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Magnolia Lane Nursing and Rehabilitation Center

107 Magnolia Drive, Morganton, NC 28655 · For profit - Limited Liability company · 121 certified beds · (828) 437-8760 Medicare & Medicaid certified

Call the home — (828) 437-8760 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Sep 2024Resident-funds citation (F0565)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2024
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 23% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
695 W Fleming Dr · (828) 580-3278 · Call to confirm hours
Pharmacy
200 W Fleming Dr · (828) 438-9355 · Call to confirm hours
Grocery
Aldi0.6 mi
528 W Fleming Dr · (855) 955-2534 · Call to confirm hours
Park
200 Collett St · (828) 438-5350 · Typically dawn to dusk
Place of worship
600 Burkemont Ave · (828) 439-9921

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.2%15.6%15.4%better
Long-stay residents who lose too much weight8.5%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection0.8%2.3%2.0%better
Long-stay residents with depressive symptoms1.7%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.8%3.5%3.3%better
Long-stay residents whose ability to walk worsened7.3%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication32.4%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%94.1%95.3%typical
Long-stay residents with pressure ulcers6.4%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control12.1%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.8%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine79.5%78.1%79.4%typical
Short-stay residents rehospitalized after admission19.0%22.9%22.6%better
Short-stay residents with an outpatient ER visit21.1%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.751.781.67typical
Long-stay outpatient ER visits per 1,000 resident days1.981.801.80typical

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.

10.6%U.S. median 10.7%
Went back to hospital
54.2%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 54.2% 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 24 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.1–16.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge29.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.2–15.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.65
RN hours/ resident / day
0.53
LPN hours/ resident / day
2.14
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.37
RN hoursweekends
50.8%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 121 beds and averages 69.0 residents a day — about 57% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.04 hrs/resident/day on weekends vs 3.42 on weekdays — 11% thinner on weekends. RN hours go from 0.76 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as 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

10
deficiencies at the latest standard inspection (2025-12-19)
11
at the previous standard inspection (2024-09-25)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2023-08-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, resident, and Medical Director interviews the facility failed to assist a resident with a transfer from the wheelchair to bed when Nurse Aide (NA) #1 stood behind Resident #4 and allowed the resident to transfer independently. Resident #4's leg slipped, the resident fell onto the bed and experienced shoulder pain. Resident #4 sustained a left humeral head fracture of the shoulder as was noted on the CT (computed tomography) scan on 7/20/2023. This was for 1 of 3 residents reviewed for supervision to prevent accidents. The findings included: Resident #4 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), primary osteoarthritis of the left shoulder, stroke, atrial fibrillation, and left hemiplegia. Review of the physician orders for Resident #4 included Apixaban (blood thinner) 5mg (milligrams) by mouth twice a day for Atrial Fibrillation. Ordered 6/19/2023. A review of the physical therapy evaluation conducted on 6/21/2023…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-19 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns and document in writing the facility's response and rationale to concerns voiced during Resident Council meetings for 5 of 10 Resident Council meetings reviewed (January 2025, March 2025, June 2025, July 2025, and August 2025).Findings included:The Resident Council minutes for December 2024 (no day listed) noted that residents voiced a concern regarding the daily menus were not being posted again. The Resident Council minutes for January 2025 (no day listed) revealed residents voiced they had noticed the daily menus were being posted but they would like more variety. There was no further details documented of the facility's response, actions and rationale taken to address of the facility concern.The Resident Council minutes for February 2025 (no day listed) revealed no documentation of the facility's response, actions and rationale taken to address the food concerns voiced during the previous meeting or if the concern was still ongoing.The 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
  • Potential for harm · E2025-12-19 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for residents who were admitted to the facility with serious mental health disorders for 4 of 4 residents reviewed for PASRR (Resident #37, Resident #7, Resident #52 and Resident #50).Findings included: 1. A PASRR Determination Notification letter dated 07/15/25 revealed Resident #37 had a Level I PASRR with no expiration date. Resident #37 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, post-traumatic stress disorder (PTSD) and bipolar disorder. A staff progress note dated 10/01/25 at 1:44 PM written by the Social Worker (SW) revealed a baseline care plan meeting was held with Resident #37. The SW noted Resident #37 shared a history of significant trauma, including experiences related to war, and had diagnoses of PTSD and bipolar disorder. A physician's progress note dated 10/03/25 revealed…

