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Signature Healthcare of Kinston

907 Cunningham Road, Kinston, NC 28501 · For profit - Limited Liability company · 106 certified beds · (252) 527-5146 Medicare & Medicaid certified

Call the home — (252) 527-5146 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Dec 2025
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2503 N Queen St · (252) 523-6000 · Call to confirm hours
Pharmacy
Grocery
2407 N Herritage St · (252) 527-0469 · Call to confirm hours
Park
(919) 807-6500 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.5%15.6%15.4%better
Long-stay residents who lose too much weight9.3%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%2.3%2.0%better
Long-stay residents with depressive symptoms8.6%5.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.7%3.5%3.3%better
Long-stay residents whose ability to walk worsened21.6%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.0%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine94.0%94.1%95.3%typical
Long-stay residents with pressure ulcers9.3%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control13.7%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.2%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine75.9%78.1%79.4%typical
Short-stay residents rehospitalized after admission25.4%22.9%22.6%worse
Short-stay residents with an outpatient ER visit18.1%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.301.781.67worse
Long-stay outpatient ER visits per 1,000 resident days3.841.801.80worse

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.

42.3% 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 160 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.3%U.S. median 51.5%
Got home and stayed home
12.7%U.S. median 10.7%
Went back to hospital
51.1%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 51.1% 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 45 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.3%CMS range 34.1–50.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.7%CMS range 9.5–16.510.7%Oct 2022–Sep 2024no 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 discharge51.1%56.6%Oct 2024–Sep 2025CMS 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 discharge42.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.4%50.0%Oct 2024–Sep 2025CMS 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 identified96.9%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 5.7–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS 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

0.52
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.33
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.44
RN hoursweekends
46.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 93.8 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.22 hrs/resident/day on weekends vs 3.94 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-12-09)
6
at the previous standard inspection (2024-10-17)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

  • Potential for harm · F2025-12-09 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews with staff, the facility failed to provide 1 of 3 meals observed at the regular scheduled times (lunch 12/01/25). The lunch meal was served 2 hours after the posted mealtimes to the dining room and all 5 halls. The findings included: The posted mealtimes documented lunch service in the dining room was to begin at 12:00 PM, the 500 hall at 12:15 PM, the 400 Hall at 12:30 PM, the 300 Hall at 12:45 PM, the 200 Hall at 1:00 PM, and the 100 Hall at 1:15 PM. Observation of the lunch meal service on 12/01/25 revealed the lunch meal trays arrived at 2:15 PM in the dining room, at 2:20 on the 500 Hall, at 2:23 PM on the 400 Hall, at 2:25 PM on the 300 Hall, at 2:32 PM on the 200 Hall, and at 2:40 PM on the 100 Hall. In an interview on 12/01/25 at 2:21 PM, the Regional Dietary Manager (acting as the interim dietary manager) confirmed the lunch trays were still being plated in the kitchen and had not been served to the 300, 200, and 100 Halls. She stated the lunch meal was being served late due to staffing issues in the kitchen. The dishes…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 and interviews with staff, the facility failed to protect a resident's right to be free from verbal abuse by staff for 1 of 5 residents reviewed for abuse (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke). He was discharged from the facility to the community on 9/19/25. Resident #101's annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, had no behaviors or signs of depression, and propelled himself in his wheelchair independently. A facility Investigation Report dated 4/08/25 documented that on 4/05/25 at 1:40 PM, Housekeeper #1 started cursing at him because he wasn't moving his wheelchair down the hallway and had blocked her cart. Housekeeper #1 was witnessed cursing at the resident and was escorted out of the building during the investigation. The facility investigation found two other employees heard the interaction and confirmed Housekeeper #1 did curse…

    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 · D2025-12-09 · 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 record review, observations, and resident, staff and Medical Director interviews, the facility failed to protect a resident's right to be free from misappropriation property and exploitation for 2 of 6 residents (Resident #103 and Resident #4) reviewed for abuse, neglect and/or misappropriation of property/exploitation. (1) In November 2024, Resident #103 reported her debit card account had been depleted to $9.34 after giving Nurse Aide (NA) #3 her debit card to pay her (NA #3's) light bill. The unauthorized spending to Resident #103's debit card totaled $2265.15. (2) In July 2025, NA #2 told Resident #4 she needed money to feed her children and Resident #4 gave NA #2 $65 dollars and was not reimbursed by the facility. Findings included: 1. Resident #103 was admitted to the facility on [DATE] with diagnoses that included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #103 was moderately cognitively impaired. An initial report dated 11/24/2024 alleging…

