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Wellington Rehabilitation and Healthcare

1000 Tandal Place, Knightdale, NC 27545 · For profit - Corporation · 80 certified beds · (919) 266-7744 Medicare & Medicaid certified

Call the home — (919) 266-7744 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Sep 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$15,642 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,642 in federal fines (most recent 2024-09-04)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Urgent care / clinic
Wellud0.6 mi
903 N Smithfield Rd · (919) 217-2924 · Call to confirm hours
Pharmacy
502 Mcknight Dr Ste 100 · (919) 229-8115 · Call to confirm hours
Grocery
107 S 1st Ave · (919) 295-1465 · Call to confirm hours
Park
209 Main St · (919) 217-2230 · 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 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 increased17.6%15.6%15.4%worse
Long-stay residents who lose too much weight5.4%7.2%5.4%typical
Long-stay residents with a catheter left in their bladder1.7%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.3%2.3%2.0%worse
Long-stay residents with depressive symptoms18.1%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 injury2.3%3.5%3.3%better
Long-stay residents on antianxiety or hypnotic medication6.3%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine87.5%94.1%95.3%typical
Long-stay residents with pressure ulcers5.8%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control23.1%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.5%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.4%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine54.6%78.1%79.4%worse
Short-stay residents rehospitalized after admission24.4%22.9%22.6%typical
Short-stay residents with an outpatient ER visit17.4%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.601.781.67typical
Long-stay outpatient ER visits per 1,000 resident days1.741.801.80typical

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.

50.9% 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 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.9%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
44.4%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 44.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.9%CMS range 39.6–63.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.8–14.110.7%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 discharge44.4%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 discharge51.9%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 identified94.5%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 stay0.0%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 worsened3.6%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 hospitalization7.3%CMS range 3.8–12.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 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

0.26
RN hours/ resident / day
1.12
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.06
RN hoursweekends
46.2%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 77.2 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.99 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.33 to 0.06 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

10
deficiencies at the latest standard inspection (2025-11-18)
7
at the previous standard inspection (2024-09-04)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2024-09-04 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Responsible Party (RP) and Physician interviews the facility failed to administer seizure medication to Resident #19 on 10/2/23 after he returned to the facility from the hospital, resulting in 4 missed doses of seizure medication. Resident #19 did not receive Keppra (an anti-seizure medication) beginning on 10/2/23 when he returned to the facility from the hospital through 10/4/23. On 10/4/23 Resident #19 suffered seizures in the facility, requiring readmission to the hospital. On 10/4/23 Resident #19 suffered a tonic/clonic seizure (loss of consciousness and violent muscle contractions which can be dangerous and potentially life threatening) lasting about 1 minute in the hospital which required the administration of intravenous (IV) Keppra. This was for 1 of 5 residents (Resident #19) whose medication administration was reviewed. Findings included: Resident #19 was admitted to the facility on [DATE] with a diagnosis of stroke (blockage of blood supply to the brain). A review…

    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 · Past Non-Compliance
  • Potential for harm · D2025-11-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observation, and resident and staff interviews, the facility failed to place a resident's call light device within reach to allow for the resident to request assistance as needed for 1 of 1 dependent resident reviewed for accommodation of needs (Resident #13). Findings included: Resident #13 was readmitted to the facility on [DATE] with diagnoses of multiple sclerosis (a chronic autoimmune disease affecting the central nervous system that leads to disruption of nerve signals traveling to the muscles of the body), and post-polio syndrome (a condition that can develop in people who previously had polio leading to a gradual decline in muscle function). Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was dependent on staff for all activities of daily living (ADL). Review of Resident #13's care plan last revised on 8/5/25 revealed a focus of the resident being at risk for falls with interventions including to be…

