Autumn Care of Marshville
311 W Phifer Street, Marshville, NC 28103 · For profit - Corporation · 110 certified beds · (704) 624-6643 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- inspectors recorded 6 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 (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $44,751 in federal fines (most recent 2025-08-21)
- 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 (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 5 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 improved from 1 to 3 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 | 4.5% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.7% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.5% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 14.1% | 5.9% | 6.5% | worse |
| 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 | 1.1% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.4% | 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 | 2.3% | 5.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.2% | 20.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.3% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.4% | 78.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.7% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.3% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.57 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.71 | 1.80 | 1.80 | worse |
‡ 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.
49.8% 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 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.5% 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 40 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 49.8%CMS range 39.6–59.6 | 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 | 12.1%CMS range 8.8–16.8 | 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 | 52.5% | 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 | 50.0% | 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 | 60.0% | 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 | 95.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 8.2%CMS range 4.2–14.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 110 beds and averages 80.0 residents a day — about 73% occupied, or roughly 30 beds typically open. It usually has some room. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 2.94 hrs/resident/day on weekends vs 3.46 on weekdays — 15% thinner on weekends. RN hours go from 0.36 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
15 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · J2024-09-26 · 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 staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1's vital signs included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range 12-18). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for notification of change of condition. The findings included: Resident #1 was readmitted to the facility 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.
- Immediate jeopardy · J2024-09-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and physician, Nurse Practitioner (NP), and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff failed to provide necessary care and services for 1 of 3 residents reviewed for neglect. Resident #1 had a significant change in condition on [DATE] and the nurse did not recognize the seriousness, notify the physician or provide thorough and ongoing assessments. In addition, Resident #1 was found not breathing and without a pulse on [DATE] and Cardiopulmonary Resuscitation (CPR) was not immediately administered. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for neglect (Resident #1). The findings included: This citation is cross referred to: 1. F580 Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible…
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 · J2024-09-26 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On 9/19/24 Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident #1's code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on 9/19/24. This was for 1 of 3 residents reviewed for CPR (Resident #1). The findings included: Review of the facility's CPR policy revised October 2023 indicated the following: Activate the emergency response team: The resident should not 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.
- Immediate jeopardy · Jcited before2024-09-26 · 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 Based on record review and staff, Nurse Practitioner (NP) and Medical Director (MD) interviews the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident's (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. Resident #1's vital signs, which included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen saturation at 89% (normal range between 95% and 100%) on room air, respirations 12 (normal range 12-18), and temperature 96.7 (axillary/arm pit). 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.
- Actual harm · G2025-08-21 · 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, observations, and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #2). Resident #2 was prescribed a daily low-dose aspirin for stroke prevention. Nursing Assistant (NA) #1 rolled Resident #2 away from her during incontinence care, and Resident #2 fell out of bed sustaining a laceration to her forehead, which necessitated 8 sutures to close. The findings included: Resident #2 was admitted to the facility 2/21/2019 with diagnoses including epilepsy, stroke, and hypertension.Review of the medical record revealed a physician order dated 12/3/24 for aspirin 81 milligrams administered daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #2 to be severely cognitively impaired. The MDS documented limited range of motion on one side of her upper body and for both legs. The MDS documented Resident #2 required substantial assistance…
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.
