Surry Community Health Center by Harborview

Location & what’s nearby

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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.

52.0% 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 107 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.2% 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 69 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 111.5 residents a day — about 93% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.82 hrs/resident/day on weekends vs 3.20 on weekdays — 12% thinner on weekends. RN hours go from 0.38 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

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.

33 citations, most serious first. The 19 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · K2024-03-27 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Resident, Resident Representative (RR) and staff interviews the facility failed to implement grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 the facility was running out of her Methadone. The Director of Nursing (DON) was assigned the grievance and on 12/01/23 confirmed Resident #21 had Methadone in the medication cart, and it had been documented as administered. The DON did not interview the resident or determine if there had been any supply issues with Resident #21's Methadone. Due to the lack of investigation this problem continued. Resident #21 reported she experienced terrible/awful pain of greater than ten on a scale of 1 to 10. Resident #21 stated she was crying during the night and her anxiety was 'out the roof' because she was afraid she would not have her medications available and feeling as though she went through withdrawals. The deficit practice occurred for 1 of 1 resident (Resident #21) reviewed for grievances. Immediate jeopardy began…

  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 · K2024-03-27 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  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 and family, Pharmacist, Medical Director (MD), Physician Assistant (PA), former staff, and current staff interviews the facility failed to protect a resident (Resident #21) from misappropriation of controlled substances by facility staff. Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift (7:00 pm to 7:00 am). Review of Resident #21's Medication Administration Record (MAR) for 11/2023 through 02/14/2024 revealed Resident #21's Methadone was signed out as administered by Medication Aide (MA) #3 every night shift she was assigned to the resident. Review of dispensary reports from the pharmacy and the facility's narcotic sign out sheets demonstrated two missing cards of Resident #21's Methadone that could not be accounted for which were signed on the dispensary report as…

  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 · Kcited before2024-03-27 · 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 and staff interviews the facility failed to implement their abuse, neglect, and exploitation policy in the areas of protection, reporting, and investigating allegations of abusive actions perpetrated by staff toward residents. On 3/10/24 Medication Aide (MA) #1 and Nurse Aide (NA) #2 placed Resident #98 and Resident #305 in involuntary seclusion and on 3/12/24 Nurse Aide (NA) #1 utilized a physical restraint for Resident #15 that was not required to treat the resident's medical symptoms. Following the incidents, MA #1 and NA #1 were allowed to continue working direct care resident assignments. Additionally, the facility failed to investigate the allegations and to report the allegations to the state agency, law enforcement, and Adult Protective Services. The deficient practice was identified for 3 of 3 residents reviewed for abuse and placed other residents at a high likelihood of serious injury or harm (Resident #15, Resident #98 and Resident #305). Immediate jeopardy began on 3/10/2024…

  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 · K2024-03-27 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management 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 observation, record review and resident, resident representative, Pharmacy, Medical Director (MD), Physician Assistant (PA), and staff interviews, the facility failed to address a resident's pain (Resident #21) after repeated reports to staff that she had not received her pain medications during the night shift (7:00 AM to 7:00 PM). Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift. Resident #21 informed the PA on 12/12/23 that her pain medications were not being given to her. On 1/05/24 Resident #21 was seen by the PA and reported increased pain primarily at night. Resident #21 reported when she was not administered her Methadone, she experienced terrible/awful pain of greater than ten on a scale of 1 to 10, was crying during the night, had nausea and a headache, and reported her…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-27 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 Resident, Pharmacist and staff interviews the facility failed to have systems in place for accurately receiving and reconciling controlled medications from the pharmacy. On 10/23/23 a possible drug diversion by Nurse #5 was reported to administration by Nurse #4. An effective investigation was not conducted which put other residents at risk for loss or diversion of controlled medications. In addition, a discrepancy was identified between the pharmacy dispensary reports and the controlled medication sign-out sheets for Resident #21's Methadone received by Medication Aide (MA) #3 on 10/13/23 and 1/16/24. The deficient practice was identified for 1 of 1 resident (Resident #21) reviewed for pharmacy services and due to the lack of effective systems there was the high likelihood of further diversion or loss of residents controlled medications. Immediate Jeopardy began on 10/23/2023 when a possible drug diversion by Nurse #5 was reported to administration and the facility did not investigate…