    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 · Dcited before2025-11-18 · 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 the Minimum Data Set (MDS) assessment in the area of Pre-admission Screening and Resident Review (PASARR) status, medication, and falls for 3 of 22 resident MDS assessments reviewed (Resident #43, Resident #4, Resident #53).Findings included: 1. Resident #43 was admitted to the facility on [DATE]. Her active diagnoses included cerebral infarction. Review of Resident #43's PASARR Level II Determination Notification letter dated [DATE] revealed an expiration date of [DATE]. Review of Resident #43's admission MDS assessment dated [DATE] revealed she was coded as not currently considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on [DATE] at 1:36 PM the Social Worker stated on [DATE] Resident #43 had a Level II PASARR determination which expired on [DATE]. She was reassessed and currently had a Level II PASARR determination with no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · 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 obtain further approval and screening through a Level II evaluation process in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Determination Notification. This was for 1 of 2 residents (Resident #53) reviewed for PASRR.Findings included:Resident #53's Pre-admission Screening Resident Review (PASRR) Level II Determination Notice dated [DATE] revealed Nursing Facility Placement was appropriate for a limited nursing facility stay, lasting no more than thirty (30) calendar days. The PASRR expiration date was [DATE].Resident #53 was admitted to the facility on [DATE] with a diagnosis bipolar affective disorder (a chronic mental health condition characterized by extreme mood swings).Resident #53's current comprehensive care plan revealed a focus area dated as initiated on [DATE] for Level II PASRR. The goal was for Resident #53 to show no change in mental status through the next review. An intervention 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 Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-11-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that included Pre-admission Screening Resident Review (PASRR) Level II (Resident #53 and Resident #43) and hospice (Resident #8) for 3 of 20 comprehensive care plans reviewed.Findings included: 1. Resident #53's Pre-admission Screening Resident Review (PASRR) Level II Determination Notice dated 9/17/24 revealed in part her Level II screening determined Nursing Facility Placement was appropriate. Resident #53 was admitted to the facility on [DATE] with a diagnosis of progressive neurological (nervous system) condition. Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #53's current comprehensive care plan revealed her Level II PASRR status was not reflected in her care plan until a focus area was initiated by 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 · D2025-11-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to revise the comprehensive care plan to accurately reflect the code status (Resident #12), a pressure ulcer (Resident #13) and the discontinuation of bed rails (Resident #7). This was for 3 of 20 comprehensive care plans reviewed. 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease dependent on hemodialysis. Review of Resident #12's medical record revealed an advance directive physician's order dated [DATE] indicating he was a full code, meaning he wished to have cardiopulmonary resuscitation (CPR) performed should his heart stop. Review of a hard copy of Resident #12's advance directive kept in a book at the nurses' station indicated Resident #12 was made a full code on [DATE]. Review of Resident #12's care plan, last revised [DATE] revealed his code status as being Do Not Resuscitate (DNR), meaning he would not want CPR performed should his heart stop. Review of Resident #12's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · 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 observations, record review, and resident, staff, and Nurse Practitioner (NP) interviews the facility failed to remove a topical pain patch in accordance with the physician's order. This was for 1 of 2 residents (Resident #82) reviewed for professional standards.Findings included:Resident #82 was admitted to the facility on [DATE] with a diagnosis of pain.The nursing admission Data Collection form for Resident #82 dated 9/24/25 at 6:02 PM completed by Nurse #10 revealed Resident #82 was alert and oriented times 4 (to person, place, time and situation).A physician's order for Resident #82 dated 9/26/25 revealed lidocaine (topical pain medication) patch 4 percent (%) apply to shoulders and chest topically one time a day for pain apply 3 patches - one on each shoulder and chest and remove per schedule. There was no physician's order for Resident #82 to self-administer medications.On 9/29/25 at 11:10 AM an observation was conducted in conjunction with an interview with Resident #82. During the observation,…

