Davidson Health & Rehab Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

66.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 43.4% 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 76 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 100 beds and averages 97.9 residents a day — about 98% occupied, or roughly 2 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.09 hrs/resident/day on weekends vs 3.66 on weekdays — 16% thinner on weekends. RN hours go from 0.38 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

43 citations, most serious first. The 16 most serious are shown; the remaining 27 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with staff, Medical Director, Nurse Practitioner (NP) and emergency room Physician, the facility failed to provide treatment and services to replace an old, discolored, and leaking gastric feeding tube after 5/04/25 when approximately 5 inches of the tube broke off during routine feeding tube care. In addition, the facility failed to schedule an appointment with a gastroenterologist to assess for a feeding tube replacement. On 6/18/25, the feeding tube site was found with approximately 25 maggots in the skin surrounding her feeding tube during care. Resident #1 was sent to the Emergency Department (ED), where approximately 5 more maggots were removed, and it was noted there was some induration (thickening and hardening of the skin) and erythema (abnormal redness of the skin or mucous membranes) concerning for cellulitis (bacterial infection of the skin and the tissue beneath the skin). The ED provider documented the feeding tube appeared aged and soiled and a new feeding…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2026-02-26 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 record review and staff and Nurse Practitioner interview, the facility failed to immediately notify the Responsible Party (RP) and the physician of Resident #1 experiencing a fall with reported pain immediately after the fall and throughout the day. This failure to immediately notify the physician resulted in a delay in diagnostics and necessary medical treatment for a fractured hip. The result of the x-ray that followed was the diagnosis of a fractured hip that resulted in the resident being sent out for medical treatment. This deficient practice affected 1 of 3 residents reviewed for notification of change (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding near the brain) without loss of consciousness, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet.A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. 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 date of correction
• Actual harm · Gcited before2026-02-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident, staff, mobile imaging provider Representative, and the Nurse Practitioner, the facility failed to identify the seriousness of a resident's unwitnessed fall and immediate reports of pain and complete and document comprehensive assessments following the fall to determine the need for transfer to a higher level of care. The Nurse did not complete a thorough assessment of Resident #1 before the resident was transferred from the floor to the bed. In addition, there were no comprehensive nursing assessments of the resident's condition documented in the medical record. The Unit Manager called the order for the stat (immediately) x-ray of the right hip to the mobile imaging provider instead of the computerized ordering system which further delayed transfer to the hospital for evaluation and treatment. An x-ray of the right hip completed at the hospital on 1/28/26 confirmed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone…

  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
• Actual harm · G2026-02-26 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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, staff, Responsible Party, and Nurse Practitioner interviews, the facility failed to provide effective pain management for a resident who reported acute severe pain rated a 10 out of 10 (0 meaning no pain and 10 meaning the worst pain the resident experienced) of the right hip after experiencing an unwitnessed fall. Despite receiving 2 doses of 1,000 milligrams (mg) of acetaminophen, the pain and discomfort the resident experienced caused the resident to cry out and wince in pain with movement. Resident #1 stated she told everyone she was in a lot of pain that day and she was not offered anything additional for pain relief. Resident #1 was transferred via Emergency Medical Services (EMS) to the hospital where an x-ray indicated the resident had a right hip fracture. This deficient practice affected 1 of 3 residents reviewed for effective pain management (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including traumatic…

  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
• Actual harm · Gcited before2024-10-16 · 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 staff and resident interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident reviewed for abuse (Resident #2). Resident #2's cognitively intact roommate (Resident #3) stated on 10/3/24 he was in the room while the curtain was pulled and he heard Nurse Aide (NA) #1 and Resident #2 fussing back and forth. NA #1 told Resident #2 you're not going to keep hitting me followed by an audible smack. After the incident, Resident #2 was identified by staff with a bright red hand mark on her right hip/thigh, she appeared agitated, and stated to NA #3 she hurt me. Resident #2 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would experience fear and intimidation from being abused in their home environment. The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's dementia. Review of the care plan that was revised on 08/22/24 revealed Resident #2 had…