  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
• Immediate jeopardy · K2024-03-27 · tag F0880 — failed to prevent and control infections — pattern
  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 observations, staff interviews, and record review, the facility staff failed to disinfect a shared blood glucose meter (glucometer) after use and before placing the glucometer back in the medication cart. Furthermore, the facility failed to disinfect a shared glucometer between residents with an approved disinfectant wipe for 3 out of 4 residents whose blood glucose levels were checked (Resident #60, Resident #54, and Resident #47). This occurred while there was a resident with known bloodborne pathogens in the facility. Three different staff were involved in the deficient practice (Nurse #1, Medication Aide #4 and Nurse #7). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. Immediate jeopardy began on 3/18/24 when three different staff failed to disinfect…

  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
• Immediate jeopardy · J2024-03-27 · tag F0603 — failed to not confine residents against their will — isolated
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, video review, physician, physician assistant and staff interviews the facility failed to protect Resident #98 and Resident #305 from involuntary seclusion when Medication Aide #1 and Nurse Aide (NA) #2 placed the residents in an activity/dining room in the evening with the doors closed, dim lighting, and no supervision due to the residents' yelling/screaming behaviors. The residents were unable to exit the room without assistance. Residents #98 and #305 were diagnosed with dementia and were at risk for falls. The reasonable person concept was applied for this deficient practice in that a reasonable person would have experienced feelings of fear and isolation from being confined to a room with no ability to exit. This deficient practice affected 2 of 2 residents reviewed for involuntary seclusion (Resident #98 and Resident #305). Immediate Jeopardy began on Sunday 3/10/24 when Resident #98 and Resident #305 were placed in involuntary seclusion. Immediate jeopardy was removed…

  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 · J2024-03-27 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to protect a resident (Resident #15) from unauthorized physical restraint when the Activities Director witnessed Nurse Aide (NA) #1 administer a COVID test to Resident #15, while Resident #15 was flailing her arms, resisting, and saying that she did not want a COVID test. NA #1 failed to identify a medical necessity that warranted restraining a resident. The reasonable person concept was applied for this deficient practice in that a reasonable person would experience feelings such as fear, pain, and dehumanization (deprivation of human qualities such as compassion). The deficient practice was revealed for 1of 3 residents (Resident #15) reviewed for the right to be free from physical restraints. Immediate Jeopardy began on 3/12/2024 when NA #1 was observed by the Activities Director physically restraining Resident #15 to administer a COVID test while Resident #15 was flailing her arms, resisting, and saying that she did not want a COVID test.…

  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 · G2024-03-27 · 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 reviews, observations, resident, and staff interviews, the facility failed to protect residents' dignity when residents were left soiled in feces and saturated in urine for 2 of 2 residents reviewed for dignity issues (Resident #4 and Resident #305). When they were not provided incontinent care Resident #4 reported feeling unworthy of being looked at, sanitary rights being ignored, uncomfortable, and nasty; Resident #305 reported feeling cold, wet, and uncomfortable. 1.) Resident #4 was admitted to the facility on [DATE] with diagnoses including muscle weakness, neuromuscular dysfunction of the bladder, and the need for assistance with personal care. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #4 was cognitively intact. She was incontinent of bowel, had an indwelling catheter, and required substantial maximum assistance by staff with toileting hygiene. The MDS indicated her vision was adequate. She had no rejection of care. An interview and observation were…