    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 · D2025-11-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility applied a resting hand splint (a brace used to keep the hand, wrist, and fingers in a neutral position preventing stiffness and contractures) without a physician's order, therapy instructions or in accordance with a splint wearing schedule. This deficient practice was for 1 of 3 residents reviewed for position and mobility (Resident #38).Findings included:Resident #38 was admitted to the facility on [DATE] with a diagnosis of right-hand contracture.Resident #38's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She had functional limitation of range of motion on both sides of her upper and lower extremities. She received 2 days of occupational therapy beginning on 9/9/25. She was not in a restorative nursing program. Resident #38 did not receive splint or brace assistance.Resident #38's medical record did not reveal a physician's order for a resting hand splint.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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · 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 observation, record review and staff interviews the facility failed to follow professional standards of practice and infection prevention measures when Unit Manager #2 (UM #2) failed to remove soiled gloves, perform hand hygiene and don clean gloves during tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) through the front of the neck to create an artificial airway and assist with breathing) care for 1 of 1 residents reviewed for tracheostomy care (Resident #17). Findings included: Resident #17 was admitted to the facility on [DATE] with a diagnosis of quadriplegia and tracheostomy status. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #17 was coded in the MDS as receiving tracheostomy care in the facility. Resident #17's care plan with a revision date of 6/22/25 revealed him to have a tracheostomy. A continuous observation of tracheostomy care was conducted on 10/2/25 starting at 8:14 AM. Unit…

    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 · D2025-11-18 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and resident interviews, the facility failed to attempt alternatives prior to installing side rails, complete a siderail assessment, assess entrapment risk, review the risks and benefits of side rails with the resident and obtain informed consent, complete a care plan for side rail usage and obtain a physician's order prior to siderail use for 1 of 3 residents (Resident #57) reviewed for side rails.Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic, progressive neurological disorder that affects movement and other bodily functions). Review of Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was cognitively intact, did not have side rails as a restraint and was independent with bed mobility. Review of Resident #57's care plan last revised 9/8/25 revealed no care plan indicating the use of bilateral quarter length side rails. Review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · 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 observation, record review and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when the business office manager failed to perform hand hygiene while passing a meal tray. This was for 1 of 8 staff members observed for hand hygiene practices (Business Office Manager). Findings included: A review of the facility policy titled Hand Hygiene with a review date of 2/5/21 stated in part: Hand hygiene should be performed after contact with inanimate objects (including medical equipment) in the immediate patient vicinity, and, before initiating a clean procedure. The policy definition of hand hygiene stated: cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel). An observation was started on 9/29/25 at 11:51 AM. The facility Business Office Manager was observed entering a resident's room to deliver the resident's lunch tray. The Business Office Manager set the tray on the resident's overbed tray table next to a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-09-04 · 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 record review, observations, staff and responsible party (RP) interviews the facility failed to identify bolsters as a restraint, failed to assess the bolsters as a restraint, and utilized them without medical justification and without a physician order. This was for 1 of 1 resident (Resident #48)reviewed for restraints. Findings included: Resident #48 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and blindness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired, was totally dependent on staff for all activities of daily living and did not have restraints in place. A review of Resident #48's assessments revealed there was no restraint assessment completed. An observation of Resident #48 was conducted on 8/26/24 at 3:37 PM. She was lying in bed on her back with her knees pulled up to her chest. The resident was nonverbal. Two bolster pillows were observed, one on either side of her under the fitted sheet.…

    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 · D2024-09-04 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident (Resident #78) reviewed for death and failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who discharged from hospice services for 1 of 1 resident (Resident #48) reviewed for accidents. Findings included: 1. Resident #76 was admitted to the facility on [DATE]. Her active diagnoses included chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's disease. Review of Resident #76's hospice election form dated 5/29/24 revealed she was admitted to hospice on 5/29/24. Review of Resident #76's electronic health record revealed no significant change in status MDS assessment had been completed for Resident #76 following hospice election. During an interview on 8/27/24 at 2:17 PM the Director of MDS Education stated a significant change in status MDS assessment was required…

