Lexington Health Care Center
17 Cornelia Drive, Lexington, NC 27292 · For profit - Limited Liability company · 100 certified beds · (336) 242-1349 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors recorded 2 serious findings 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 (40) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.8% | 15.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 16.6% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 26.9% | 5.9% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.8% | 18.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 21.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.4% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.3% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.6% | 78.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.5% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.04 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.24 | 1.80 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
50.7% 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 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.6% 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 79 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.7%CMS range 42.5–58.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.6–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 64.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.3%CMS range 5.0–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 97.0 residents a day — about 97% 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 3.61 on weekdays — 11% thinner on weekends. RN hours go from 0.53 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above 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
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.
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.
40 citations, most serious first. The 12 most serious are shown; the remaining 28 are one tap away and print in full.
- Immediate jeopardy · Kcited before2022-10-14 · tag F0580 — failed to tell family and doctor about changes — patternImmediately 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, staff, nurse practitioner (NP), and Physician interviews, the facility failed to notify the physician or the nurse practitioner that an anti-seizure medication (lacosamide) was not available for administration for 1 of 1 resident reviewed for notification of change (Resident #244). The facility failed to notify the NP or the Physician that lacosamide was not available for administration on 4/30/2022, 5/1/2022, 5/4/2022, 5/8/2022, 5/24/2022, and 5/26/2022. Resident #244 was hospitalized with cardiac issues on 5/11/2022 and with seizure activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses to include stroke, seizures, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS documented Resident #244 had seizure disorder. 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.
- Immediate jeopardy · K2022-10-14 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Nurse Practitioner (NP), and Physician interviews, the facility failed to administer an anti-seizure medication (lacosamide) as ordered by the physician for 1 of 1 resident reviewed for significant medication errors (Resident #244). Resident #244 missed 34 doses of lacosamide. The facility failed to administer lacosamide on 4/28/2022 to 4/30/2022, 5/1 to 5/11/2022; 5/23 to 5/27/2022. Resident #244 was sent to the emergency room from a physician appointment on 5//11/2022 with cardiac issues (and admitted for treatment) and was sent to the emergency room for evaluation after seizure activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses to include stroke, seizures, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews, the facility failed to report reasonable suspicion of a crime to law enforcement when Resident #1 was identified with an odor of marijuana after he returned inside the facility from the smoking area. A subsequent drug screen was completed and the resident tested positive for Tetrahydrocannabinol (THC [the main psychoactive ingredient in marijuana] ). This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). The findings included:Review of the facility policy and procedure titled Substance Use with a date of 01/29/24, states to protect the health and safety of resident, the center prohibits unprescribed use of drugs and alcohol. The policy indicated if items were found that posed a health and safety risk they were to be confiscated if in plain sight and law enforcement was to be contacted. Resident #1 was admitted to the facility on [DATE].Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews, the facility failed to complete smoking assessments when a resident was identified as a smoker and to provide supervision and retain smoking materials in accordance with the smoking policy for a resident assessed as a supervised smoker for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Review of the policy titled Patient Smoking dated 01/29/24 indicated if supervision was deemed necessary, the resident would be supervised by staff or other appropriate person (i.e., family member). Residents who wished to smoke would be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine need for supervision. The facility would maintain all smoking paraphernalia for residents who required supervision with smoking. Resident #1 was admitted to the facility on [DATE] with diagnoses of tobacco use. Resident #1's care plan with a date of 04/12/25 revealed the resident preferred to smoke. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff, Nurse Practitioner, Pharmacist, and Physician the facility failed to ensure a nurse accurately measured a liquid narcotic medication per professional standards of practice resulting in a wrong administration dose. This was for 1 of 3 residents whose medications were reviewed (Resident #1). The findings included:Resident # 1 was admitted to the facility on [DATE]. Review of a hospital discharge summary revealed that prior to Resident # 1's facility residency he had been hospitalized from [DATE] to 9/2/25. The resident was diagnosed with pulmonary nodules, a large chest mass with evidence of metastatic disease to multiple areas in his bones along with enlarged lymph nodes. Additionally, Resident # 1 had diagnoses of heart failure with a decreased ejection fraction (percent of blood flow the heart pumps with each heart beat), chronic obstructive pulmonary disease, anxiety disorder, schizophrenia, hypertension, and seizure disorder. Resident # 1'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.