  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 · D2025-06-11 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to initiation for 1 of 5 residents reviewed for unnecessary medications (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, and depression. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was severely cognitively impaired, had no behavioral symptoms, and received antipsychotics on a routine basis only. Resident #32's Medication Administration Record for June 2025 indicated an active order which started on 6/6/25 for Lorazepam (an anti-anxiety medication) 0.5 milligrams 1 tablet by mouth as needed for anxiety for 14 days. The order had a stop date of 6/20/25. A review of Resident #32's medical record indicated no information whether Resident #32's representative…

  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 · D2025-06-11 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, lorazepam (medication used to relieve anxiety), had a stop date of 14 days for 1 or 5 residents reviewed for unnecessary medications (Resident #7). The findings included: Resident #7 was readmitted to the facility on [DATE] with diagnoses that included anxiety. Review of Resident #7's physician orders dated 04/23/25 indicated lorazepam 0.25 milligrams (mg) every 8 hours as needed (PRN) for anxiety. There was no stop date. Review of Resident #7's quarterly Minimum Data Set, dated [DATE] revealed the Resident's cognition was severely impaired and he received an antianxiety medication. Review of Resident #7's May 2025 Medication Administration Record (MAR) revealed the lorazepam 0.25 mg every 8 hours PRN for anxiety remained an active order and was administered 21 times. Review of Resident #7's June 2025 Medication Administration Record (MAR) revealed the lorazepam 0.25…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-11 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #7 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder with major neurocognitive disorder due to Alzheimer's Disease. Review of Resident #7's medical record revealed an order dated 03/17/25 for quetiapine 50 milligrams (mg) by mouth twice a day for major depressive disorder with major neurocognitive disorder due to Alzheimer's Disease. Review of Resident #7's Medication Administration Record for 03/2025 indicated the Resident received 50 mg quetiapine by mouth twice a day beginning 03/17/25. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Antipsychotic Medication Review section indicated the Resident had not received antipsychotic medication since readmission/reentry or since the last assessment. On 06/11/25 at 10:06 AM an interview was conducted with the Minimum Data Set Nurse who reviewed Resident #7's 03/20/25 quarterly MDS and acknowledged she had marked the wrong answer in the Antipsychotic Medication 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews resident and staff interviews, the facility failed to secure an oxygen cylinder stored in Resident #11's room for 1 of 4 residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE]. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident's cognition was moderately impaired and she did not receive oxygen therapy. Review of Resident #11's care plan reviewed 03/12/25 indicated the Resident did not receive oxygen. Review of Resident #11's current monthly (06/2025) physician orders indicated there was no order for oxygen. On 06/08/25 at 2:31 PM an observation and interview were conducted with Resident #11 who was sitting in her wheelchair in her room. During the interview an oxygen cylinder was stored upright near the window sill that was approximately ¾ full of oxygen according to the gauge. The Resident stated she did not know why the oxygen cylinder was in her room and she did not know if she…

  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 · D2025-06-11 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 31 opportunities, resulting in a medication error rate of 6.45% for 2 of 6 residents observed during the medication administration (Resident #52 and Resident #49). The findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease. Review of Resident #52's physician orders dated 10/14/25 revealed give metoclopramide (gastrointestinal stimulant and antiemetic) 5 milligrams (mg) by mouth before meals. An observation was made of Medication Aide (MA) #1 on 0610/25 at 8:47 AM during a medication administration of Resident #52. The MA prepared Resident #52's medications which included metoclopramide 5 mg. The MA took the morning medications to Resident #52 who was sitting on the side of her bed eating her breakfast which was approximately 50% consumed. An interview was conducted…