    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 · D2025-12-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to report allegations of abuse and misappropriation of property/exploitation to Adult Protective Services (APS) for 3 of 6 residents reviewed for abuse, neglect, misappropriation of property and/or exploitation (Resident #103, Resident #101 and Resident #74). Findings included: The facility's Abuse, Neglect and Misappropriation of Property policy statement last reviewed 1/31/2025 indicated the facility Administrator was responsible for reporting all investigation results of abuse, neglect and misappropriation of property to applicable State agencies as required by Federal and State law. 1. Resident #103 was admitted to the facility on [DATE]. An initial report dated 11/24/2024 for misappropriation of property was completed by the former Director of Nursing #1 and faxed to the State Agency. The initial report recorded the facility became aware on 11/24/2024 at 5:00 pm that Resident #108 alleged an employee, Nurse Aide (NA) #3 had borrowed money from…

    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 · D2025-12-09 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for a resident who was admitted to the facility with serious mental health diagnoses for 1 of 1 resident reviewed for PASRR (Resident #18).Findings included:A PASRR Level 1 Determination Notification Letter dated 8/11/25 indicated Resident #18 had a Level I PASRR with no expiration date and no mental or behavioral health restrictions. The hospital's Discharge summary dated [DATE] included bipolar disorder as a secondary diagnosis for Resident #18 and recorded Resident #18's psychiatric history consisted of bipolar disorder, post-traumatic stress disorder (PTSD) and depression that included significant anxiety and trauma history.Resident #18 was admitted to the facility on [DATE] with diagnoses including a bipolar disorder, an anxiety disorder, depression, PTSD and tremors.Physician progress notes dated 8/27/25 recorded Resident #18 had an history…

    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 · D2025-12-09 · 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 observations, record review, and staff and Medical Director interview, the (a) facility failed to ensure that required emergency tracheostomy (trach) equipment, including an Ambu bag (self-inflating bag that pushes air into lungs), was kept at the bedside as ordered and as required by facility policy and (b) failed to ensure infection-control practices were followed during tracheostomy care for 1 of 2 residents reviewed for tracheostomy care (Resident #8).Findings included:(a) A review of the facility's Tracheostomy Policy revealed that, for emergency management, an emergency tracheostomy tube and an Ambu bag were required to be kept at the resident's bedside.A review of standing admission orders included maintain trach equipment at the bedside at all times, including the obturator (An obturator is a curved rod that fits inside the tracheal cannula, which is a tube inserted into the trachea during tracheostomy), a spare trach tube, and an Ambu bag.On 10/13/2025 Resident #8 was admitted with diagnoses…

    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 · D2025-12-09 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews with staff, the facility failed to follow the approved menu for 1 of 7 residents on a pureed diet (Residents #80). The findings included: The Week 2 dietitian approved menu indicated residents on a pureed diet were to receive pureed cornbread. Resident #80 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing). Resident #80's physician orders dated [DATE] documented he was to receive a pureed diet. During an observation of tray line on [DATE] at 12:07 PM, [NAME] #1 plated Resident #80's meal which included pureed chicken, pureed broccoli, and pureed candied yams. There was no pureed cornbread or pureed bread product available to serve and none was observed on his tray. Resident #80's tray was then covered and put into the dining room cart for service. In an interview on [DATE] at 12:08 PM, [NAME] #1 stated she forgot to make a pureed bread item to serve. In an interview on [DATE] at 12:09 PM, the Corporate Dietary…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-17 · tag F0641 — pattern
    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, observations, resident Interview and staff interviews, the facility failed to accurately code the Minimum data Set (MDS) assessment in the areas of medications, smoking, elimination and behaviors for 4 of 28 residents whose MDS assessments were reviewed (Resident #14, #17, #13, and #33). Findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus. There was a physician order for the following hypoglycemic medications on Resident #14's electronic medical record (EMR): * On 11/23/2023, Novolin Regular flex pen insulin 100 units per milliliter, give 11 units subcutaneous three times a day * On 11/23/2023, Novolin Regular flex pen insulin 100 units per milliliter per sliding scale before meals and at bedtime. * For blood glucose reading 200-250, give 3 units subcutaneous. * For blood glucose reading 251 -300, give 5 units subcutaneous. * For blood glucose reading 301-350, give 7 units subcutaneous. * For blood glucose reading 351-400,…