- Potential for harm · Dcited before2025-10-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview the facility failed to ensure a resident's medical record was complete regarding medication orders given by a Nurse Practitioner and documentation of the administration of medications. This was for 1 of 3 of three sampled residents whose medications were reviewed (Resident # 1).The findings included: Resident # 1 was admitted to the facility on [DATE] with a diagnosis of metastatic lung cancer disease.Review of a Nurse Practitioner's (NP) progress note for the date of 10/3/25 revealed the NP had ordered some medications when the resident was not responding. According to the NP's note she ordered two doses of Narcan and one dose of Lasix which were administered to the resident.Review of Resident # 1's orders revealed these orders were never entered into the resident's electronic record. Review of Resident # 1's MAR (Medication Administration Record) revealed no documentation when these medications were given. They did not appear on the MAR. Review of the facility'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.
- Potential for harm · Dcited before2025-09-02 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, family member, neighbor and staff interviews, the facility failed to protect a resident's right to be free from exploitation. In [DATE], Nurse Aide (NA) #1 told Resident #1 that her landlord raised the rent at her apartment and she was going to be evicted. Resident #1 reported that NA #1 asked to live in his personal home and being a goodhearted trusting person, he was considering letting NA #1 and her friend house-sit his personal home while he was at the facility. NA #1 asked the resident if she could look at his house and he informed her where the keys were located. NA #1 went to the resident's home and due to being unable to find the keys she went to Resident #1's neighbor's home to request a key at which time the neighbor did not give her the key preventing NA #1 from entering the home and having access to all of Resident #1's personal belongings. The deficient practice occurred for 1 of 3 residents reviewed for abuse, neglect and/or misappropriation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to report an allegation misappropriation of property/exploitation to Adult Protective Services (APS) for 1 of 3 residents reviewed for abuse, misappropriation of property and/or exploitation (Resident #1).Findings included:The Facility's Reporting Requirements/Investigations policy statement dated effective 2/5/2023 indicated the Administrator will immediately notify the adult protective services agency for any incident of patient abuse, mistreatment, neglect or misappropriation of personal property or other reasonable suspicion of a crime. Resident #1 was admitted to the facility on [DATE].An initial allegation report dated 7/10/2025 at 2:13 pm was completed by the former Administrator and faxed to the State Agency alleging misappropriation of Resident #1's property on 7/9/2025. The initial report recorded the facility became aware of the incident on 7/10/2025 at 10:45am. Details of the allegation stated NA #1 convinced Resident #1 to allow her 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.
- Potential for harm · E2025-04-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with staff, resident and Nurse Practitioner, the facility failed to: 1) provide oxygen at the rate ordered by the physician: provide clean air intake filters on oxygen concentrators for 1 of 5 residents (Resident #79); 2) post oxygen signs for 3 of 5 residents (Resident #10, Resident #13, and Resident #33); 3) change oxygen tubing for 2 of 5 residents (Resident #10 and Resident #33); and 4) obtain physician's order for oxygen delivery for 1 of 5 residents (Resident #250) reviewed for respiratory care. Findings included: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses of respiratory failure, pneumonia, and stroke. A Physician's Order dated 3/24/2025 indicated Resident #79 should receive 2 liters per minute oxygen by nasal cannula. An admission Minimum Data Set assessment dated [DATE] indicated Resident #79 was cognitively intact and required oxygen therapy. The 10-liter Oxygen Concentrator Guide stated the air filter should be cleaned at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to allow residents who were assessed to be safe smokers to smoke independently per their individual preference for 2 of 3 residents (Resident #8 and #249) reviewed for smoking. The findings included: Review of the Facility Smoking Acknowledgement read, in part: patients who wish to smoke will be evaluated using the smoking safety screen upon admission and as needed to determine need for supervision. The patient must also agree to the policy and sign the Patient Smoking Acknowledgement form . based on the Smoking Safety Screen, a patient may smoke in designated smoking area either independently or with supervision . The smoking schedule for the facility dated 3/18/25 was reviewed. Times for smoking were listed as 8:30 AM, 11:00 AM, 1:30 PM, 3:30 PM, 5:30 PM, and 8:00 PM. The form read Staff members go with residents out back to designated smoking areas. Ensure the resident is in proper clothing and