    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 before2024-09-04 · 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 the Minimum Data Set (MDS) assessment in the area of medications for 1 of 5 residents (Resident #64) reviewed for unnecessary medications. Findings included: Resident #64 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She was taking antianxiety medication and an indication was noted. A review of Resident #64's physician orders revealed an order dated 3/25/24 for clonazepam (an antianxiety medication) 0.5 milligrams give one tablet by mouth every 8 hours as needed for anxiety for 5 days. There were no other physician's orders for antianxiety medication for Resident #64 from 3/19/24 through 3/30/24. A review of Resident #64's March 2024 Medication Administration Record (MAR) revealed no documentation clonazepam 0.5 milligrams was administered to her. It further revealed no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to keep dependent resident's fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #4). Findings included: Resident #4 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, and other lack of coordination. Review of Resident #4's Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He was assessed to have no rejection of care and required substantial/maximal assistance with bathing and setup or clean up assistance with personal hygiene. Review of Resident #4's care plan dated 8/27/24 revealed he was care planned for an Activities of Daily Living self-care performance deficit related to impaired mobility. The interventions included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During observation on 8/26/24 at 2:29 PM Resident #4's fingernails were observed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · tag F0761 — failed to label and store drugs safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended medication cart (Rooms 143-150 hall) for 1 of 5 medication carts. Findings included: A continuous observation was conducted of the medication cart on 8/27/24 from 8:35 AM to 8:47 AM. The cart was parked between rooms [ROOM NUMBERS], facing out into the hallway. The cart was visible from the nurse's station but there were no staff there. There were two Nurse Aides passing breakfast trays on the hall. No residents were observed near the medication cart. The medication cart was observed to have the red dot on the push lock visible, which meant the push lock was not engaged. There was no staff member with the medication cart. Medication Aide #1 came out of resident room [ROOM NUMBER] which was at the end of the hall on the opposite side. She returned to the medication cart at 8:47 AM. Medication Aide #1 opened the top drawer without having to unlock the cart. During an interview with Medication Aide…

    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 before2024-09-04 · 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 observation, record review and staff interviews, the facility failed to implement their hand hygiene policy when the Respiratory Therapist (RT) failed to perform hand hygiene after touching a contaminated surface and before touching the tracheostomy and failed to implement their policy for enhanced barrier precautions when the RT failed to wear a gown while performing tracheostomy care for 1 of 1 resident (Resident #53) reviewed for tracheostomy care, and failed to perform hand hygiene between the removal of soiled gloves and the application of clean gloves for 1 of 2 residents (Resident #71) reviewed for pressure ulcers. Findings included: 1. A review of the facility policy titled Handwashing/Hand hygiene dated August 2019 provided by the facility stated in part: This facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. before or after handling an invasive device (e.g.…

    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 · E2024-01-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interviews, and staff interviews, the facility failed to ensure repairs for cracks, holes, a water damaged wall, broken blinds, and discolored flooring were completed for two (Residents # 6 and # 7) of two residents reviewed for environmental concerns and for two random rooms. The findings included. 1a. Resident # 7 was admitted to the facility on [DATE]. The resident's 1/3/24 quarterly MDS (Minimum Data Set) assessment coded the resident as having moderate cognitive impairment. According to Resident # 7's record, she had resided in the same room since 8/8/23. Resident # 7's room was observed on 1/22/24 at 10:35 AM and the following observations were made. The resident's AC/Heating unit was one which was installed through the wall. Around the unit, a large part of the wall was filled with plaster which had not been smoothed off or painted. Two slats were broken on her blinds. Resident # 7 stated the wall and blinds had been like that since she had moved into 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 · E2024-01-26 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interviews the facility failed to obtain medications from the pharmacy for administration. This was for two (Residents # 1 and # 5) of two residents whose medications were reviewed. The findings included: 1. Resident # 1 resided at the facility from [DATE] to [DATE]. The resident had diagnoses which included chronic obstructive pulmonary disease, hypertension, anxiety, coronary artery disease, and a history of coronary artery bypass surgery. Prior to residing at the facility, Resident # 1 had been hospitalized from [DATE] to [DATE] and treated for RSV (Respiratory Syncytial Virus) bronchitis. Resident # 1's care plan, dated [DATE], noted Resident # 1 contracted COVID on [DATE]. On [DATE] Resident # 1 was ordered to receive Molnupiravir 200 mg (milligrams) four capsules two times per day. (Molnupiravir is a an antiviral medication used to treat COVID.) Review of Resident # 1's [DATE] MAR (Medication Administration Record) revealed the medication was scheduled…