    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 · Ecited before2025-12-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to discard food past its use-by date in 1 of 1 walk-in cooler and store food off the floor in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Dietary Manager on 12/15/25 at 9:59 AM, the walk-in cooler had two (2) one-quart sized containers of lemon-flavored thickener with a use-by date of 10/28/25.b. During an initial observation of the facility's kitchen with the Dietary Manager on 12/15/25 at 10:12 AM the walk-in freezer was noted to have the following concerns:-Three (3) boxes of frozen turkeys, four turkeys per box, placed on the floor in the center of the walk-in freezer.-One (1) box of french toast sticks placed on the floor in the center of the walk-in freezer.An interview with the Dietary Manager on 12/16/25 3:14PM revealed that food items should not be available to be served to residents past the use-by date and the turkeys and french toast sticks were not stored correctly in…

    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 · D2025-12-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the Do Not Resuscitate (DNR) form was signed by the physician and part of the medical record after the physician ordered for the resident to be Do Not Resuscitate for 1 of 21 residents reviewed for advanced directives (Resident #2). The findings included:Resident #2 was admitted to the facility on [DATE]. Review of the physician's signed orders dated [DATE] revealed admission to Hospice with diagnosis of malignant neoplasm (a cancerous tumor) of the gallbladder. Review of the physician's signed orders dated [DATE] revealed an order for Resident #2 to be a Do Not Resuscitate (DNR).An interview with the former Assistant Director of Nursing (ADON) who entered the DNR order was attempted but unsuccessful. Review of Resident #2's electronic medical record revealed no evidence a DNR form was completed and signed by the physician.An attempt to contact Resident #2's Responsible Party (RP) was made but unsuccessful.Review of the quarterly Minimum…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) to beneficiaries who intended to continue services and the SNF believed the services may not be covered under Medicare prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification review (Residents #6, #16, and #76).Findings included:1. Resident #6 was admitted to the facility on [DATE].A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #6 on 09/19/25 which indicated his Medicare Part A coverage for skilled services would end on 09/23/25. Resident #6 remained in the facility. Resident #6's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #6. During an interview on 12/16/25…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-19 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to ensure a qualified staff member with the necessary skills and licensure inserted a peripheral intravenous (IV) catheter when a Medication Aide used the needle from an IV catheter kit and inserted it into a resident's arm (Resident #78). The deficient practice was identified for 1 of 5 nursing staff reviewed for sufficient and competent nurse staffing (Medication Aide #1). Findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses that included arthritis, dementia, Alzheimer's disease, and diabetes mellitus. Resident #78 was discharged from the facility on 11/16/25. The admission Minimum Data Set assessment dated [DATE] revealed Resident #78 was severely impaired cognitively, was dependent or required substantial to maximum assistance with activities of daily living, and had taken antianxiety, antibiotic, antiplatelet medications during the lookback period of the assessment.Review of Resident #78's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-19 · 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, observations, and staff interviews, the facility failed to maintain oral hygiene for a dependent resident unable to brush their teeth for 1 of 3 residents reviewed for activities of daily living (Resident #31). The findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses including autoimmune disease affecting the central nervous system, paralysis or severe weakness affecting the ability to move, and visual impairment. A review of the dental visit note dated 10/13/25 revealed Resident #31's periodontal health was documented as red tissue with a heavy buildup, plaque and calculus as heavy and oral hygiene as poor. The recommendations were for routine oral hygiene and follow up as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely impaired cognitively, had upper extremity range of motion impairment on both sides, and was dependent on staff for oral hygiene. The care plan revised on 10/23/25 revealed Resident #31…