  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 · Past Non-Compliance
• Actual harm · G2024-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to provide care in a safe manner which resulted in a resident (Resident #21) falling from the bed. One of two falls from bed resulted in Resident #21 being sent to the emergency department for a laceration to her forehead that required 5 stitches. This was for 1 of 5 residents reviewed for accidents. The findings include: 1. Resident #21 was originally admitted to the facility on [DATE] with diagnoses that included cellulitis of right and left lower limbs, morbid obesity, and anxiety. Record review revealed Resident #21 had a closed care plan initiated on 09/11/23, last reviewed 02/29/24, and closed on 03/11/24, that included a focus that Resident #21 was at risk for falls characterized by history of falls, injury and/or multiple risk factors. The interventions included for staff to implement preventative fall interventions/devices and to educate resident/family regarding preventative fall interventions/safety devices as appropriate. An intervention…

  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 · E2025-08-28 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to mark medications with opened-on or discard-by dates and failed to maintain medication refrigerator temperatures within the recommended range. This was for 5 of 6 areas reviewed for medication storage (Medication Carts #1, #4 and #5, and medication storage room refrigerators for Granny's Place and Lillian's).Findings included:1. On [DATE] at 11:40 AM Medication Cart #1 was reviewed with Nurse #5. Four dropper bottles of ophthalmic solution were discovered with no opened-on or discard-by dates:2 bottles- dorzolamide-timolol 2%/0.5% ophthalmic solution 10 milliliters (ml).1 bottle- netarsudil ophthalmic solution 0.02% % 2.5 ml.1 bottle- latanoprost 0.005% ophthalmic solution 2.5 ml.On [DATE] at 11:45 AM during the medication cart review, Nurse #5 stated that two of the eye drop bottles had been sent with the resident from the hospital and they all should have had opened-on dates.On [DATE] at 12:20 PM during an interview with 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 label, date, and seal food items left open to air and stored for use in 1 of 1 walk-in refrigerator and failed to label and remove expired food items stored for use 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.The findings included: Accompanied by the Dietary Manager, an observation was made of the walk-in refrigerator on 8/25/25 at 9:32 AM. The following items were stored in the refrigerator: -One undated box of turkey sausage that was open and partially used with the remaining contents unwrapped and exposed to air. -One undated package of Danishes open and partially used with the remaining contents unwrapped and exposed to air. An observation of the walk-in freezer revealed the following stored item:-One large plastic, zippered storage bag containing unlabeled and uncooked ground meat dated 7/7/25. The Dietary Manager was interviewed on 8/25/25 during the kitchen tour at 9:32 AM. He stated food should be wrapped once it's opened and labeled with the contents and date…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to provide cueing assistance during a meal as specified in the resident's plan of care. Resident #90 was seated at a table in the main dining room with her meal tray in front of her not eating while other residents at other tables were eating their lunch. This deficient practice affected 1 of 8 residents reviewed for dignity.The findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, dysphagia (difficulty swallowing), and memory deficit following other cerebrovascular disease.Review of a quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #90 to be severely cognitively impaired without behaviors. She was assessed as requiring set-up or clean-up assistance with eating.According to the active care plan for Resident #90 dated 6/28/25, the resident had an ADL (activities of daily living) self-care performance deficit related to Alzheimer'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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and staff interviews, the facility failed to protect residents' private healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 1 of 5 medication carts observed (100 hall medication cart). Findings included: A continuous observation of the upper 100-hall medication cart occurred on 8/26/25 from 2:28 PM until 2:33 PM. The medication cart was in the hallway unattended and was observed to have the computer screen opened which showed multiple residents' personal identifying information such as resident name, diagnoses, medications, date of birth , and room number. The medication cart was observed for five minutes, and during that time one Nurse Aide and the Wound Nurse walked past the cart. Nurse #3 was interviewed on 8/26/25 at 2:33 PM. She confirmed she was responsible for the 100-hall medication cart. Nurse #3 stated she should have locked the computer screen before leaving the cart. The nurse further stated, I'm so far behind giving medications that I just ran down the hall 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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 observations and staff interviews, the facility failed to ensure a resident room was in good repair and failed to maintain a clean and sanitary conditions in a resident room. The deficient practice was evidenced for 2 of 8 residents (Resident #67 and Resident #83) observed for a safe, clean and homelike environment on 1 of 4 resident halls (200 hall). a. An initial observation was completed on 08/25/25 at 10:33 AM of Resident #67 and Resident #83's room. The observation revealed a hole in the wall at the corner of Resident #83's headboard that measured approximately 11.5-inch x 8 inches with sheetrock exposed. On the wall to the left side of Resident # 83's bed paint was peeling off the wall between the bottom of the window frame and the packaged terminal air conditioner (PTAC) unit. The area of peeling paint extended was the length of the PTAC unit. During subsequent observations on 08/25/25 at 12:35 PM and 08/25/25 at 3:00 PM the room was still in need of wall repairs. An interview and observation were conducted on 08/25/25 at 3:00 PM with the Maintenance Director. 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 · D2025-08-28 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 Representative (RR) and staff interviews, the facility failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #9, #70 and #91).The findings included: A review of the facility grievance policy, dated 8/2018, included, in part, The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved, if applicable. A copy of the written grievance decision will be provided to the resident, upon request. The policy did not address how grievance resolutions would be handled by anyone else that filed a grievance concern, such as the RR. 1. Resident #9 was originally admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. A review of the facility grievance logs from August 2024 to August 2025 revealed a concern form had been initiated on 7/15/25 by…

