Mount Olive Center

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.

43.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 62.2% 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 45 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 150 beds and averages 132.8 residents a day — about 89% occupied, or roughly 17 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 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 2.62 hrs/resident/day on weekends vs 3.05 on weekdays — 14% thinner on weekends. RN hours go from 0.34 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

30 citations, most serious first. The 15 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-10-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, staff, Nurse Practitioner, (NP) Psychiatric NP and Medical Director interviews, the facility failed to assess a resident for self-administration of her enteral feedings (a method of delivering nutrition directly into the gastrointestinal tract, typically through a feeding tube, for individuals who cannot consume food orally) and to put effective interventions in place after Resident #13 was repeatedly observed by staff putting unidentified liquids in her gastronomy tube (g-tube [provides nutrition via a liquid formula delivered through a flexible tube that is surgically placed through the abdomen into the stomach]); rummaging through the trash for food /liquids; chewing and spitting out food items into the trash can; obtaining food as a prize for bingo; and disconnecting herself from her g-tube pump and removing the tube feeding formula bag during continuous feedings. Resident #13 had a diagnosis of vascular dementia and had an order for NPO (nothing by mouth)…

  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 · J2024-10-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, medical physician, responsible party, nurse practitioner and paramedic, the facility failed to ensure staff notified the physician when a resident (Resident # 13) was observed by nurse aides to be zonked, talking out of his head, not eating any of his supper meal and complaining of being tired in conjunction with a new rash observed on multiple areas of his body by multiple staff members. Additionally, one staff member referenced the rash as a death rash and thought the physician had already been notified. The resident was transferred to the hospital by emergency services when staff called 911 the following day. The resident was identified to be in septic shock and expired while hospitalized . (Sepsis occurs when an individual's immune system has a wide spread reaction to an infection which can lead to multi system organ failure and is considered life threatening. Septic shock is the last stage of sepsis and results in a low blood pressure). Additionally, 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
• Immediate jeopardy · Jcited before2024-10-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, physician, and paramedic, the facility failed to ensure staff recognized the need for communication amongst themselves and with the physician to ensure a resident received medical services to address an emergency situation (Resident # 13). Resident # 13 reportedly had a death rash in conjunction with nurse aides' observations of him being zonked, talking out of his head, not eating any of his supper meal and complaining of being tired. The morning following these observations, which were noted by staff members on the previous evening and night shift, the resident was found by the morning shift staff nurses to be without a detectable radial pulse, without a detectable oxygen level, mottled skin (discolored patches of skin which can result from a lack of blood flow to the skin), and not responding to a sternal rub. The resident required emergency transfer to the hospital where he was identified to be in septic shock. (Sepsis occurs when an individual's immune…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, Nurse Practitioner (NP), surgical specialist's staff and Medical Director interviews, the facility failed to administer the bowel preparation (the process of cleaning out the intestines) on two separate occasions. The first was for a scheduled colonoscopy (an exam used to look for changes in the large intestine) on 12/17/24 and the second was for a limited sigmoid colon (part of the large intestine that is close to the rectum) resection (the process of cutting out tissue or part of an organ) for a suspicious colon polyp (small growths on the lining of the large intestine) scheduled on 2/24/25. Review of the hospital Discharge summary dated [DATE] revealed Resident #4 was placed under general anesthesia and the abdominal incisions had been made when the surgeon observed the colon was full of stool and aborted the surgery. The incisions were closed with sutures and a liquid topical skin adhesive and the resident returned to the facility. Resident #4 will require another…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-03 · 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 interviews with staff, Responsible Party, Nurse Practitioner and Medical Director the facility failed to 1) ensure staff were providing transfer assistance as care planned for a resident (Resident # 1) identified as at risk for injuries due to osteoporosis and 2) ensure mats were at the bedside to prevent injuries for a resident with a history of falls (Resident # 2). Resident # 2 sustained a large hematoma and fractured nose when she was found on the floor without a fall mat in place. This was for two of three sampled residents reviewed for accidents (Resident #1 and Resident #2). The findings included: 1. Resident # 1 was admitted to the facility on [DATE]. The resident had multiple diagnoses which in part included osteoporosis, osteoarthritis, spinal stenosis, chronic pain, dementia, hypertension, diabetes, a history of hip replacement surgery, and polyneuropathy. The resident also had a history of vertebrae fracture due to osteoporosis. Resident # 1's quarterly Minimum Data Set…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · D2026-01-28 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of $300.00 after Resident #1 mistakenly transferred funds to Nurse Aide #1 on a money transfer application. This was for 1 of 3 residents reviewed for misappropriation of property (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE].The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact.During an interview on 1/22/2026 at 3:05 PM, Resident #1 reported that around Christmas he asked Nurse Aide (NA) #1 to obtain groceries for him from a local store. The resident stated he transferred $120.00 to NA #1 through a money transfer application on his phone to pay for the groceries. Resident #1 confirmed NA #1 did bring him his groceries and provided a reciept. The resident further stated that on the following day, 12/27/2025, he accidentally transferred an additional $300.00 to NA #1 while…