  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 · F2024-03-27 · tag F0867 — failed to act on quality-improvement findings — widespread
  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 record review and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee had put into place following the recertification survey and complaint investigation on 12/01/2022. The failure included five deficiencies that were originally cited in the areas of Free from Abuse and Neglect (F600), Developing/Implementing Abuse/Neglect Policies (F607), Accuracy of Assessments (F641), Nutrition/Hydration Status Maintenance (F692), Sufficient Nurse Staffing (F725), Pharmacy Services and Procedures (F755), and Significant Medication Errors (F760) that were subsequently recited on the current recertification and complaint investigation on 3/27/2024. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F600: Based on record review, staff and Medical Director interviews, the facility neglected to implement a physician order for intravenous…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 observations, record review, resident and staff interviews the facility failed to provide baths and showers, and incontinence care for residents requiring or dependent on staff assistance with activities of daily living (ADL). This was for 3 of 8 residents reviewed for ADLs (Residents #59, #305 and #4). The findings included: 1. Resident #59 was admitted on [DATE] with chronic obstructive pulmonary disease (COPD) and a need for assistance with personal care. Resident #59 was care planned on 11/17/23 for needing assistance with grooming, bathing and personal hygiene related to mobility and self-care impairments. Review of the comprehensive care plan did not include a problem area of his refusals of assistance with his ADL. The quarterly Minimum Data Set, dated [DATE] indicated Resident #59 was cognitively intact, exhibited no behaviors and required partial to moderate assistance with bathing and showering. Review of Resident #59's bath documentation from 1/1/24 to 3/21/24 noted the following: *January…

  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 before2024-03-27 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations, resident and staff interviews, the facility failed to provide sufficient nursing staff to honor a resident's preference for showers for 2 of 4 residents (Resident #59 and Resident #256) and to provide baths, showers, and incontinence care to dependent residents for 3 of 8 (Resident #4, Resident #59, and Resident #305) residents reviewed for sufficient nursing staff. The findings included: This tag was cross-referenced to: F677 - Based on observations, record review, resident and staff interviews, the facility failed to provide baths and showers, and incontinence care for residents requiring or dependent on staff assistance with activities of daily living (ADLs). This was for 3 of 8 residents reviewed for ADLs. F561 - Based on resident, staff interviews and record review, the facility failed to honor resident's preference for showers. This was for 2 of 4 residents reviewed for choices. An interview was conducted with Nurse #3 on 3/20/24 at 6:15 AM. Nurse #3 revealed she started working at the facility in January 2023 and worked 2nd shift (7:00 PM…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-03-27 · 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 resident, staff interviews, observations and record review, the facility failed to honor resident's preference for showers. This was for 2 (Resident #59 and Resident #256) of 4 residents reviewed for choices. The findings included: 1. Resident #59 was admitted on [DATE] with chronic obstructive pulmonary disease, diabetes, atrial fibrillation, and a need for of assistance with personal care. Resident #59 was care planned on 11/17/23 for needing assistance with grooming, bathing and personal hygiene related to mobility and self-care impairments. Review of the comprehensive care plan did not include a problem area for any refusals of assistance with his ADLs. Review of Resident #59's admission Activity Interview for Daily and Activity Preferences assessment dated [DATE] read choosing between a bed bath and shower was very important to him. The quarterly Minimum Data Set, dated [DATE] indicated Resident #59 was cognitively intact, exhibited no behaviors and required partial to moderate assistance with…

  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 · D2024-03-27 · 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, Medical Director, resident, and staff interviews, the facility failed to ensure a resident's urinary catheter collection bag was drained for 2 of 2 residents reviewed for catheter care (Resident #4 and Resident #52). The findings included: 1. Resident #4 was admitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of the Bladder (a condition where normal bladder function is disrupted due to nerve damage). Review of Resident #4's physician orders dated 01/04/24 and 3/20/24 revealed she had orders for a suprapubic catheter (device that's inserted into the bladder to drain urine if one can't urinate on their own). Catheter care every shift, every day and night shift, catheter to be secured with an anchor and monitor for placement. Review of care plan dated 01/29/24 revealed Resident #4 had an alteration in bladder elimination with indwelling urinary catheter related to Neuromuscular Dysfunction of the Bladder. Interventions included: catheter care every…

  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

“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

$145,262 in federal fines across 1 penalty.

• $145,262 — penalty dated 2024-03-27

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HARBORVIEW HEALTH SYSTEMS — 22 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 →

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

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.

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