    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 · D2024-01-26 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    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 family, staff, physician assistant, independent apartment manager, staff from the Program of All-Inclusive Care for the Elderly (PACE), and contracted van driver for the PACE program, the facility failed to implement an effective discharge planning process that ensured care was coordinated with the resident's primary physician through PACE. On the day of discharge Resident #1 had a change in condition and the PACE physician was not made aware of the change prior to discharge. The PACE program is a community program that helps provide and coordinate medical care and basic care services for older adults. This was for one (Resident # 1) of three residents reviewed for discharge planning. The findings included: The hospital Discharge summary dated [DATE] indicated Resident # 1 had been hospitalized from [DATE] to 12/28/23 and treated for RSV (Respiratory Syncytial Virus) bronchitis. Resident # 1 was admitted to the facility on [DATE] with diagnoses which included chronic…

    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 before2024-01-26 · 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 observation, record review and staff, and contracted respiratory therapist interviews the facility failed to ensure 1) individualized care for Resident # 10's tracheostomy was clarified regarding routine frequency of care and type of inner cannula he needed 2) supplies were available to exchange his disposable inner cannula and 3) clarification regarding when the resident's external cannula exchange should be completed. This was for one of two sampled residents with a tracheostomy (Resident # 10). The findings included: Resident # 10's specialty hospital Discharge summary dated [DATE] indicated Resident # 10 had made slow progress. The discharge summary noted Resident # 10 had a tracheostomy and was tolerating a PMV (Passy-Muir Speaking Valve. A PMV allows a tracheostomy resident to speak). It also directed that tracheostomy capping (when the airflow is blocked from flowing through the tracheostomy cannula and is at times done as a person progresses to possibly no longer needing the tracheostomy) was no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility laboratory employee interview the facility failed to ensure a urine specimen was received by the facility's lab in a timeframe which the lab considered acceptable to run the specimen for results. This was for one (Resident # 10) of one sampled resident whose lab results were reviewed. The findings included: Record review revealed Resident # 10 was admitted to the facility on [DATE]. Resident # 10's diagnoses in part included stroke, gastrostomy placement, and tracheostomy placement. Review of Resident # 10's lab report results revealed a urine analysis and a urine culture specimen were collected on 1/10/24. There was no order entered in Resident # 10's electronic medical record for the lab to be done. The lab report included documentation that the lab received the specimen six days after it was collected. Specifically, the report lab noted the received date was 1/16/24 and that the results were reported on 1/18/24. The urinalysis results showed the urine 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-12 · tag F0836 — widespread
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and 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, and staff interview the facility failed to ensure a nurse's license was verified for 1 of 5 nurses reviewed for licenses. (Nurese # 1) The findings included: Nurse #1 was hired on [DATE] as a Registered Nurse (RN) and terminated on [DATE]. A review of an RN license with the North Carolina Board of Nursing (NCBON) dated [DATE] revealed license number of an RN with the same name as Nurse #1 was issued on [DATE]. Nurse #1 would have been 5 years old at the time of issue. A review of the NCBON license verification with the same name as Nurse #1 revealed an RN permanent license with approval date of [DATE] and expiration date of [DATE] that was active. A review of the NCBON license verification with Nurse #1 revealed an expired Licensed Practical Nurse (LPN) permanent licensed that was expired. An RN license was not found for Nurse #1. An interview with the Administrator was conducted on [DATE] at 12:03 PM. The Administrator stated he was not working with the facility in November of 2022. All…

    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
  • Potential for harm · E2023-07-12 · tag F0745 — failed to provide medically-related social services — pattern
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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, Physician interview and staff interviews the facility failed to arrange transportation for an outside appointment to avoid missing medical appointment for 1 of 2 residents reviewed for medically related social services (Resident #38). Findings included: Resident # 38 was admitted on [DATE] with diagnoses that included peri-urethra abscess, cystitis and nephrolithiasis(Kidney stone). A review of Resident #38's physician orders revealed on 10/26/2022 an order written by the Physician Assistant (PA) to schedule a follow-up appointment with urology regarding a ureteral stent. A facility Physician progress note dated 3/29/2023 revealed the facility's Physician Assistant had called the urology department at the hospital on 3/29/2023 and per the Urology Medical Assistant at the hospital, Resident #38's stent had been removed by facility nursing staff via the string on 11/18/2022. Resident #38 was to see the Urology Physician in January of 2023 for a follow-up of a kidney, ureter and bladder…

    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

“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

$15,642 in federal fines across 1 penalty.