    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 · D2024-10-17 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident interview and staff interviews, the facility failed to assess the ability of a resident to self-administer medications prior to leaving the resident's medications on the overbed table in the resident's room for 1 of 1 resident reviewed for pharmacy services (Resident #18). Resident #18 indicated she could not take a lot of medications together at one time and the medications were left on her overbed table to take when she wanted to. Findings included: Resident #18 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact. Physician orders included the following medication orders for Resident #18 that were active on 10/14/24: - Acetaminophen 325 milligram (mg) tablets give two tablets for pain or fever every six hours as needed. - Augmentin 875-125 mg tablet give twice a day ending 10/15/2024. - Ciprofloxacin HCL 500 mg tablet give one tablet twice daily for seven days. There 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 · D2024-10-17 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (form 10123) and the and failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for 1 of 3 residents reviewed for beneficiary protection notification review (Resident #75). The findings included: Resident #75 was admitted to the facility on [DATE] with Medicare Part A skilled services. Resident #75's admission Minimum Data Set assessment dated [DATE] revealed she had moderate cognitive impairment. Resident #75's Medicare Part A skilled services ended on 4/12/24 and her Medicare Part A Skilled Nursing Facility benefit was not exhausted. She remained in the facility. Record review revealed no evidence that Resident #75 or the resident's responsible party were provided the NOMNC notice or the ABN. During an interview with the Business Office Manager on 10/16/24 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-10-17 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 review and resident and staff interviews the facility failed to refer a resident with a new diagnosis of mental illness for a Preadmission Screening and Resident Review (PASARR) evaluation for 1 of 1 resident reviewed for PASARR (Resident #33). Findings included: Resident #33 was admitted to the facility on [DATE] with diagnosis that included adjustment disorder. A physician progress note revealed Resident #33 was newly diagnosed with post-traumatic stress disorder on 6/27/24. Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she was cognitively intact. She was not coded as being screened for a PASARR evaluation. A review of Resident #33's care plan last reviewed 7/29/24 revealed she was care planned for behaviors such as nervousness, fears, and a general feeling of uneasiness related to history of a traumatic event. The interventions included encouraging the resident to voice fears and referral to a physician. During an interview with Resident #33 on 10/16/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to complete an accurate medical record in documenting the administration of medication for 1 of 29 residents whose medical records were reviewed (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease. Physician orders dated 2/14/2024 included Acetaminophen 325 milligram (mg) tablets give two tablets for pain or fever every six hours as needed for Resident #18. On 10/14/2024 at 10:52 am, Nurse #1 was observed administering Resident #18 Acetaminophen 650 mg in applesauce to Resident #18. There was no record of Resident #18 receiving Acetaminophen 650 mg on 10/14/2024 on Resident #18's October 2024 Medication Administration Record (MAR). There was no nursing documentation in Resident #18's medical record that Acetaminophen 650 mg was administered by Nurse #1 on 10/14/2024. On 10/17/2024 at 10:15 am in a phone interview with Nurse #1, he stated pain…

    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 · E2023-07-13 · tag F0607 — failed to have anti-abuse policies — pattern
    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 review, resident interviews and staff interviews, the facility failed to implement their abuse policy and procedure in the following areas: administration reporting allegations of abuse within two hours to the state agency from the time of notification of the alleged abuse incident (Resident #76 and Resident #40) and completing a thorough investigation that included assessments of all residents for abuse and statements from all residents and involved staff for an allegation of abuse (Resident #40, Resident #7, and Resident #15) for 4 of 7 residents reviewed for abuse. Findings included: The facility's Abuse, Neglect and Misappropriation of Property policy dated 10/17/2022 stated any abuse allegation must be reported to state within 2 hours from the time the allegation was received, and any reasonable suspicion of a crime plus serious bodily injury must be reported to the state and police. The investigation guidelines stated the facility's administrator will investigate all allegations, reports,…