has shoes or foot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff and resident interviews, the facility failed to resolve grievances that were reported in the Resident Council meetings for 4 of 6 months (11/19/2024, 12/18/2024, 1/29/2025 and 2/26/2025). Findings included: A review of the Resident Council Minutes indicated the residents had complained on 11/19/2024, 12/18/2024, 1/29/2025, and 2/26/2025, during the Resident Council meeting, that they received potatoes and green beans several times during the same week. A Departmental Response/Resolution dated 11/26/2024 indicated the facility's menu was provided by the corporate office and the Dietary Manager stated the menu could not be changed. The Department Response/Resolution also stated green beans were served three times a week and mashed potatoes were served two times a week per the facility's menu. On 12/18/2024 the Departmental Response/Resolution form updated by the Administrator stated they continued to report the residents' concerns to the Dietary Manager to see if any substitutions could be made. On 1/29/2025 the Departmental Response/Resolution form…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 completely fill out the Do Not Resuscitate (DNR) form for 1 of 2 residents reviewed and Advanced Directives (Resident # 30). The findings included: Resident # 30 was admitted to the facility on [DATE]. Resident # 30's diagnosis included hypertension, and cognitive impairment. Review of Resident # 30's paper medical record revealed Resident # 30's DNR form signed by the Nurse Practitioner (NP) # 1 was not dated. Review of Resident # 30's Electronic Medical Record (EMR) revealed a physician's order dated 1/21/2025 for code status DNR. An interview was conducted on 4/14/2025 at 1:05 PM with Unit Manager # 2. Unit Manager # 2 revealed upon admission, the nurse would complete the DNR. Unit Manager # 2 continued by stating the form would then go to the Nurse Practitioner (NP) to be signed, dated, and then scanned into the EMR. The hard copy would be kept at the nurse's station in a binder. Unit Manager # 2 further stated the DNR form should correspond…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 28 citations
- Potential for harm · Dcited before2025-04-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 Nurse Practitioner and staff interviews, the facility failed to notify the Nurse Practitioner (NP) after an International Normalized Ratio (INR) test (monitors the effectiveness of blood-thinning medications) was not completed as ordered for 1 of 1 resident (Resident # 255) reviewed for monitoring anticoagulant medicine. The findings included: Resident #255 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation. Resident #255's physician order dated 01/30/25 revealed the resident was ordered to receive a warfarin sodium (anticoagulant/blood thinner) oral tablet 2 milligram (mg), give 1 tablet by mouth at bedtime related to unspecified atrial fibrillation. A progress note dated 03/05/25 completed by Nurse Practitioner (NP) #1 revealed Resident #225's INR was recently checked, and it was at 4.0 that morning (normal range 2-3). It was further noted Resident #255's warfarin was to be held until 3/7/25. The note indicated Resident #255's INR was 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.
- Potential for harm · Dcited before2025-04-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to ensure a resident swallowed medications during medication administration when Nurse #5 left medications at the bedside for 1 of 5 residents observed for medication administration (Resident #2). The findings included: Resident #2 was admitted to the facility 12/19/24 with diagnoses including diabetes and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #2 to be moderately cognitively impaired. Review of the physician orders for Resident #2 revealed the following medications to be administered: - Digoxin 125 micrograms 1 tablet daily for atrial fibrillation at 9:00 AM - Furosemide 20 milligrams (mg) 1 tablet daily for blood pressure at 8:00 AM - Nadolol 40 mg 1 tablet daily for blood pressure at 9:00 AM - Oxybutynin chloride 5 mg 1 tablet daily for bladder spasm at 8:00 AM - Sennosides-docusate sodium 8.6 mg/50 mg 2 tablets daily for constipation at 9:00 AM - Divalproex Sodium 125…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff and Psychiatric Nurse Practitioner interviews, the facility failed to provide the necessary supervision to prevent a resident with known wandering behaviors from entering the room of another resident and attempting to take the other resident's (Resident #94's) belongings during the night for 1 of 3 residents reviewed for accidents (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by imbalances in the body's metabolism, often due to underlying systemic illnesses), alcohol-induced persisting dementia, major depressive disorder, and anxiety disorder. A physician's order for Resident #91 dated 3/11/25 indicated Olanzapine (an antipsychotic medication) 5 milligrams (mg) every 8 hours for severe alcohol abuse disorder with unspecified mood disorder. A care plan developed on 3/11/25 addressed behaviors for Resident #91, including safety concerns regarding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 review, observations, and staff interviews, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for 1 of 3 residents (Resident #79) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination. Findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses of stroke and difficulty swallowing. A Physician's order dated 3/24/2025 stated Resident #79 should have placement checked to her gastrotomy tube before each feeding and medication administration every shift; her residual should be checked each shift; a 20 to 30 milliliter flush of water should be given before and after administration of medication; she should receive a flush of 150 milliliters of water four times a day, and she should receive 50 milliliters an hour of enteral feeding. An admission Minimum Data Set assessment dated [DATE] indicated Resident #79 was cognitively intact and received 51% or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record review and staff and Nurse Practitioner interviews, the facility failed to complete an International Normalized Ratio (INR) test as ordered by the physician for 1 of 1 resident (Resident # 255) reviewed for monitoring anticoagulant medicine. The findings included: Resident #255 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation. Review of Resident #255's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was coded for anticoagulant use. Review of Resident #255's care plan created on 03/30/21 revealed the was on anticoagulant therapy. The goal for Resident #255 would be to be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions included complete labs as ordered and report abnormal lab results to the Medical Director (MD). Review of Resident #255's physician order dated 01/30/25 revealed the resident was ordered to receive a warfarin sodium(anticoagulant/blood thinner) oral tablet 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.
- Potential for harm · Dcited before2024-10-30 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews with staff, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation of a resident's property (Resident #3). The resident received her pain medication as scheduled. Findings included: The facility's Abuse, Neglect, and Exploitation Policy, last updated on 3/20/23, was reviewed and it included misappropriation in part was the protection of resident property the deliberate misplacement, exploitation, or wrongful, temporary or permanent of a resident's belongings or money without the resident's consent. Resident #3 was admitted to the facility on [DATE] with the diagnosis of arthritis. A review of the facility record revealed Resident #3 had an order for Oxycodone 5 mg three times a day for pain dated 7/10/24. A review of the facility record revealed Resident #3 had an order for Hydrocodone 10-325 mg every 6 hours as needed for pain dated 7/10/24. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews, the facility failed to care for a resident in a safely manner for 1 of 3 residents were reviewed for accidents (Resident #5). Resident #1 was assisted by Hospice Aide #1 during a bed bath and the resident fell to the floor. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, muscle weakness, and osteoporosis. Review of Resident #5's significant change Minimum Dat Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance of two staff for bed mobility. Review of Resident #5's care plan revised 02/21/23 revealed Resident #5 required assistance with activities of daily living (ADL). The goal was for Resident #5 to remain a current level of function through the next review date. Interventions included two people assist with bed mobility and transfers. Review of Resident #5's care guide not dated revealed nursing staff to educate hospice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with the staff and Regional Director of Culinary Operations, the facility failed to seal, label/date, and discard expired food items stored in the Dietary Department's walk-in freezer, reach-in refrigerators, and 1 of 2 Nourishment Rooms observed (100 Hall Nourishment Room). The findings included: An initial tour was conducted of the Dietary Department on 2/18/24 at 10:01 AM. Neither the Dietary Manager nor the Assistant Dietary Manager were available to join the initial tour of the Department. Observations made at the time of the initial tour identified the following concerns in the walk-in freezer: --An opened, undated box with an opened and unsealed interior plastic bag was observed to contain pancakes. The interior plastic bag was estimated to be 1/2 full. Neither the box nor the plastic bag was closed, leaving the pancakes exposed to air (not sealed). --An opened, undated box with an opened and unsealed interior plastic bag was observed to contain scrambled egg patties.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-01 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after each of the following surveys with citations that were recited on the current recertification / complaint survey of 2/21/24: 1) The annual recertification / complaint investigation survey of 1/10/22. This was evident for three recited deficiencies in the areas of Accuracy of Assessments (F641); Development and Implementation of Comprehensive Care Plans (F656); and Posted Nurse Staffing Information (F732). 