedures dated 04/01/24 read in part, EBP refer to an infection control intervention designed to reduce transmission of multidrug- resistant organisms (abbreviated as MDRO and refers to a type of bacteria that are resistant to one or more classes of antibiotics) that employs targeted gown and gloves use during high contact resident care activities. High-contact resident care activities include wound care: any skin opening requiring a dressing and device care or…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-20 · tag F0945 — failed to train staff on abuse prevention — pattern
  Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
  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 follow their infection control policy and procedure to ensure: 1) facility staff received infection control training on Enhanced Barrier Precautions (EBP) to know what required EBP and when to implement EBP and/or 2) failed to communicate to facility staff which residents required the use of EBP for 4 of 4 nursing staff reviewed for infection control (Nurse Aide #9, Nurse #1, Nurse #4, and Nurse #5). This practice had the potential to affect all residents. Findings included: Review of the facility's Enhanced Barrier Precautions (EBP) policy and procedures dated 04/01/24 read in part, a) all staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions, b) all staff receive training on high-risk activities and common organisms that require EBP, and c) the facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-20 · tag F0947 — failed to train nurse aides adequately — pattern
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  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 provide required dementia and/or abuse training for 6 of 6 (Nurse Aide #1, #2, #3, #5, #6, and #7) reviewed for training requirements. The findings included: a. Nurse Aide (NA) #1's hire date was 4/4/2013. The education record (November 2023-November 2024) from the Staff Development Coordinator (SDC) revealed NA #1 had no abuse training. b. NA #2's hire date was 10/28/1992. The education record (November 2023-November 2024) from the SDC revealed NA #2 had no documented abuse or dementia training. c. NA #3's hire date was 3/7/2024. The education record (November 2023-November 2024) from the SDC revealed NA #3 had no documented abuse or dementia training. d. NA #5's hire dated was 7/27/2022. The education record (November 2023-November 2024) from the SDC revealed NA #5 had no documented abuse or dementia training. e. NA #6's hire date was 2/29/2024. The education record (November 2023-November 2024) from the SDC revealed NA #6 had no documented abuse or dementia training. f. NA #7's hire date was 5/17/2022. The…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$28,973 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $4,271 — penalty dated 2024-11-20
• $8,400 — penalty dated 2024-11-20
• $8,401 — penalty dated 2024-11-20
• $7,901 — penalty dated 2023-10-25
• Medicare payment denial — starting 2024-12-21 for 13 days

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

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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 $1.5M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC