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Emerald Health & Rehab Center

54 Red Mulberry Way, Lillington, NC 27546 · For profit - Limited Liability company · 96 certified beds · (910) 814-8030 Medicare & Medicaid certified

Call the home — (910) 814-8030 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 20 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its 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)

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.

2/5
CMS overall
2 of 5
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

Hospital
Urgent care / clinic
701 S Main St · (910) 814-3201 · Call to confirm hours
Pharmacy
Grocery
Food Lion0.3 mi
401 S Main St · (999) 999-9999 · Call to confirm hours
Park
350 Alexander Dr · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 fell from 3 to 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.3%15.6%15.4%better
Long-stay residents who lose too much weight12.1%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%2.3%2.0%better
Long-stay residents with depressive symptoms5.0%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.0%3.5%3.3%better
Long-stay residents whose ability to walk worsened6.0%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.2%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.1%95.3%typical
Long-stay residents with pressure ulcers2.0%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control22.2%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.4%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine63.2%78.1%79.4%worse
Short-stay residents rehospitalized after admission27.3%22.9%22.6%worse
Short-stay residents with an outpatient ER visit11.5%12.9%12.0%typical

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.

61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.5%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
32.5%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 32.5% 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 80 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.5%CMS range 53.4–67.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.0–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge32.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting78.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge85.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.5–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.50
RN hours/ resident / day
0.84
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.26
Total nurse hours/ resident / day
0.30
RN hoursweekends
44.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 91.5 residents a day — about 95% occupied, or roughly 4 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.79 hrs/resident/day on weekends vs 3.45 on weekdays — 19% thinner on weekends. RN hours go from 0.58 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-07-24)
11
at the previous standard inspection (2024-05-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · D2025-09-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with resident, staff, and Physician, the facility failed to communicate with the physician and obtain further instructions 1) regarding steps to take when a rehabilitation resident was refusing to cooperate with safety recommendations while experiencing difficulty and pain while transferring in the manner she was attempting and which was not recommended by therapy and 2) when the resident screamed during the transfer, reported pain following the transfer, and requested to go to the hospital. This was for 1 of 3 residents reviewed for accidents (Resident # 1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] after undergoing a total left knee replacement on 7/3/25 and finding she could not care for herself at home. Additionally Resident # 1 had diagnoses of rheumatoid arthritis, gout, osteoporosis, and muscle weakness.Review of an EMS (Emergency Medical System) report revealed that prior to Resident # 1 residing at the facility,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with resident, staff, and Physician the facility failed to 1) assist a resident, who had been experiencing problems following surgery, in a transfer manner recommended by physical therapy and 2) failed to stop and communicate with the physician and the Director of Nursing for further directions when a resident was refusing a safe transfer technique before proceeding to attempt the transfer. This was for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] after undergoing a total left knee replacement on 7/3/25 and finding she could not care for herself at home. Additionally, Resident # 1 had diagnoses of rheumatoid arthritis, gout, osteoporosis, and muscle weakness. Review of an EMS (Emergency Medical System) report revealed that prior to Resident # 1 residing at the facility, she had problems with the left knee post operatively and had called emergency medical…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2025-07-24 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, records reviews, and staff interviews, the facility failed to follow the approved menu related to portion size. Seven (7) of 7 residents with physician-ordered large or double portions were served a single portion (Residents #21, #26, #36, #37, #6, #47, and #52). Seven (7) of 7 residents ordered a pureed diet received 4 ounces (oz.) of chili instead of 6 oz as specified on the menu (Residents #22, #2, #11, #1, #74, #80, and #90). Twelve (12) residents with an order for a regular or mechanical soft, low concentrated sweets diet received a full slice of cake rather than a half slice of cake as indicated on the menu (Residents #29, #30, #41, #49, #65, #69, #70, #72, #75, #79, #84, and #93). This deficient practice affected 26 of 91 residents.The findings included: 1. The Facility South Spring/Summer 2025 Diet Guide sheet indicated a single portion of chili with beans to be 6 oz. The facility dietary order list dated 7/24/25 indicated 7 residents had physician orders for double or large portions. The residents on the list included Residents #21, #26, #36, #37, #6,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews with staff, the facility failed to ensure dishware and cookware were washed and sanitized according to the manufacturer's recommendations for 1 of 1 dishwashing machine and 1 of 1 three compartment sink. This practice had the potential to affect food served to residents.The findings included: 1. The NSF Machine Operating Requirements as Manufactured by American Dish Service, Model AF3DS Operating Requirements posted information on the dishwasher indicated that wash and rinse cycles should reach a temperature of 120 degrees F. The posted information included the sanitizer level in a low-temperature dish machine was required to be 50 parts per million (ppm). Observations of the dishwasher on 7/23/25 at 11:41 AM revealed the Dietary Manager (DM) ran a load of plate domes (covers to help maintain warm food temperatures), plates, and cups through the dish machine. The wash load temperature was 84 degrees Fahrenheit (F), and the rinse load temperature was 98 degrees F. The DM stated in an interview at that time that it would take a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-24 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 staff and Resident Representative interviews and record review, the facility failed to maintain accurate code status information throughout the medical record for 1 of 15 residents reviewed for advance directives (Resident #11).The findings included:Resident # 11 was readmitted to the facility on [DATE] with diagnoses of malignant neoplasm of other parts of the uterus, anxiety, depression, and non-Alzheimer's dementia.Resident #11 had a physician's order dated 01/13/2025 for code status of Do Not Resuscitation (DNR).The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 was moderately cognitively impaired. Resident #11's care plan updated on 06/02/2025 specified the resident was a full code.On 7/23/2025 at 11:26 AM an interview with Resident #11's Representative revealed Resident #11 had been DNR since her hospital stay in January 2025 and that no changes had been made to her code status since January 2025 and there were no plans to change her code status. On 7/23/2025 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Swallowing/Nutritional Status for 1 of 24 residents reviewed for accuracy of the MDS (Resident #80).The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition and dysphagia (difficulty swallowing). An RD progress note dated 7/07/25 documented Resident #80 was not on a physician-prescribed weight-loss regimen. Review of Resident #80's comprehensive care plan revised 7/07/25 by the Registered Dietitian (RD) noted Resident #80 had an increased nutritional risk due to factors which included having an unintentional weight loss and being underweight for her age group. The care plan noted an intervention dated 7/07/25 for her to receive fortified foods with all meals due to unintended weight loss. Resident #80's annual Minimum Data Set (MDS) dated [DATE] revealed she had cognitive impairment and had no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff and Medical Director, the facility failed to provide fortified foods as ordered by the physician for weight loss and wound healing for 2 of 2 residents reviewed for nutrition (Residents #80 and #25).The findings included: 1. Resident #80 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia, dementia, Type 2 diabetes, severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). Resident #80's weights from December 2024-July 2025 revealed she had lost 14 pounds or 11.2% of her body weight in 6 months. Resident #80's Minimum Data Set (MDS) dated [DATE] noted she had impaired short and long-term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS noted she required supervision or touching assistance to eat and that she had lost more than 5% in one month or 10% of her weight in 6 months. Resident #80's comprehensive care plan updated 7/07/25 indicated she was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-28 