    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 before2025-12-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on record review and interviews with the Pharmacy Operation Manager and staff, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy for 3 of 3 residents (Resident #15, Resident #25 and Resident #79).The findings included:a. The physician's order dated 03/19/25 revealed Resident #15 was to receive hydrocodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication to relieve pain) 5-325 milligrams (mg) every 4 hours as needed (PRN) for left leg pain.The controlled substance count record dated 03/20/25 revealed Resident #15 had 30 tablets of hydrocodone-acetaminophen 5-325 mg with the RX# (prescription number) 17427852. Starting on 03/20/25, nurses signed the form indicating the medication was removed and administered to Resident #15 as follows: one dose on 3/20/25, one dose on 3/21/25, one dose on 3/24/25, one dose on 3/26/25, one dose on 3/31/25, one dose on 4/1/25, one dose on 4/8/25, one dose on 4/11/25, one dose on 4/12/25, one dose on 4/13/25, two doses on 4/14/25, one dose on…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-12-19 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews with the Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order for double portions at breakfast and the enriched meal program for 1 of 5 residents reviewed for nutrition (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and moderate protein-calorie malnutrition. The admission Minimum Data Set assessment dated [DATE] revealed Resident #52 was severely impaired cognitively, required partial to moderate assistance with eating, had no swallowing disorders, weighed 101 pounds with no documented weight changes, and had a stage two (partial-thickness loss of skin with exposed dermis) pressure ulcer that was present on admission. Review of the RD progress note dated 10/27/25 included recommendations Resident #52 participated in the enriched meal program and received double portions at breakfast. Review of the physician's orders revealed a diet…

    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 · D2025-12-19 · 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

    Based on record review, observations, and staff interviews, the facility failed to implement their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #2 did not put on a protective gown prior to a high contact care activity that involved administering a nutritional supplement and water flushes through a resident's (Resident #45) feeding tube (a medical device inserted into the stomach). This occurred for 1 of 5 staff members reviewed for infection control practices (Nurse #2). Findings included: The facility's Infection Control Policy and Procedures guideline for initiation of precautions last revised on 6/13/24 read in part, isolation precautions for EBP was utilized by staff for residents who had an implanted medical device when providing care and precautions included to wear a gown. A continuous observation on 12/15/25 at 12:04 PM through 12:27 PM revealed an EBP sign was posted on the door of Resident #45's room with instructions staff must wear a gown for high contact resident care activities. High contact care activities listed included…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-09-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 and interviews with resident, staff, Medical Director (MD) and Pharmacy staff, the facility failed to have effective systems in place for acquiring and maintaining the supply of medications in the controlled medication emergency kit which resulted in an as needed pain medication not being available for Resident #1 when he was admitted to the facility. This deficient practice occurred for 1 of 3 residents reviewed for pharmacy services (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, hypertension, type 2 diabetes mellitus. Resident #1 went to the emergency room within 24 hours of admission, returned to the facility, and discharged to the hospital on 9/1/2025.During a telephone interview on 9/3/2025 at 1:52 PM Resident #1 stated he arrived at the facility late in the evening on the day he was admitted and was told he would not get any medication for at least 12 hours. Resident #1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and staff interviews, the facility failed to dry insulated bases, lids, pans and baking sheets before they were stacked for use, failed to store perishable food off the floor, failed to remove a dented canned good item stored for use, and failed to discard expired food and food items with signs of spoilage stored in 1 of 1 walk-in cooler and main dining room refrigerator. In addition, the facility failed to cover facial hair during food preparations. These practices had the potential to affect food served to residents. The findings included: a. An initial tour of the kitchen occurred on 09/22/24 at 10:34 AM with [NAME] #1 which revealed stacked wet items on tray line and storage rack: - 12 of 50 insulated bases - 10 of 10 dome lids - 2 rectangular pans - 3 deep rectangular pans - 2 small, deep rectangular pans - 2 long, rectangular pans - 5 large baking sheets An interview with [NAME] #1 on 09/22/24 at 11:03 AM revealed all kitchen staff were responsible for making sure dishware was dry before stacking. During a combined interview on 09/24/24 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-25 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to maintain the grounds surrounding one of two trash dumpsters free of broken equipment and to keep the grease trap surrounding area clean and free from debris. These failures had the potential to impact sanitary conditions and to attract pests and rodents. The findings included: An observation of the dumpster area was conducted on 09/24/24 at 12:53 PM with the Dietary Manager (DM). The trash observed around one of two dumpsters were the following: - dirty linen/cart containing cardboard boxes, plastic bags, rinse aid pail with cover - one recliner - 4 folded wheelchairs - Four, 15-gallon plastic containers - bleach, laundry detergent, fresh liquid alkali (concentrated laundry builder that prepares the fabric for the washing process), liquid detergent - 2 ½ wooden pallets resting on the building wall - one stainless steel rack - 3 wooden planks resting on the building wall An observation of the grease trap was conducted on 09/24/24 at 1:00 PM with the DM. The area surrounding the grease trap included old cardboard,…