  • $15,642 — penalty dated 2024-09-04

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

Part of a chain

This home belongs to AVARDIS HEALTH — 38 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 1 of 52.0-1.0 vs chain
Health inspection 2 of 51.9+0.1 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 2 of 53.2-1.2 vs chain
The other 37 homes this chain runs (chain average 2.0★, per CMS)
1 of 5Ashland Nursing And RehabilitationAshland, VA 1 of 5Augusta Nursing and RehabilitationFishersville, VA 1 of 5Biltmore Haven Nursing and RehabilitationArden, NC 1 of 5Courtyard Health And RehabilitationMcComb, MS 1 of 5Emerald Ridge Health and RehabilitationAsheville, NC 1 of 5Ghent Health and RehabilitationNorfolk, VA 1 of 5Grand Trace Health And RehabilitationNatchez, MS 1 of 5Hibriten Mountain Nursing and RehabilitationLenoir, NC 1 of 5Highfield Nursing and RehabilitationCary, NC 1 of 5Kings Daughters Community Health & RehabStaunton, VA 1 of 5Middleton Oaks Health And RehabilitationWinona, MS 1 of 5Newport News Nursing & RehabNewport News, VA 1 of 5Pennknoll VillageEverett, PA 1 of 5The Oaks Rehabilitation And Healthcare CenterMeridian, MS 1 of 5Westwood Health and RehabilitationArchdale, NC 1 of 5Woodstock Valley Health and RehabilitationWoodstock, VA 2 of 5Clay County Health and RehabilitationHayesville, NC 2 of 5Crown Haven Health and RehabilitationCharlotte, NC 2 of 5Kannapolis Health and RehabilitationKannapolis, NC 2 of 5Manor At Penn Village, TheSelinsgrove, PA 2 of 5Manor At St Luke Village,theHazleton, PA 2 of 5Pavilion At St Luke Village, TheHazleton, PA 2 of 5Pheasant Ridge Nursing and RehabilitationRoanoke, VA 2 of 5Valley View Care and RehabilitationAndrews, NC 2 of 5Walnut Cove Health and RehabilitationWalnut Cove, NC 2 of 5Wilora Lake HealthcareCharlotte, NC 2 of 5Windsor Grove Health and RehabilitationWindsor, VA 3 of 5Forrest Oakes HealthcareAlbemarle, NC 3 of 5Hilltop Manor Health And Rehabilitation CenterUnion, MS 3 of 5Locust Grove Retirement VillageMifflin, PA 3 of 5Skyline Nursing & RehabilitationFloyd, VA 4 of 5Jamestown Health and RehabilitationWilliamsburg, VA 4 of 5Oak Grove HealthcareRutherfordton, NC 4 of 5Willowbrook Rehabilitation and CareYadkinville, NC 5 of 5Cardinal Healthcare and RehabilitationLincolnton, NC 5 of 5Grayson Health and RehabilitationIndependence, VANot rated (Special Focus)Starkville Manor Health Care And Rehabilitation CeStarkville, MS

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 / managerTypeRoleSince
KNIGHTDALE PARENTCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 06/01/2025
NCOP HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
NU C II IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
NU C IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
SNF CARE CENTERS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
WAKE HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
ZENITH HOLDCO II LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
ZENITH HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
CSE KNIGHTDALE LPOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 05/01/2025
HOBACK, TIFFANYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
MORGAN, DANIELIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
SNF MGR LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
CLARKE, WENDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
JONES, TEQUILLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
O BRIEN, PATRICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
WARRICK, GLORIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025

CMS files one row per role, so the 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

10 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.

$8.7M
Net patient revenuemost recent cost report
-2.7%
Operating marginrevenue minus expenses
$455K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 7%Other / private 22%

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 $455K 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

$341per resident / day
operating cost
$10,376per month
≈ monthly operating cost
$332per 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 345436. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, 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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