- Actual harm · Gcited before2025-01-24 · 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 Based on record review and staff and physician interviews, the facility failed to complete and document ongoing comprehensive assessments for a resident after an unwitnessed fall and to have effective systems in place for communicating changes in condition. Resident #1 was severely cognitively impaired and had an unwitnessed fall from bed on 1/5/2025. Resident #1 was assessed by a nurse immediately after the fall, with no pain or injury noted at that time. This was the only documented nursing assessment. During the 7:00 AM to 3:00 PM shift on 11/6/2025, a nurse aide observed Resident #1 wince when she was turned on her left side during care, and this was not reported to a nurse. On 1/6/2025, between 2:20 PM and 3:00 PM, the Physical Therapist (PT) and Occupational Therapist (OT) went to work with Resident #1, and she did not want to get out of bed and complained of pain in her lower right extremity after sustaining a fall over the weekend. OT #1 pulled back the covers and noted Resident #1's right lower…
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 · D2026-02-12 · 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 Resident #101, the resident's Power of Attorney (POA), and staff, the facility failed to follow professional standards of practice for medication administration for 1 of 1 resident reviewed (Resident #101) when Nurse #3 crushed and administered Atorvastatin 40 mg (milligrams), a medication used to lower cholesterol and reduce the risk of cardiovascular events such as heart attack and stroke.The findings included:Resident #101 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, epilepsy, slurred speech, and dysphagia.Review of physician orders dated 02/07/2026 revealed Atorvastatin 40 mg was ordered to be administered orally once daily. The order specified the medication was to be administered whole and was not to be crushed.Review of the manufacturer's Prescribing Information for Atorvastatin dated February 2023, revealed the tablets are to be swallowed whole and should not be crushed, chewed, or broken.Review of 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 · D2026-02-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Physician and staff interviews, the facility failed to have effective systems in place for shift change narcotic reconciliation and failed to keep discontinued narcotic medications under two locks for return to the pharmacy. This failure resulted in 30 missing oxycodone/acetaminophen 10/325 milligrams (mg) and 50 missing oxycodone 5 mg for a total of 80 missing tablets. This occurred for 2 of 2 residents reviewed for misappropriation of medications (Resident #98 and Resident #103).The findings included:Review of the medical record for Resident #98 revealed a physician order dated [DATE] for oxycodone/acetaminophen (a narcotic pain medication) 10/325 mg one (1) tablet by mouth twice per day as needed for moderate pain.Review of the medication administration record revealed on [DATE] Resident #98 received oxycodone/acetaminophen 10/325 mg at 9:21 AM for pain he rated 9 (1-10 scale with 1 being no or minimal pain and 10 being intense pain). This was administered by Medication Aide (MA) #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.
- Potential for harm · D2026-02-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 observation, record review, and interviews with Resident #101's Power of Attorney (POA), Facility Physician, Pharmacist, Nurse Practitioner #1 (NP), and staff, the facility failed to ensure Resident #101 was free from a significant medication error when Nurse #3 crushed and administered Brivaracetam (anticonvulsant medication used to control partial -onset seizures) 100 milligram (mg) extended-release, Eslicarbazepine 800 mg (anticonvulsant used to treat seizure disorders), Lamotrigine 200 mg (anticonvulsant medication used to control various types of seizures), and Xcopri 150 mg (anticonvulsant used to treat partial-onset seizures), despite physician orders indicating the medications were to be administered whole and not crushed. This deficient practice occurred 1 of 1 resident reviewed for significant medication errors (Resident #101).The findings included:Resident #101 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, epilepsy, slurred speech, 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 · D2026-02-12 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Power of Attorney (POA), the Nurse Practitioner, three dental offices, the dental Chief Compliance Officer, Chief Medical Officer, and facility staff, the facility failed to ensure necessary assistance was provided to obtain routine and emergency dental services for 1 of 1 resident reviewed (Resident #95).The findings included:Resident #95 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anoxic brain damage, unspecified intellectual disability, and hypertensive heart disease without heart failure. Resident #95 discharged from the facility on 10/13/2025.Resident #95 was care planned on 08/19/2025 with no identified dental health problems.The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #95 as cognitively intact, receiving a therapeutic diet, with no significant weight loss. The MDS further indicated no mouth or facial pain and no discomfort with chewing. Resident #95 required partial/moderate assistance with ADL,…
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 · D2024-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 disinfect a dedicated resident glucometer according to the manufacturer's germicidal disinfectant instructions for 1 of 1 observations of glucometer disinfection (Nurse #1). The findings included: The facility policy Glucometer/Point of Care blood testing and disinfection procedure dated 10/15/2015 with a revision date of 12/27/2023 read in part: wipe meter using friction with recommended type of germicidal disinfectant wipe; maintain visible wetness of meter for required kill time according to the germicidal disinfectant instructions . The label for the germicidal disposable bleach wipe instructed: Unfold wipe and thoroughly wet surface. Allow surface to remain visibly wet for 4 minutes. Let air dry. A continuous observation of Nurse #1 was conducted 11/19/24 at 11:34 AM. Nurse #1 removed Resident #73's glucometer from an unsealed zip top plastic bag with Resident #73's name on it from the medication cart drawer and proceeded to his room to check his blood glucose level. Nurse #1 placed 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 · D2023-06-22 · 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 Based on record review and staff interviews the facility failed to accurately code the behavior section and failed to code the medication section on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for MDS accuracy. (Resident #34, and #39). Findings included: 1. Resident #34 was admitted to the facility on [DATE] with a diagnosis of dementia, psychotic disturbance, mood disturbance and anxiety. A nursing progress note dated 6/4/23 read in part; Resident had been yelling mom for approximately one hour, several attempts to redirect without positive results. Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had not exhibited any behaviors during the assessment period. An interview was conducted on 6/22/23 at 12:07 PM with the facility's MDS Nurse. The MDS Nurse stated that she was responsible for coding resident behaviors on the MDS. The MDS Nurse stated that any behavior that is on the care plan would not need to be documented on the MDS if it is 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.