    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 · D2024-09-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended with resident health information exposed in an area accessible and visible to the public on 1 of 2 medication carts (medication cart #1). The findings include: During a continuous observation of Main Hall on 9/24/24 from 3:38 PM to 3:40 PM, medication cart #1 was observed unattended. The laptop screen was open and displayed resident information including, names, medications, and diagnosis. Several staff members and two visitors were observed passing by medication cart #1 while the laptop screen was open with the resident information exposed in an area accessible and visible to the public. On 9/24/24 at 3:40 PM Nurse #2 was observed returning to medication cart #1 from the nurse's desk that was approximately 20 feet away. An interview with Nurse #2 was completed on 9/24/24 at 3:40 PM. Nurse #2 reported she usually would have minimized the patient information screen to hide resident information when walking away from the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · 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 observations, record reviews, resident, staff, Pharmacy Consultant and Medical Director (MD) interviews, the facility failed to protect the resident's rights to be free from misappropriation of controlled substance for 1 of 1 resident reviewed for misappropriation of resident property (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome and phantom limb syndrome with pain. A review of the Physician orders for Resident #43 showed an order with a date of 10/3/23 for Oxycodone 10 milligrams (mg) (narcotic pain medication/controlled substance) to be given by mouth three times a day. A review of the electronic medication administration record (eMAR) for 3/1/24 through 3/21/24 revealed Resident #43 had received the Oxycodone 10 mg three times a day for the entire month. A review of the packing slip from the Pharmacy dated 3/22/24 showed 60 tabs of Oxycodone 10 mg had been delivered for Resident #43 and signed by Nurse #7.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-25 · 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 observation, staff and resident interviews, and record review, the facility failed to provide assistance with oral care for 1 of 2 dependent residents (Resident #30) reviewed for activities of daily living (ADL). The findings included: Resident #30 was admitted to the facility on [DATE] With a diagnoses of hemiplegia following cerebrovascular disease affecting left non-dominant side, muscle weakness, and chronic pain. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 required set-up assistance with oral care, and he had obvious or likely cavities, broken teeth, and inflamed or bleeding gums with loose natural teeth. A review of the Care Area Assessment (CAA) dated 2/11/24 showed Resident #30 had natural teeth that were in poor repair. Within the CAA, reference to a physician note date 1/8/2024 revealed Resident #30 had a diagnosis of necrotizing periodontal disease, chronic periodontal disease and gingival disease. Review of the quarterly MDS assessment dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to label tube feeding formula with the date and time the formula was hung and flow rate for 1 of 1 resident reviewed for tube feeding (Resident #26). The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses which included unspecified severe protein-calorie malnutrition and gastrostomy status (medical procedure where a tube is inserted through the abdominal wall and into the stomach). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was rarely/never understood and rarely/never understands. The nutritional approach while a resident was via feeding tube. Review of Resident #26's baseline care plan dated 05/29/24 revealed the resident was dependent on gastrostomy (G) tube for eating. The goal for Resident #26 was to maintain or achieve the highest practical level of functioning. Review of a physician order dated 08/05/24 revealed an order for Resident #26 to receive feeding formula…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, facility Corporate Dietitian, Dialysis Center Registered Dietitian, and Medical Director interviews the facility failed to obtain a physician order for the resident to receive dialysis, monitoring of the dialysis access site, and fluid restrictions for 1 of 1 resident reviewed for dialysis (Resident #4). The findings included: a. Resident #4 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD) and Dependence Upon Renal Dialysis. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had moderate cognitive impairment with unclear speech and required substantial to partial assistance with activities of daily living (ADLs). The MDS further showed Resident #4 received dialysis. During a review of Resident #4's care plan that was last updated on 7/9/2024 revealed Resident #4 was at risk for complications due to hemodialysis and attended dialysis 3 days a week, Monday, Wednesday 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to determine a resident's food preferences and failed to offer an alternative option. This occurred for 1 of 1 resident reviewed for choices (Resident #23). The findings included: Resident #23 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #23 was cognitively intact. A review of Resident #23's medical record revealed no food preference form. During an interview on 9/22/24 at 11:14 am Resident #23 stated he did not like chicken and did not wish to eat it. Resident #23 stated he did not ask staff for an alternate because he did not know he could. Resident #23 stated staff had not offered him an alternative when chicken was left on his plate. The resident stated he had not told a specific person that he did not eat chicken, but that he had complained about it to the staff that delivered and picked up his tray, when chicken came on his tray, which the 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-25 · tag F0575 — widespread
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, the home and community based service programs, and the Medicaid Fraud Control Unit. This observation occurred for 3 of the 4 days during the onsite recertification survey. The findings included: Observations of the entire facility were completed on 9/22/24 at 2:37 pm and on 9/23/24 at 10:35 am. The observations revealed no signage or postings which included name and contact information for the State Survey Agency, complaint intake, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, or the…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2024-09-25 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident council and staff interviews, the facility failed to post signage about the availability of the most recent survey results for three (3) of four (4) days during the recertification survey. This had the potential to affect all residents residing in the building. The findings included: An observation was completed on 9/22/24 at 10:20 am of the front lobby which revealed no signage for the location of survey results. Additional observations were completed of the front lobby on 9/23/24 at 8:53 am and 9/24/24 at 9:15 am which revealed no signage for the location of the survey results. A Resident Council group meeting was conducted on 9/24/24 at 3:06 pm. During the meeting, all five of the residents in attendance indicated they did not know where the survey results were located. During a tour of the facility on 9/24/24 at 5:19 pm with the Administrator, signage for the location of survey results was not located in the building. Along the right wall of the front lobby was a brown side table. On the bottom shelf of the brown side table there was a grey binder…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2024-09-25 · tag F0732 — widespread
    Post 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 Registered Nurse (RN) staffing information for 8 days of the 205 days reviewed for daily posted staffing (3/22/24, 4/10/24, 4/12/24, 4/22/24, 5/13/24,7/20/24, 8/17/24, 8/31/24). The findings included: Review of the daily posted staffing from March 2024 through August 2024 revealed the daily posted staffing sheets were missing the Registered Nurse (RN) hours for the following days: a. The daily posted staffing sheet for 3/22/24 revealed the sections for RN hours were blank for all 3 shifts. b. The daily posted staffing sheet dated 4/10/24 revealed the sections for RN hours were blank for all 3 shifts. c. The daily posted staffing sheet dated 4/12/24 revealed the sections for RN and LPN hours were blank on 3rd shift. d. The daily posted staffing sheet dated 4/22/24 revealed the sections for RN hours were blank for all 3 shifts. e. The daily posted staffing sheet dated 5/13/24 revealed the sections for RN hours were blank for all 3 shifts. f. The daily posted staffing sheet dated 7/20/24 revealed 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.

