Glenwood Health & Rehabilitation

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

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

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

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

43.5% 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 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.3% 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 59 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% 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.

Staffing

How full it usually is: this home is certified for 130 beds and averages 98.4 residents a day — about 76% occupied, or roughly 32 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.03 hrs/resident/day on weekends vs 3.38 on weekdays — 10% thinner on weekends. RN hours go from 0.68 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 61% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

49 citations, most serious first. The 19 most serious are shown; the remaining 30 are one tap away and print in full.

• Immediate jeopardy · J2025-04-08 · 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 reviews, and facility staff, Physician Assistant (PA) and Medical Director interviews, the facility failed to immediately notify the PA when Resident #1 had an acute change in condition after a fall. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. The PA was not notified until 4:50 PM on 03/26/25 of the acute change in condition. The PA ordered bloodwork, urinalysis with culture and sensitivity, and a chest x-ray for reports of lethargy. On 03/27/25 at 9:58 AM Resident #1's family came to the facility and found him…

  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
• Immediate jeopardy · J2025-04-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, Emergency Medical Services (EMS) records, facility staff, Emergency Department (ED) Physician, Physician Assistant (PA) and Medical Director interviews, the facility failed to recognize the severity of an acute change in condition after a fall for Resident #1. Resident #1 had a past medical history that included atrial fibrillation with anticoagulation, recent pulmonary embolism, recent COVID-19, history of traumatic brain injury (TBI), history of hemiplegia (paralysis on one side of body) following a cerebral infarction, and history of previous subdural hematoma. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately…