2) The annual recertification / complaint investigation survey of 10/14/22. This was also evident for four recited deficiencies in the areas of Notification of Changes (F580); Development and Implementation of Comprehensive Care Plans (F656); Care Plan Timing and Revision (F657); and Food Safety Requirements (F812). The continued failure of the facility during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAA Program.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 reviews, Nurse Practitioner (NP), resident and staff interviews the facility failed to notify the NP when a resident experienced pain and the acetaminophen order expired for 1 of 2 (Residents #43) residents sampled for change in condition. The findings included: Resident #43 was admitted to the facility on [DATE] from the hospital with diagnoses that included chronic first vertebra of the lumbar spine (L1) compression fracture. Hospital discharge summary revealed Resident #43 was admitted to the hospital on [DATE] with acute chronic lower back pain and inability to walk. Magnetic Resonance Imaging (MRI) of the spine revealed chronic first vertebra of the lumbar spine (L1) compression fracture. On [DATE], while a patient at the hospital, Resident # 43 had a stroke. Resident #43 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, wedge compression fracture of first lumbar vertebra, fall from bed, and repeated falls. When…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to submit an initial report of an abuse allegation to the State Agency within the required 2- hour time frame for 1 of 3 residents (Resident #32) reviewed for abuse. The findings included: A review of the facility's Administrative Policies and Procedures included Policy #703 (Effective Date 10/17/23) entitled, Abuse/Neglect/Misappropriation/Crime: Reporting Requirements/Investigations. The policy stated, The Administrator will ensure the timely reporting, investigating, and follow up reporting of incidents of alleged/suspected patient abuse, neglect, mistreatment, exploitation, or crime against a patient to the State Agency and any other appropriate authorities. The procedures for this policy read, in part: Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report 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.
- Potential for harm · D2024-03-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #80 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] documented Resident #80 was discharged to a short-term general hospital on [DATE]. A physician order dated 11/26/2023 ordered Resident #80 to be discharged home with home health services. A nursing note dated 11/26/2023 documented Resident #80 discharged home on [DATE]. A nurse practitioner (NP) note dated 11/27/2023 documented that Resident #80 was discharged to home on [DATE]. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 2/21/2023 at 12:12 PM. MDS Nurse #1 reported the discharge MDS assessment for Resident #80 should have been coded for discharge home. MDS Nurse #2 explained she made an error when documenting on the discharge MDS for Resident #80. The Administrator was interviewed on 2/21/2023 at 2:36 PM. The Administrator explained that she thought the error in coding was an oversight on MDS Nurse #2's part. Based on record reviews and staff interviews, the facility failed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-21 · tag F0660 — isolatedPlan 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 Family Member, staff, and Nurse Practitioner interviews the facility failed to provide a safe discharge for 1 of 3 residents (Resident #1) reviewed for discharge from the facility. Resident #1 was discharged home on [DATE] to an independent living apartment with Family Member #1 who was not capable of providing care and the facility did not notify Adult Protective Services the resident discharged without a care giver that could provide toileting and bathing. Resident #1 fell and was transported to the hospital shortly after arriving home from the facility. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of necrotizing enterocolitis (inflammation of the bowel) which resulted in surgical intervention. An admission Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact and required moderate assistance with upper body bathing and dressing, maximum assistance with lower body bathing and dressing, and was dependent for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and staff interviews the facility failed to remove expired medications in one of two medication storage rooms and on one of three medication carts. The facility also failed to label an opened insulin vial with an expiration date located in the refrigerator in one of two medication rooms. (Medication storage room B Hall and Medication cart A hall - North side). Findings included: 1. A review of the medication storage room on the B hall was conducted on 10/13/22 at 11:27 AM. The Staff Development Coordinator (SDC) opened the medication storage room and stated the normal procedure was for the Unit Manager (UM) to check the expiration dates for medications. SDC explained that B hall does not have a UM, so the Director of Nursing (DON) was reviewing the B hall storage