    Nursing and Physician Services 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.

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.0-1.0 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 2 of 53.0-1.0 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 39 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Ayden Court Nursing and Rehabilitation CenterAyden, NC 1 of 5Greendale Forest Nursing and Rehabilitation CenterSnow Hill, NC 1 of 5River Trace Nursing and Rehabilitation CenterWashington, NC 1 of 5Somerwoods Rehabilitation and Healthcare CenterSomerset, KY 1 of 5University Place Nursing and Rehabilitation CenterCharlotte, NC 2 of 5Cherry Point Bay Nursing and Rehabilitation CenterHavelock, NC 2 of 5Clear Creek Nursing & Rehabilitation CenterMint Hill, NC 2 of 5Graham Healthcare and Rehabilitation CenterRobbinsville, NC 2 of 5Greenwood Rehabilitation and Healthcare CenterBowling Green, KY 2 of 5Macon Valley Nursing and Rehabilitation CenterFranklin, NC 2 of 5Northchase Nursing and Rehabilitation CenterWilmington, NC 2 of 5Tower Nursing and Rehabilitation CenterRaleigh, NC 2 of 5Westwood Hills Nursing and Rehabilitation CenterWilkesboro, NC 2 of 5Willow Creek Nursing and Rehabilitation CenterGoldsboro, NC 3 of 5Bethany Woods Nursing and Rehabilitation CenterAlbemarle, NC 3 of 5Franklin Oaks Nursing and Rehabilitation CenterLouisburg, NC 3 of 5Greenhaven Health and Rehabilitation CenterGreensboro, NC 3 of 5Harmony Hall Nursing and Rehabilitation CenterKinston, NC 3 of 5Pine Ridge Health and Rehabilitation CenterThomasville, NC 3 of 5Piney Grove Nursing and Rehabilitation CenterKernersville, NC 3 of 5Premier Nursing and Rehabilitation CenterJacksonville, NC 3 of 5Richmond Pines Healthcare and Rehabilitation CenteHamlet, NC 3 of 5Riverpoint Crest Nursing and Rehabilitation CenterNew Bern, NC 3 of 5Smoky Mountain Health and Rehabilitation CenterWaynesville, NC 3 of 5Springbrook Nursing and Rehabilitation CenterClayton, NC 4 of 5Barbour Court Nursing and Rehabilitation CenterSmithfield, NC 4 of 5Carolina Rivers Nursing and Rehabilitation CenterJacksonville, NC 4 of 5Chowan River Nursing and Rehabilitation CenterEdenton, NC 4 of 5Croatan Ridge Nursing and Rehabilitation CenterNewport, NC 4 of 5Kerr Lake Nursing and Rehabilitation CenterHenderson, NC 4 of 5Lake Park Nursing and Rehabilitation CenterIndian Trail, NC 4 of 5Lake Way Rehabilitation and Healthcare CenterBenton, KY 4 of 5Northampton Nursing and Rehabilitation CenterJackson, NC 4 of 5Wayland Nursing And Rehabilitation CenterKeysville, VA 4 of 5Wilson Pines Nursing and Rehabilitation CenterWilson, NC 5 of 5Grantsbrook Nursing and Rehabilitation CenterGrantsboro, NC 5 of 5Harnett Woods Nursing and Rehabilitation CenterDunn, NC 5 of 5Jacob's Creek Nursing and Rehabilitation CenterMadison, NC 5 of 5Maple Grove Health and Rehabilitation CenterGreensboro, NC

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 / managerTypeRoleSince
JOHNSON, DIANNEIndividualCORPORATE DIRECTORsince 01/01/2011
BOICE, GALEIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/05/2018
PRINCIPLE LONG TERM CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2011
HINTON, HEIDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2025
DETAR, DEWEYIndividualADP OF THE SNFsince 04/01/2024
HILL, RAYMONDIndividualADP OF THE SNFsince 01/01/2011
HILL, ROBERTIndividualADP OF THE SNFsince 01/01/2011
HILL, STEPHENIndividualADP OF THE SNFsince 01/01/2011

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$5.8M
Net patient revenuemost recent cost report
-5.7%
Operating marginrevenue minus expenses
$1.4M
Related-party expense23% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 6%Other / private 17%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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

$366per resident / day
operating cost
$11,139per month
≈ monthly operating cost
$346per day
avg. revenue, all payers

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

What families pay in NC

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345219. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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