    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 · E2023-07-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 and staff interviews, the facility failed to maintain a medication storage refrigerator within the recommended temperature range and failed to discard outdated ophthalmic solution bottles for 2 of 3 medication storage areas reviewed (#1 Medication Room and Medication Cart #2). Findings included: 1. An observation of the medication storage refrigerator located in the #1 Medication Room was made on 7/11/23 at 3:00 PM with Nurse #1. The refrigerator thermometer was observed at 32 degrees Fahrenheit (°F). Nurse #1 viewed the refrigerator thermometer and indicated it appeared to read between 32°F and 34 °F. The July 2023 temperature monitoring log for the medication storage refrigerator had been noted daily. Temperatures recorded included: 7/4/23 was 34 °F, 7/5/23 was 32 °F, 7/6/23 was 32 °F, 7/8/23 was 34 °F, 7/9/23 was 34 °F, and 7/10/23 was 30 °F. The instructions on the monitoring log indicated Temperature of refrigerator must be between 36-41 degree F, Freezer must be at or below freezing, If not contact maintenance immediately! Only maintenance…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · 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, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 1 resident whose MDS was reviewed for the use of restraints (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE], and diagnoses included dementia and use of gastrostomy tube. Nursing documentation dated 7/24/2022 recorded Resident #61's representative provided consent for the use of an abdominal binder and was educated on the use of restraints and side effects from the use of the abdominal binder. Physician orders dated 12/1/2022 included an enteral feeding at 60 milliliters an hour from 6 p.m. to 6 a.m. twice a day, and phsyican orders dated 3/23/2023 included abdominal binder release and assess skin every two hours. If any change of condition, notify physician. Surgical progress notes for percutaneous endoscopic gastrostomy (PEG) placement date 3/21/2023 due to self-removal of gastrostomy tube stated it was essential that 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to follow a physician's order to call the physician for a blood glucose reading greater than 550 for two incidents of a high blood glucose reading on 6/25/2023 and to obtain physician orders to administration insulin coverage for the high glucose readings for 1 of 2 residents reviewed for the use of insulin. (Resident #82) Findings included: Resident #82 was admitted to the facility on [DATE], and diagnoses included Diabetes Mellitus. There was a physician order dated 6/20/2023 to check Resident #82's blood glucose four times a day before meals and at bedtime and to administer Tresiba 100 units per milliliter (mL) 6 units once a day at night. On 6/21/2023, Humalog sliding scale insulin 100 units per milliliter was ordered as the following: * Blood glucose reading less than 60; call the physician. * Blood glucose reading between 200-250; give 3 units Humalog insulin. * Blood glucose reading between 251-300; give 5units Humalog insulin. * Blood…

    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 · D2023-07-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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 expired chocolate milk cartons from the walk-in refrigerator. On 7/10/2023, expired chocolate milk cartons dated 7/9/2023 were observed on 2 of 2 resident's breakfast meal trays (Resident #56 and Resident #22) when breakfast meal trays were returned to the kitchen. This practice had the potential to cause food borne illness. Findings included: On 7/10/2023 at 9:52 a.m. during an observation of the walk-in refrigerator in the kitchen with the Dietary Manager and Regional Dietary Manager, six chocolate milk cartons with an expiration date of 7/9/2023 were observed in the milk crate in the walk-in refrigerator. The Dietary Manager and Regional Dietary Manager were observed discarding the six cartons of expired chocolate milk into the trash. On 7/10/2023 at 9:52 a.m., the Regional Dietary Manager stated she was watched the breakfast serving line the morning of 7/10/2023, and none of the residents received chocolate milk at breakfast. The Dietary Manager stated the expiration date on the chocolate milk cartons 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set 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 record review and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation survey of 5/24/22. The deficiency is in the area of food procurement, storage and preparation (F812). The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F812: Based on observations and staff interviews, the facility failed to discard expired chocolate milk cartons from the walk-in refrigerator. On 7/10/2023, expired chocolate milk cartons dated 7/9/2023 were observed on 2 of 2 resident's breakfast meal trays (Resident #56 and Resident #22) when breakfast meal trays were returned to the kitchen. This practice had the potential to cause food borne illness. During the recertification and complaint investigation survey of 5/24/22 the facility was cited at F812 for failing 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-12-09 · tag F0641 — pattern
    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 the physician's documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for 1 of 31 residents reviewed for MDS assessment accuracy (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE].A review of the psychiatric provider note dated 9/5/25 revealed an attempted dosage reduction to the psychotropic regiment was likely to impair the resident's function and exacerbate underlying psychiatric condition. confirmed she had completed that section of the MDS for the 9/17/25 assessment.The annual MDS dated [DATE] for Resident #4 indicated a GDR had not been documented by the physician as clinically contraindicated.An interview was conducted with MDS Nurse #1 on 12/5/25 at 10:55 AM who confirmed she had completed the Medication section of the MDS for Resident #4's 9/17/25 assessment. She stated the physician documented GDR as clinically contraindicated…

    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 · No revisit needed
  • No harm found · B2024-10-17 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    Based on observation, resident and staff interviews, the facility failed to provide maintenance to the bathroom door and keep the grout on the floor at the base of the bathroom doorway clean from buildup of debris for 1 of 2 resident rooms (Resident #63's room) reviewed for environment. The findings included: a. Observation of Resident #63's room on 10/14/24 at 10:40 AM revealed the surface of the bathroom door approximately three quarters from the top of the doorframe, and as well as the sides of the doorway were scuffed. A large area, approximately 3 inches in height, and across the length of the bathroom door revealed peeling paint which exposed what appeared to be a wood-like color underneath. b. Observation of Resident #63's room on 10/14/24 at 10:40 AM revealed the bathroom doorway had what appeared to be a buildup of debris, black in color, on the grout in the right and left spaces at the base of the bathroom doorway. An interview was conducted on 10/14/24 at 10:40 AM and on 10/15/24 at 8:59 AM with Resident #63. During both interviews Resident #63 expressed how unhappy 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.