  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 before2025-08-28 · 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 resident, family member and staff interviews, the facility failed to protect a resident's right to be free from staff to resident abuse when Nurse Aide (NA) #1 slapped Resident #74's hand when she became combative after removing her from another resident's room. This was for 1 of 1 resident reviewed for employee to resident abuse (Resident #74). The findings included: Resident #74 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances, osteoporosis, and major depressive disorder. Resident #74 resided on the Lillian's Way Hall. An annual Minimum Data Set (MDS) assessment dated [DATE] prior to the incident and the most recent on 8/7/2025 indicated that Resident #74 had severely impaired cognition with behavioral symptoms. She had limited range of motion to extremities and utilized a wheelchair for mobility. Resident #74 was coded as weighing 115 pounds and was 63 inches tall on 5/7/2025. Resident #74's care plans on 5/7/2025 prior to…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0646 — isolated
  Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the facility failed to notify the State Mental Health Authority after a resident diagnosed with a serious mental illness experienced a change in condition. This deficient practice affected 1 of 1 resident reviewed for (PASRR) Preadmission Screening and Resident Review (Resident #91).Findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, in partial remission and generalized anxiety disorder. Resident #91had a level I PASRR dated 5/23/24, which stated no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness or a change in treatment needs for those conditions.Record review of the psychiatric follow-up evaluation dated 12/10/24 revealed on 12/5/24 Resident #91's Depakote dose was increased to 500 milligrams by mouth three times a day for treatment of bipolar disorder to assist with mood. According to the psychiatric evaluation, the Lexapro 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · 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 person-centered care plan for 1 of 26 residents reviewed for comprehensive care plans (Resident #55).Findings included:Resident #55 was admitted on [DATE] with diagnoses including multiple fractures of the pelvis, glaucoma, and anxiety. Resident #55's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. The Care Area Assessment (CAA) Summary indicated eight areas of concern which were triggered from the MDS and identified for care planning. These included: Visual Function, Activities of Daily Living Function, Urinary Incontinence, Falls, Dental Care, Pressure Ulcer, Psychotropic Drug Use, and Pain. Four Care Plans were observed in Resident #55's record and included Social Services discharge planning and Advanced Directives both dated 7/26/25, Activities dated 7/28/25, and Nutritional Status dated 8/2/25. On 8/28/25 at 8:48 AM an interview with MDS Nurse #2 was conducted. MDS nurse #2…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · 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, resident, Medical Director and staff interviews, the facility failed to initiate physician orders on admission for the care of a surgical wound for 1 of 2 residents reviewed for quality of care (Resident #100).The findings included: Review of the hospital records dated 8/7/24 through 8/9/24 revealed Resident #100 had a total left knee replacement and was admitted to the orthopedic unit for continued care. The hospital Discharge summary dated [DATE], included the following wound management orders:- Leave the Aquacel dressing (a type of dressing used for wounds to include surgical wounds) in place for seven days after surgery. On postoperative day seven, remove the Aquacel dressing and apply a dry dressing daily if needed.- If you have a Zipline dressing (a non-invasive skin closure device designed for surgical incisions): the Zipline dressing is adhesive and may be peeled off 14 days after surgery. Once removed, dressings or steri-strips are not needed. Resident #100 was admitted to 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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$54,389 in federal fines across 3 penalties.

• $31,746 — penalty dated 2026-02-26
• $9,318 — penalty dated 2024-10-16
• $13,325 — penalty dated 2024-07-25

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 SABER HEALTHCARE GROUP — 126 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 →

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

CMS files one row per role, so the 25 rows in the source record cover these 15 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.

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

Follow the money — this home’s finances

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

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

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

What families pay in NC