- Potential for harm · D2023-06-22 · 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 provide feeding assistance (Resident #54) for 1 of 5 residents who were dependent on staff for their activities of daily living needs (ADL) needs. Findings included: 1. Resident #54 was admitted to the facility on [DATE] with a diagnosis which included vascular dementia, cerebral infarction due to embolism, hemiplegia, weakness, and dysphagia. Review of Resident #54's annual Minimum Data Set, dated [DATE] revealed that she was severely cognitively impaired and required extensive assistance with eating. The Care Area Assessment worksheet dated 4/18/23 read in part; Resident #54 received a regular, mechanical soft with thin liquids diet daily requiring assistance with meals. A review of Resident #54's care plan dated 4/18/23 included a focus are for self-care deficits with an intervention which required extensive one person feeding assistance. Review of Resident #54's [NAME] form (a desktop file system that gives a brief overview 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 · D2023-06-22 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification dated 11/4/21 for one deficiency in the area of Activities of Daily Living (ADL) for dependent residents. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included: This tag is crossed referenced to: F677 - Based on record review, observation and staff interviews the facility failed to provide feeding assistance (Resident #54) for 1 of 5 residents who were dependent on staff for their activities of daily living needs (ADL) needs. During the recertification survey of 11/4/21 the facility failed to provide personal care for 2 of 3 residents related to incontinence care and nail care. An interview was conducted with the Administrator on 6/22/2023 at 12:55 PM. The Administrator…
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 · C2024-11-20 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews the facility failed to post accurate totals of licensed nurses for 4 of 4 days (11/1/2024, 11/2/2024, 11/3/2024, and 11/4/2024) reviewed for posted nurse staffing. Findings included: Review of the Daily Posted Nurse Staffing with the Staffing Coordinator on 11/20/2024 at 12:40 pm to 12:49 pm revealed discrepancies in the number of Licensed Nurses for the following dates: On 11/1/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 Licensed Practical Nurses (LPNs), but the nursing schedule indicated there was 1 LPN and 2 Certified Medication Aides (CMA). On 11/2/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 LPNs, but the nursing schedule indicated there were 2 LPNs and 1 CMA. On 11/3/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 LPNs, but the nursing schedule indicated there was 1 LPN and 2 CMAs. On11/4/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 1 Registered Nurse (RN) and 2 LPNs, but the nursing schedule indicated there was 1 RN, 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.
“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
$44,751 in federal fines across 4 penalties.
- $15,015 — penalty dated 2025-08-21
- $12,935 — penalty dated 2025-01-24
- $8,400 — penalty dated 2024-09-26
- $8,401 — penalty dated 2024-09-26
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.9 | -1.9 vs chain |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SHG AUTUMN, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2016 |
| WWBV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 09/30/2019 |
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER | — | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2019 |
| HOPPING, DARIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/21/2021 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $911K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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
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 345268. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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.