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 1 of 36 days reviewed for sufficient staffing (4/13/24). Findings included: A review of the daily nursing staffing sheets for the month of April 2024 and May 1-6,2024 indicated there was no RN scheduled for 4/13/2024. A review of the daily census posting sheets for the month of April 2024 and May 1-6, 2024 recorded there was one RN for eight hours on 4/13/2024 during the day shift (7a.m. to 3 p.m.). The census was recorded as 88 residents on 4/13/2024. There was also no RN recorded for the evening shift (3p.m. to 11p.m.) and the night shift (11p.m. to 7 a.m.) on 4/13/2024. Therefore, on 4/13/2024, there was no RN coverage for 24 hours in the facility. A review of Nurse #1's employee timecard for April 2024 showed no time punch for 4/13/2024. In an interview with the Scheduler on 5/10/2024 at 6:32 p.m., she stated Nurse #1 only worked weekends and should had been recorded on the daily nursing staffing sheet for April 13,…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-28 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 interview, pharmacy interview and Physician interview, the facility failed to have a medication error rate less than 5% as evidenced by 6 medication errors out of 29 opportunities, resulting in a medication error rate of 20.69% for 1 of 2 residents observed during the medication administration observations. Finding included: Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, Myasthenia Gravis (an autoimmune condition that causes muscle weakness that gets worse with activity and better with rest), anxiety disorder and atrial fibrillation (irregular heart rate). The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #76 was cognitively intact was using a gastrostomy tube (a devices surgically placed in the stomach for supplemental feeding, hydration and medications) for a nutritional approach Physician's orders included the following medications for Resident #76: * Amiodarone HCL (used to treat irregular…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interviews, the facility failed to maintain kitchen equipment in a clean and sanitary condition to prevent cross contamination by failing to clean under the shelf of 1 of 1 steam table observed. This practice had the potential to affect food served to the residents in the facility. The findings included: During an observation of the kitchen on 5/08/24 at 8:36 AM, the five well steam table was observed with dark dried food particles under the 5-foot steam table shelf. During an observation of the kitchen on 5/10/24 at 8:23 AM, the five well steam table was observed with dark dried food particles under the 5-foot steam table shelf. In an interview with the Dietary Manager on 5/10/24 at 8:39 AM, he indicated he would have staff clean the steam table shelf and start a daily check of the area. In an interview on 5/10/24 at 12:34 PM, the Administrator indicated he would expect the kitchen staff to clean the steam table shelf.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2024-05-28 · tag F0839 — pattern
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    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, North Carolina Board of Nursing (NCBON) verification registry and staff interviews, the facility failed to verify a staff member working as a nurse (Nurse Aide #7) had an active professional nursing license with the NCBON for 1 of 4 nursing staff reviewed. NA #7 was in nursing school, did not have a professional nursing license and performed the job responsibilities of a nurse. Findings included: A review of NA #7's application with the facility indicated she was hired as a Nurse Aide on [DATE] and was attending school for nursing. The North Carolina Health Care Professional Registry (NCHCPR) validation inquiry dated [DATE] indicated NA #7's Nurse Aide I Registry listing expired on [DATE]. NA #7 was not listed as a North Carolina Medication Aide on the NCHCPR. An Employee Change of Status form dated [DATE] indicated a promotion for NA #7, and the employment status change was due to NA #7 receiving a licensed practical nursing (LPN) license. There was no LPN licensure verification for NA…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-28 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interviews and Physician #1 interview the facility failed to complete an accurate medical record in documenting blood glucose (sugar) levels and sliding scale insulin coverage of blood glucose levels (Resident #66), the administration of enteral feedings (Resident #76), and the administration of medications (Resident #66, Resident #76 and Resident #245) for 3 of 10 residents whose medication regimen was reviewed. Findings included: 1. a. Resident #66 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus. Physician's orders dated 12/18/2023 included an order for Humalog (fast acting insulin that lowers the blood glucose level) injection Solution 100 units/milliliter per sliding scale insulin subcutaneously before meals and at bedtime for Diabetes Mellitus. The sliding scale instructions