room. An observation of a box was on the counter and partially open. Inside the box was a package of Sodium Chloride 0.45%. The package had been out of the shrink wrap and had a written expiration date of 7/24/22 and the ports were exposed. A review of the medication refrigerator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-10-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to label opened beverages, failed to clean fluids off the bottoms of coolers, failed to label and close frozen foods, failed to air-dry steamer pans, and failed to label and date resident food in 1 of 2 nutritional rooms observed (200 hall). This had the potential to affect 86 of 87 residents in the facility. Findings included: A tour of the kitchen was conducted on 10/10/2022 at 10:16 AM with the Dietary Manager (DM). Cooler #1 was observed with purple and orange colored liquid spilled on the bottom of the cooler. The DM reported he thought that juice was spilled this morning during the breakfast service. The DM reported the bottom of the cooler should be cleaned. Cooler #3 was observed with thawing ground beef in a metal steamer pan. The packages of meat were wrapped in plastic and the metal bins were sitting on the bottom of the cooler. On the shelf above the ground beef was a metal steamer pan with pork loins wrapped in plastic. Red colored liquid was dripping from the packages of pork loins in the metal steamer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, observations, and record review the facility failed to include residents in the care planning process by not inviting 4 of 10 residents to their care plan meetings (Residents #80, # 59, #34 and #38). Findings included: 1.Resident # 80 was admitted to the facility on [DATE]. A review of a significant change Minimum Data Set (MDS) dated [DATE] revealed [NAME] Resident #80 had no cognitive impairment. Review of a care plan meeting note dated 09/29/22 at 11:10 AM revealed in part that Resident #80 and or her family were invited to the care plan meeting but did not attend. On 10/13/22 at 10:45 AM an interview conducted with Resident #80. She was asked if she had been invited to a care plan meeting or attended a care plan meeting. Resident #80 responded that she had not been invited and did not know what a care plan meeting was. On 10/14/22 at 1:41 PM MDS Nurse #1 and MDS Nurse #2 were interviewed and revealed that they believed that the secretary mailed care plan meeting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to follow orders to apply non-medicated cream for dry skin for 1 of 7 residents reviewed for treatment orders. (Resident #71) Findings Included: Resident #71 was admitted to the facility on [DATE] with a diagnosis of acute chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) exacerbation and venous insufficiency. An admission minimum data set (MDS) dated [DATE] assessed Resident #71 as being cognitively intact. A record review of the treatment authorization report (TAR) revealed Resident #71 had an order dated 9/21/22 for a non-medicated cream to both lower and upper extremities every day and evening shift for dry skin. On 10/3/22, 10/4/22, the day shift of 10/5/22 and evening shift on 10/9/22 no treatments were signed off as completed on the TAR. An observation and interview were conducted on 10/10/22 with Resident #71 at 3:24 PM who was sitting in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews the facility failed to ensure 1 of 6 residents, Resident #88, dependent for activities of daily living was assisted with nail care. Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses of left-hand contracture and hemiplegia. A Therapy Restorative Nursing Referral dated 4/13/2022 at 12:38 pm indicated Resident #88's palm guard splint should be applied to her left hand during daytime and removed at night. The referral also stated Resident #88's hand should be washed and dried and range of motion provided prior to splint application and her nails should be kept short to prevent skin breakdown. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was mildly cognitively impaired and required extensive assistance with bathing and personal hygiene. On 10/10/2022 at 10:12 am an observation of Resident #88 in bed revealed she had a contracture to her left hand and her fingers are curled into her palm.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 2. Resident #71 was admitted to the facility on [DATE] with a diagnosis of acute chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) exacerbation and venous insufficiency. A review of a NP #2 visit who saw Resident #71 on 10/12/22 for edema. The note read in part; 'patient was seen today for reports of edema to BLEs. Patient lying in bed with feet elevated on oxygen and in no acute distress. Patient endorses a headache that started 2 days ago, occasional cough, nasal congestion, and runny nose. Lungs, clear to auscultation (the action of listening to sounds from the heart lungs or other organs with a stethoscope), heart rate, regular rate and rhythm. BLEs with dependent edema, dry flaky skin, no erythema, warmth, or open areas. Educated patient on elevating legs while sitting up. Documentation revealed a plan ordered by the NP #2 read in part; Chest X-ray related to congestion, and compression wraps: apply kerlex (gauze) and ace wrap to BLEs apply in morning and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 record review, observation and staff interviews the facility failed to ensure a mobility aide was provided as ordered for 1 of 2 residents, resident #88, who required a left hand splint to prevent further contracture of left hand. Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses of hemiplegia and left hand contracture. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was mildly cognitively impaired and had impairment of range of motion to extremities on one side of her upper body. An Inservice/Education Record dated 4/12/2022 stated resident #88 should have a palm splint to her left hand during the day and removed at night, and her hand should be washed and dried before the left palm splint is applied. The Inservice/Education Record was signed by Nurse Aides on the 7:00 am to 3:00 pm and 3:00 pm to 11:00 pm shifts. A Therapy Restorative Nursing Referral Note written by Occupational Therapist #1 and dated 4/13/2022 at 12:38 pm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews the facility failed to ensure 1 of 4 residents, Resident #87, reviewed for indwelling catheters had a catheter bag that was secured off the floor. Findings included: A Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #87 was moderately cognitively impaired and had an indwelling catheter. Resident #87 re-admitted to the facility on [DATE] with diagnoses of chronic kidney disease and urinary retention. Resident #87's Care Plan dated 10/6/2022 indicated he required a urinary catheter and catheter care should be provided every shift. Resident #87 was interviewed on 10/10/2022 at 3:11 pm and stated he did not want to be interviewed. On 10/10/2022 at 3:20 pm Resident #87's catheter bag was found on the floor. Nurse #4 had entered the room and stated Resident #87's catheter bag should not be on the floor. Nurse #4 secured the catheter bag on the side of the bed, off the floor. During an observation and interview with Nurse…
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.
- No harm found · Bcited before2025-01-30 · tag F0657 — failed to keep the care plan current — patternDevelop 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 record review and staff interviews, the facility failed to revise a care plan for an indwelling urinary catheter for 1 of 3 residents whose care plans were reviewed (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a neuromuscular disorder of the bladder. A nursing progress note dated 9/18/24 read that Resident #1's indwelling urinary catheter was removed. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had frequent urinary incontinence. He was not coded as having an indwelling urinary catheter. Review of Resident #1's active care plan, last reviewed on 12/3/24, revealed a care plan for an indwelling urinary catheter due to neurogenic bladder. On 1/30/25 at 1:40 PM, an interview occurred with the MDS nurse. She reviewed Resident #1's care plan and verified that he no longer had a urinary catheter, and the care plan should have been resolved. She felt it was an oversight. 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.
- No harm found · Bcited before2025-01-30 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to maintain accurate medical records in the area of medication management for 1 of 3 residents reviewed for accurate medical records (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. A review of the January 2025 physician orders included the following: - Atorvastatin 80 milligrams (mg) one tablet via G-tube in the evening for hyperlipidemia. - Insulin Lispro inject per sliding scale subcutaneously every six hours for diabetes type 2. - 150 milliliters (ml) water flush six times a day via G-tube for hydration. A review of the January 2025 Medication Administration Record (MAR) indicated that the Atorvastatin, Insulin Lispro and water flush were not signed off as provided or refused by Resident #1 on 1/18/25 at 6:00 PM. A phone interview occurred with Nurse #1 on 1/30/25 at 1:26 PM. She was assigned to care for Resident #1 on 1/18/25 from 7:00 AM to 7:00 PM. The January 2025 MAR was reviewed, and she stated…
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.
- No harm found · B2024-03-01 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for 1 of 28 residents reviewed for MDS assessments (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses to include stroke and dementia. A significant change in condition MDS was completed 12/20/2022. Quarterly MDS assessments were completed on 3/15/2023, 6/15/2023, 9/15/2023, and 12/15/2023. No annual MDS had been completed for Resident #54. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 2/21/2023 at 12:12 PM. MDS Nurse #1 reported the quarterly MDS assessment dated [DATE] should have been completed as a comprehensive annual assessment. MDS Nurse #2 explained that she used an Assessment Reference Date (ARD) manager to keep track of when assessments were due. MDS Nurse #2 displayed the ARD manager, and a warning was noted for Resident #54 that his annual comprehensive assessment was overdue. 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.