  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
• Immediate jeopardy · K2024-02-01 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, news article review, North Carolina Board of Nursing Investigator, power of attorney, and detective interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to immediately initiate protective measures to safeguard residents from misappropriation of property and complete a thorough investigation when they received a report from local law enforcement of misappropriation of resident property. On 05/18/23 the facility received a call from Detective #1 informing them that Nurse #1 had been involved in a traffic stop and was in possession of Resident #156's driver's license, social security card, and debit card. There was a high likelihood that Nurse #1 misappropriated the property of other residents leading to the loss of financial resources for residents who resided at the facility at the time of Nurse #1's employment. The facility also failed to thoroughly investigate an allegation of abuse (Resident #28). This deficient practice was for 2 of 3…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-01 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, news article review, North Carolina Board of Nursing Investigator, staff, power of attorney, and detective interviews the facility failed to assure that a resident's (Resident #156) property was safeguarded, and that staff did not misappropriate the resident's property. Nurse #1 was found to have in her possession Resident #156's driver's license, social security card, and debit card without his permission or knowledge and was alleged to have made unauthorized charges on the debit card which included reoccurring charges to a taxi services, online shopping services, and a gas station in a nearby county (Gastonia). The unauthorized charges started in February 2023 and recurred until the card was cancelled in [DATE] for an undisclosed amount of money. The reasonable person concept was applied for this deficient practice in that a reasonable person would have the high likelihood of being upset about the loss of financial resources, the invasion into one's personal financial status, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, and record reviews, the facility failed to protect a resident's right to be free from physical abuse when a Nursing Assistant woke a resident from his sleep to provide incontinent care against his will and held the resident's arms while the resident was fighting for 1 of 3 sampled residents (Resident #2). A skin tear to the resident's left lower forearm was noted after this incident. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, pacemaker, type II diabetes mellitus with chronic kidney disease, and major depressive disorder. A review of the 09/26/2024 provider progress notes on Resident #2 revealed major depression with psychosis with psychiatric features, moderate depression with psychosis, intermittent unfounded accusations toward staff and facility with paranoid ideations, and that [NAME] wanted to kill him. Psychotherapy and evaluation and aggression with paranoid ideations were pending…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-07-15 · 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, family, and staff interview the facility failed to treat a resident in a dignified manner by not responding to a call light and meeting the resident's request which led to the resident's brief and bed being wet with urine requiring an entire bed change. The resident stated this made her feel unwanted, belittled, and uncared for by everyone except her family or 1 of 2 residents reviewed for dignity (Resident #72). The findings included: Resident #72 was readmitted to the facility on [DATE] with diagnoses of Guillain Baree syndrome and dementia and was discharged from the facility on 07/09/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of one staff member for toileting and was always incontinent of bladder. Review of the facility daily assignment sheet for 07/09/22 for 3:00 PM to 11:00 PM revealed that Nurse Aide (NA) #3, NA #10, and NA #11 were assigned on the unit where Resident #72…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-07-15 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interview the facility failed to honor a resident choice to have two showers a week (Resident #131) and failed to keep a resident's wheelchair beside his bed per his choice (Resident #47) for 2 of 3 resident reviewed for choices. The findings included: 1. Resident #131 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of Social Service assessment dated [DATE] revealed Resident #131 was cognitively intact. Review of the facility's shower schedule revealed Resident #131 was scheduled for showers on Wednesday and Friday on first shift. Review of Resident #131's documentation report for bathing dated July 2022 indicated that on first shift on Wednesday 07/06/22 Nurse Aide (NA) #4 documented a partial but did not specify if it was a bed bath or shower and on Friday 07/08/22 NA #5 documented a bed bath. An observation and interview were conducted with Resident #131 on 07/11/22 at 10:28 AM. Resident…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-07-15 · 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, family, and staff interviews the facility failed to provide incontinence care before the resident wet through her brief and bed linens (Resident #72) and provide assistance to maintain personal hygiene (Resident #131) for 2 of 5 resident reviewed for activities of daily living. The finding included: Resident #72 was readmitted to the facility on [DATE] with diagnoses of Guillain Baree syndrome and dementia and was discharged from the facility on 07/09/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of one staff member for toileting and was always incontinent of bladder. Review of the facility daily assignment sheet for 07/09/22 for 3:00 PM to 11:00 PM revealed that Nurse Aide (NA) #3, NA #10, and NA #11 were assigned on the unit where Resident #72 resided. An interview was conducted with Resident #72's family member on 07/11/22 at 1:58 PM who stated on 07/09/22 she received a video…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-07-15 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interview the facility ' s Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 4/15/21 and the complaint investigation completed on 01/14/22. This was for four repeat deficiencies in the area of advance directives, home like environment, medication storage, and food storage that were originally cited on 04/15/21 during a recertification and complaint survey and for three repeat citations in the area of respect and dignity, grievances, and activities of daily living that were originally cited on 01/14/22 during a complaint investigation. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The finding included: This citation is cross referred to: F550: Based on record review,…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-15 · 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 and staff interviews, the facility failed to label and date open food items and discard items that were beyond their expiration date in 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator in the kitchen. The findings included: An observation of the facility's kitchen completed on 5/12/25 at 10:31 AM revealed a small plate with six slices of tomato with no use by date and a carton of whole milk with a use by date of 4/14/25 located in the facility's reach-in refrigerator. Additional observations at this time of the facility's walk-in fridge revealed an open and undated package of diced ham, two open and undated packages of sliced ham, an open and undated package of sliced turkey breast, a pan of cooked alfredo pasta that was open and undated, an open and undated pan of sliced pork, and open and undated bag of white and orange shredded cheese, and open and undated package of sliced American cheese, and 16 premade peanut butter and jelly and ham and cheese sandwiches that were dated to be used by 4/05/25. During an interview with the Dietary Manager 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with new mental health diagnoses for 2 of 3 residents (Resident #18 and #61) reviewed for PASRR. The findings include: 1. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. PASRR level I was completed on 6/12/23 prior to Resident #18's admission with a recommendation to resubmit paperwork for a PASRR level II if Resident #18 received a new mental health diagnosis or if there was a significant change in condition. The electronic medical record revealed Resident #18 was diagnosed with bipolar disorder on 10/15/24 and major depressive disorder on 12/17/24. No PASRR level II was completed. An interview on 5/14/25 at 2:00 PM with Social Worker (SW) #1 revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff and Resident interviews, the facility failed to obtain an order for the size of a urinary catheter and change the catheter as ordered for 1 of 1 resident (Resident #87) reviewed for urinary catheters. The findings included: a. Resident #87 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy (a blockage or hinderance in the flow of urine from the kidneys through the ureters and into the bladder, and then out through the urethra). Review of Resident #87's Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and had an indwelling urinary catheter. Review of Resident #87's physician orders dated 4/04/25 revealed an order to change urinary catheter in the facility every 28 days. There was no order for the size of urinary catheter. Review of Resident #87's Medication Administration Record for 4/2025 indicated the Resident's urinary catheter was changed last on 4/04/25 by Nurse #4. An interview 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to post cautionary oxygen signage on 1 of 2 oxygen storage rooms where full portable oxygen cylinders were stored. The facility also failed to maintain a clean oxygen concentrator filter for 1 of 5 residents reviewed for respiratory care (Resident #46). Findings included: 1. Observations of oxygen storage closet #1 located on the 300 hall on 05/14/25 at 10:48 AM, 1:34 PM, and 3:58 PM revealed closet #1 had a laminated sign labeled full tanks. There was no cautionary oxygen signage noted on the door. There were 48 full oxygen tanks stored in closet #1. An interview with the Interim Director of Nursing on 05/15/25 at 8:43 AM revealed that oxygen storage areas should be labeled with cautionary no smoking signage. #2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, sleep apnea, and chronic respiratory failure. Review of Resident #46's quarterly Minimum Data Set assessment…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  b. On 05/13/25 at 9:45 AM the Wound Nurse prepared to perform wound care on Resident #61 who had an Enhanced Barrier Precaution sign on his door. The sign indicated wearing gloves and a gown for high contact resident care activities which included wound care. The Wound Nurse washed her hands and applied her gloves then prepared the work field on the over bed table. She then positioned Resident #61 on his right side to expose the stage IV pressure ulcer on his left ischium (hip bone) which had no dressing on it. The Wound Nurse cleansed the wound then removed her gloves and applied clean gloves without washing her hands. The Wound Nurse then applied the ordered treatment and covered the wound with a border dressing to complete the wound care. The Wound Nurse did not don a gown per the Enhanced Barrier Precautions. An interview was conducted with the Wound Nurse on 05/14/25 at 2:34 PM. The Wound Nurse explained that she was aware of the Enhanced Barrier Precautions sign that was posted on Resident #61's door but she thought she only had to wear the gown if the wound had the potential…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-02-01 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interviews the facility failed to employ a qualified director of food and nutrition services. The findings included: An interview was conducted with the Interim Dietary Manager #1 (DM) on 1/25/24 at 2:17 PM and revealed that he had taken over as the Dietary Manager this week. He stated that the food service company that employed him sent him to this facility on 01/22/24 (Monday) to assume the Dietary Manager position. He stated the previous DM #2 was out sick this week, but she had been working as the DM for this facility for about 8-9 months. DM #1 stated he had worked in the food industry for about 40 years, and he confirmed he had a dietary manger certification. However, he stated he and his organization were aware DM #2 did not have a Dietary Manager certification and he was unsure how long he would be in this current role. He stated DM #2 would be working in the facility as a dietary aide for now. In a phone interview on 1/30/24 with DM #2, she stated she had been working at the facility since March 2023. DM #2 stated she did not have her Dietary Manager…