    Resident Rights Deficiencies · Deficient, Provider has plan 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SIGNATURE HEALTHCARE — 67 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 →

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 2 of 52.8-0.8 vs chain
Quality measures 2 of 53.9-1.9 vs chain
The other 66 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Danville Centre for Health & RehabilitationDanville, KY 1 of 5Liberty Care & Rehabilitation CenterLiberty, KY 1 of 5Mayfair ManorLexington, KY 1 of 5Signature Health Of Portland Rehab & Wellness CentPortland, TN 1 of 5Signature Healthcare Of BremenBremen, IN 1 of 5Signature Healthcare Of ErinErin, TN 1 of 5Signature Healthcare Of MuncieMuncie, IN 1 of 5Signature Healthcare Of Putnam CountyCookeville, TN 1 of 5Signature Healthcare Of Terre HauteTerre Haute, IN 1 of 5Signature Healthcare at Colonial Rehab & WellnessBardstown, KY 1 of 5Signature Healthcare at Heritage Hall Rehab & WellLawrenceburg, KY 1 of 5Sunrise Manor Nursing HomeHodgenville, KY 2 of 5Fountain Circle Care & Rehabilitation CenterWinchester, KY 2 of 5Oakview Nursing & Rehabilitation CenterCalvert City, KY 2 of 5Rockcastle Health & Rehabilitation CenterBrodhead, KY 2 of 5Signature Healthcare Of ClarksvilleClarksville, TN 2 of 5Signature Healthcare Of Fentress CountyJamestown, TN 2 of 5Signature Healthcare at North Hardin Rehab & WellnRadcliff, KY 2 of 5Signature Healthcare at Summerfield Rehab & WellneLouisville, KY 2 of 5Signature Healthcare of East LouisvilleLouisville, KY 2 of 5Signature Healthcare of ElizabethtownElizabethtown, KY 2 of 5Signature Healthcare of GeorgetownGeorgetown, KY 2 of 5Signature Healthcare of McCreary County Rehab andPine Knot, KY 2 of 5Signature Healthcare of Roanoke RapidsRoanoke Rapids, NC 2 of 5Signature Healthcare of Spencer CountyTaylorsville, KY 3 of 5Harrodsburg Health & Rehabilitation CenterHarrodsburg, KY 3 of 5Lee County Care & Rehabilitation CenterBeattyville, KY 3 of 5Morgantown Care & Rehabilitation CenterMorgantown, KY 3 of 5Pickett Care And Rehabilitation CenterByrdstown, TN 3 of 5Signature Healthcare Of ClevelandCleveland, TN 3 of 5Signature Healthcare Of Monteagle Rehab & WellnessMonteagle, TN 3 of 5Signature Healthcare Of NorfolkNorfolk, VA 3 of 5Signature Healthcare Of Ridgely Rehab&wellness CtrRidgely, TN 3 of 5Signature Healthcare Of South Pittsburg Rehab & WeSouth Pittsburg, TN 3 of 5Signature Healthcare at HillcrestOwensboro, KY 3 of 5Signature Healthcare at Jackson Manor Rehab and WeAnnville, KY 3 of 5Signature Healthcare of Chapel HillChapel Hill, NC 3 of 5Spring City Care And Rehabilitation CenterSpring City, TN 3 of 5Westmoreland Care & Rehab CtrWestmoreland, TN 4 of 5Bluegrass Care & Rehabilitation CenterLexington, KY

Showing 40 of 66; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
SHC LP HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2014
ASBR HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2018
JJLA LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2014
LPSNF LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2014
WHEATEN LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2014
STEIER III, ELMERIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2014
JONES, STEVENIndividualW-2 MANAGING EMPLOYEEsince 09/19/2023
HARRISON, JOHNIndividualCORPORATE OFFICERsince 08/01/2014
SIGNATURE HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 08/01/2014

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.0M
Net patient revenuemost recent cost report
-11.8%
Operating marginrevenue minus expenses
$1.3M
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 12%Other / private 17%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$373per resident / day
operating cost
$11,349per month
≈ monthly operating cost
$334per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

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 345365. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-09, 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.

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