- No harm found · Bcited before2024-03-01 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and staff interviews, the facility failed to update care plan interventions related to fall prevention (Resident #44) and behavioral interventions (Resident #54) for 2 of 28 residents reviewed for care plan accuracy. The findings included: 1. Resident #44 was admitted to the facility 2/17/2023 with diagnoses to include dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #44 was severely cognitively impaired. A care plan initiated on 2/17/2023 addressed Resident #44's risk for falls and interventions included a fall mat on the floor beside the bed with a revision date of 5/29/2023. Resident #44 was observed in her bed on 2/19/2024 at 11:38 AM, 2/20/2024 at 12:09 PM, and 2/21/2024 at 1:59 PM. No fall mats were noted to be on the floor beside her bed. An interview was conducted with nursing assistant (NA) #4 on 2/20/2024 at 11:37 AM. NA #4 reported that Resident #44 did not move in bed and the fall mats were not used. NA #5 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.
- No harm found · Bcited before2024-03-01 · tag F0657 — failed to keep the care plan current — patternDevelop 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 staff interviews and facility and hospital record reviews, the facility failed to review and revise the comprehensive care plan related to a medication that was discontinued after the resident underwent bilateral above knee amputations (AKA). This occurred for 1 of 28 residents (Resident #79) whose care plans were reviewed. The findings included: Resident #79 was admitted to the facility from a hospital on 9/19/23. Her cumulative diagnosis included diabetes, severe peripheral vascular disease, and status post a bilateral (left and right) transmetatarsal amputation (a surgery to remove part of the foot due to poor blood flow or a severe infection). The resident's admission orders dated 9/19/23 included 5 milligrams (mg) apixaban (an anticoagulant) to be given as one tablet by mouth twice daily related to peripheral vascular disease. Resident #79's comprehensive care plan included the following area of focus, in part: Anticoagulant: The resident is at risk for bleeding, hemorrhage, excessive bruising and…
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.
- No harm found · Bcited before2022-10-14 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure a comprehensive care plan was accurate for 1 of 32 reviewed for comprehensive care plans. Findings included: Resident # 152 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #162 discharged on 6/8/22. Resident #152 was admitted with a diagnosis of acute chronic congestive heart failure, displaced fracture of right femur, morbid obesity due to excess calories. Residents comprehensive care plan revised on 5/17/22 included a focus area of Activities of Daily living (ADLs) self-care performance deficit related to activity intolerance. The following interventions were included for transfers: Resident #152 is a one assist. An admission minimum data set (MDS) dated [DATE] assessed Resident #152 as having a moderate cognitive impairment. Resident's MDS revealed resident #152 required extensive assistance with the assistance of two plus persons for physical assist for bed mobility, transfers, dressing and personal hygiene.…
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.
- No harm found · Bcited before2022-10-14 · tag F0657 — failed to keep the care plan current — patternDevelop 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 staff interview, record review the facility failed to review and revise comprehensive care plans for 3 of 10 residents reviewed for comprehensive care plan review and revision. The resident's care plan must be reviewed after each assessment time frame and revised based on changing goals, preferences and needs of the resident and in response to current interventions for the resident to meet resident care needs (Residents # 80, # 59, and # 34). Findings included: 1.Resident # 80 was admitted to the facility on [DATE] with diagnoses that included weakness, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), cerebral infarction, cervical disc degeneration and fracture of the left tibia (larger of the two bones between the knee and the ankle) and left medial malleolus (the bump that protrudes on the inner side of your ankle it is part of the tibia). Review of a care plan for Resident # 80 revised most recently on 03/17/22 revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFEWORKS REHAB — 64 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.1 | -0.1 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 63 homes this chain runs (chain average 2.1★, per CMS)
Showing 40 of 63; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LEXINGTON HOLDINGS I LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/2021 |
| CHARLES 1994 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| CK 2008 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| DRM SOUTH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| EDWARD 1998 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| LAUREN 2020 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| LAUREN 2020 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| LEPS 2003 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| NORMAN 5571 & FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2019 |
| NORMAN 5571 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| NORMAN 5571 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| RL 2008 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| ROBIN 2008 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| ROBIN 2008 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SAUL 2012 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SPRINGROCK SOUTH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SUMMER SOUTH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| GARRETT, ALEXANDRA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 01/26/2024 |
| RSBRM SOUTH MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2021 |
CMS files one row per role, so the 20 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
18 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345419. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-29, 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.