  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 · Ecited before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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, video footage review, staff, and Nurse Practitioner interviews the facility failed to redirect and implement effective interventions to prevent a severely cognitively impaired resident with a history of wandering and exit seeking behaviors and wore a wander guard (alarm used to prevent resident from exiting the building) from exiting the building unsupervised (Resident #155). The facility also failed to effectively supervise and remain with a resident with dementia and had a history of wandering and wore a wander guard who was observed by the Receptionist to exit the building (Resident #95). This deficient practice affected 2 of 2 residents reviewed for accidents. The findings included: 1. Review of a facility policy titled, Elopements and Wandering Residents dated 11/23/23 read, Elopement occurs when a resident leaves the premises or safe area without authorization (i.e an order for discharge or leave of absence) and /or any necessary supervision to do so. Any staff member…

  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 · Ecited before2024-02-01 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff and consultant pharmacist interviews the facility failed to: 1) label medications with the minimum information required, including the first and last name of the resident on 1 of 7 medication (med) carts observed (300 Distal); 2) store medications in accordance with the pharmacy storage instructions on 3 of 7 med carts (100 Even, 200 and 200/600 Split); 3) failed to remove lose and unsecure pills/capsules from 6 of 7 med carts (300 Distal, 100 Even, 300 Proximal, 200 Hall, 200/600 Split and 600 Hall) and 4) failed to remove expired medication from the refrigerator in 1 of 2 med rooms (100 Hall) reviewed for medication storage. The findings included: The medication storage information sheet from the facility's pharmacy dated 09/2021 revealed Humulin R insulin expired within 28 days of opening. 1. On [DATE] at 2:41 PM an observation was conducted on 300 Distal med cart with Nurse #3. Stored on the med cart was a vial of Humulin R insulin that had no resident's name or…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-01 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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, staff, and resident interviews, and test tray observation the facility failed to serve food that was palatable in temperature and appearance for 3 of 8 residents reviewed for food (Resident #42, Resident #65, and Resident #107). The findings included: 1a. Resident #42 was admitted to the facility on [DATE] with diagnoses that included moderate protein calorie malnutrition, and history of pressure ulcer of left lower back. Review of a physician order dated 02/29/20 read, regular diet, regular texture, and regular thin consistency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 was cognitively intact and required set up assistance only with feeding. An observation and interview were conducted with Resident #42 on 01/25/24 at 2:01 PM. Resident #42 had just returned to her room from the dining room. As Resident #42 was going down the hallway to her room she was overheard telling her next-door neighbors that were on the hall, don't get excited…

  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 · Ecited before2024-02-01 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set 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 reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigations that occurred on 01/14/22, 09/20/22 and the recertification and complaint investigations that occurred on 04/15/21 and 07/15/22. This failure was for seven deficiencies that were originally cited in the areas of Resident Assessment (F641), Quality of Life (F677), Quality of Care (F689), Pharmacy Services (F761), Resident Rights (F550 & F584) and Comprehensive Resident Centered Care Plan (F661) and were subsequently recited on the current recertification and complaint survey on 02/01/24. The continued failure of the facility during five federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F550: Based on record reviews, and resident and staff interviews, the facility failed to treat residents in 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.

  Administration Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$201,886 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $105,195 — penalty dated 2025-04-08
• $96,691 — penalty dated 2024-02-01
• Medicare payment denial — starting 2024-03-02 for 3 days

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.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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 $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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