for administration were the following: *If Blood Sugar was 71 to 150, give 0 Units. *If Blood Sugar was 151 to 200, give 2 Units. *If Blood Sugar was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, residents and staff interviews, the facility failed to allow a resident to participate in the development of their care plan for 1 of 6 residents reviewed for care plan participation (Resident # 66). The findings were: Resident #66 was admitted to the facility on [DATE] and was discharged from the facility due to a hospitalization on 11/28/2023. Resident #66 was re-admitted to the facility on [DATE]. Resident #66's initial care plan dated 11/01/2023 had been updated on the following dates: *12/11/2023 to include a focus for bladder incontinence related to immobility. *2/19/2024 to include a focus for long term placement at the facility due to wound care. *3/13/2024 to include a focus for edema. There was no documentation of a care plan meeting that included the resident's participation in Resident #66's medical record since his readmission on [DATE]. Quarterly Minimum Data Set (MDS) assessments were conducted on 12/20/2023 and 02/20/2024 and both indicated Resident #66 was cognitively…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews, the facility failed to provide incontinence care to a resident that was incontinent for 1 of 4 residents dependent on staff for activities of daily living (ADL) care (Resident #244). Findings included: Resident #244 was admitted to the facility on [DATE] to the facility with diagnoses including Diabetes Mellitus and hypertension. Resident #244's care plan dated 4/19/2024 included a focus for assisting with activities of daily living and stated Resident #244 required one person to assist with toileting. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #244 was cognitively intact, had an indwelling urinary catheter, frequently was incontinent of stool and was dependent on nursing staff for toileting. Physician orders dated 4/30/3024 indicated Resident #244's urinary catheter was discontinued. Physical Therapy Aide (PTA #1) recorded on 5/6/2024 in Resident #244's therapy notes she was tearful and was waiting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and family, staff and physician interviews, the facility failed to implement interventions to reduce the risk for further falls for a resident at high risk for falls for 1 of 4 residents reviewed for accidents (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses including encephalopathy (damage or disease that affects the brain), diabetes, Crohn's disease, aphasia (difficulty expressing herself), epilepsy and epileptic syndromes (seizures), right sided paralysis, cerebral infarction (stroke), congestive heart failure, and muscle weakness. Review of Resident #82's comprehensive care plan dated 2/26/24 revealed she needed the assistance of one staff member for transfers. The care plan noted Resident #82 was at risk of falls related to cerebral infarction, muscle weakness, Crohn's Disease and Congestive Heart Failure. Interventions included to minimize risks for falls / minimize injuries, educate resident / family 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-28 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    Based on record review, and staff and Medical Director (MD) interviews, the facility failed to ensure a resident did not receive anticoagulant medication (blood thinner) that had been discontinued for a resident with a subdural hematoma (brain bleed) and at risk for falls for 1 of 3 residents reviewed for unnecessary medications (Resident #82). The findings were: Resident #82 was admitted to the facility 2/26/24 with diagnoses including epilepsy and epileptic syndromes, hemiplegia and hemiparesis affecting right dominant side, and cerebral infarction (stroke). Review of Resident #82's hospital discharge note dated 5/02/24 revealed she was diagnosed with a 2 millimeter subdural hematoma (brain bleed). While in the hospital, Resident #82's Eliquis was discontinued to prevent further bleeding. Review of Resident #82's physician's orders revealed she was taking Eliquis (a blood thinner) 2.5 mg twice a day. The order was discontinued on 5/2/24. There were no orders to restart the medication. Review of Resident #82's electronic Medication Administration Record (eMAR) for May 2024 on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-28 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to ensure the area surrounding the one dumpster on the campus was free of debris and the dumpster door was closed for 2 or 2 observations. The findings included: During an observation of the dumpster area on 5/08/24 at 8:10 AM, the dumpster door was open with one disposable glove and one clear plastic trash bag observed beside the dumpster. During an observation of the dumpster area on 5/10/24 at 10:02 AM, the dumpster door was open with one disposable glove, and one clear plastic trash bag observed beside the dumpster. An observation was conducted with the Dietary Manager on 5/10/24 at 10:17 AM and the dumpster area was observed to be in the same condition (with one disposable glove, and one clear plastic trash bag observed beside the dumpster). In an interview on 05/10/24 at 10:17 AM, the Dietary Manager revealed kitchen staff shared responsibility with housekeeping staff to keep the dumpster area clean and door closed. In an interview on 5/10/24 at 12:34 PM, the Administrator indicated he would remind all staff 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews, the facility failed to ensure staff spoke to a resident in a respectful and dignified manner for 1 of 1 resident (Resident #44) reviewed for dignity. Findings included: Resident #44 was admitted to the facility on [DATE] and discharged on 1/4/2023. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. In an initial pool interview with Resident #44 on 1/3/2023 at 3:45 p.m., she stated on 12/24/2022 at 8:00 p.m. when she went up to the nursing station and asked the nurse (name unknown) who was head of housekeeping because her room had been nasty for two days. She stated the nurse and her got into a shouting match with each other and stated the nurse asked her, Why you up here at 8:00 p.m. to ask about housekeeping and you had all day. Ain't no nurse going to clean the room tonight. Resident #44 stated she had spoken to Nurse #4 about the incident and was unable to recall exactly when. On 1/6/2023…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to discard an expired medication and store Gabapentin liquid, a seizure medication, in the refrigerator as indicated on the pharmacy label and bottle of medication for 1 of 2 medications carts observed (Front 300-Hall Medication Cart). Findings included: a. An observation of the Front 300-Hall Medication Cart was conducted on 1/4/2023 at 5:36 a.m. in the presence of Nurse #1. A four ounce opened bottle of Guaiasorb DM (dextromethorphan) liquid, an expectorant cough suppressant, was observed in the facility stock medication drawer for liquids dated opened on 12/20/2022, and the expiration date on the bottle of Guaiasorb DM was 6/2022. The medication was not prescribed to one particular resident. Nurse #1 stated she checked medication expiration dates when administering medications and had not administered the medication to any residents. She stated she had not checked all medications on the cart for expiration dates and was unsure who was responsible for checking the medication cart for expired medications. Nurse #1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-05-28 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident interviews and staff interviews, the facility failed to display survey results in a location accessible to residents during observations of the facility. This failure affected all residents in the facility. The findings included: During a tour of the facility on 5/07/24 at 10:07 AM, the survey results were not located in the building. A Resident Council group meeting was conducted on 5/08/24 at 1:15 PM. During the meeting, the residents indicated the survey results were located on a wall near the nurse's station. Tours of the facility on 5/08/24 at 1:26 PM and 5/10/24 at 8:54 AM revealed the survey inspection results binder were not located in the facility. In an interview on 5/10/24 at 8:54 AM, Nurse #2 stated she was not aware of the location of the survey inspection results. In an interview on 5/10/24 at 8:56 AM, the Social Worker indicated she was not aware of where the survey results were posted and indicated Nurse #2 should know. During an interview and observation conducted with the Administrator on 5/10/24 at 9:11AM, he stated the survey…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
BUNDLE TENANT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/01/2023
SABER GOVERNANCE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/01/2020
SHG MANAGEMENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICERsince 03/01/2019
DAVIS, TIMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/02/2025
JOINER, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/17/2023
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 08/01/2012
HARNETT HEALTH INVESTORS LPOrganizationADP OF THE SNFsince 08/01/2015
THE HUNTINGTON NATIONAL BANKOrganizationADP OF THE SNFsince 07/19/2019
WALKER & ASSOCIATES PCOrganizationADP OF THE SNFsince 12/18/2023
PIEPER, JOELIndividualADP OF THE SNFsince 01/09/2023

CMS files one row per role, so the 21 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$11.2M
Net patient revenuemost recent cost report
+16.0%
Operating marginrevenue minus expenses
$989K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 7%Other / private 29%

This home reported $989K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$296per resident / day
operating cost
$9,004per month
≈ monthly operating cost
$353per day
avg. revenue, all payers

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

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345173. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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