  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 · D2026-01-28 · tag F0607 — failed to have anti-abuse policies — isolated
  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 resident and staff interviews, the facility failed to implement the abuse policy and procedures when the Administrator was not immediately notified of an allegation of misappropriation of funds resulting in delayed protection, reporting, and investigation for 1 of 3 residents reviewed for misappropriation of property (Resident #1). Findings included:Review of the facility's abuse policy and procedures, last reviewed on 11/14/2025, revealed: Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of the shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. The abuse policy and procedure additionally stated: Immediately upon receiving information concerning a report of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-18 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Pharmacy Consultant, Medical Director, and Corporate Medical Director interviews, the facility did not ensure a resident was free of a significant medication error when Resident #1 received 60 milligrams (mg) of oxycodone (a short-acting opioid which is a class of drug used to reduce moderate to severe pain). Oxycodone 60 mg was not prescribed to Resident #1. On 11/28/25 Resident #1 was given oxycodone 60mg medication prescribed to another resident. This deficient practice affected 1 of 5 residents reviewed for significant medication error.Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that primarily affects movement) with dyskinesia (involuntary, erratic movements), dementia, and palliative (specialized medical support for people with serious illnesses) care.Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and did not receive opioid…

  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 · Dcited before2025-12-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not maintain accurate records related to documentation of medication administration for 1 of 7 residents reviewed for accurate medical records (Resident #2). The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and fibromyalgia (a chronic condition causing widespread body pain, fatigue, sleep problems, and cognitive difficulties).A review of Resident #2's physician orders revealed an order dated 12/12/25 for oxycodone-acetaminophen 5-325 milligrams (mg) give one (1) tablet by mouth every 6 hours as needed for pain.Resident #2's individual narcotic record sheet for oxycodone-acetaminophen 5-325 mg was reviewed. The narcotic record revealed Resident #2 received one (1) oxycodone-acetaminophen 5-325 mg tablet on 12/12/25 at 4:30 PM and at 10:00 PM.A review of Resident #2's December 2025 Medication Administration Record (MAR) indicated oxycodone-acetaminophen 5-325 mg was not…

  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 · E2025-10-01 · tag F0605 — failed to not use drugs as a restraint — pattern
  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 interviews with staff and the facility Consultant Pharmacist, the facility failed to provide ongoing Abnormal Involuntary Movement assessments to assess for potential adverse medication reactions for 2 of 3 residents (Residents #75 and #1) reviewed for receiving antipsychotic medications. The findings included: 1. Resident #75 admitted to the facility on [DATE] with diagnoses including depression with psychosis.Resident #75's physician's order dated 10/25/2024 documented a revision of Quetiapine Fumarate (an antipsychotic) to 300 milligrams (MG) at bedtime. The admission Minimum Data Assessment (MDS) dated [DATE] indicated Resident #75 had cognitive impairment with no display of behaviors coded. The MDS was coded for Resident #75 receiving antipsychotic medications on a routine basis. Resident #75's care plan reviewed 9/16/2025 indicated a risk for complications related to the use of psychotropic and psychotic medications. Interventions included AIMS testing per protocol. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-10-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews and Nurse Practitioner interview, the facility failed to administer supplemental oxygen as prescribed by the physician and failed to post cautionary signage indicating the use of oxygen for 3 of 9 residents reviewed for respiratory services (Resident #39, #91 and #49). 4. Resident #49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was cognitively intact and was coded as receiving oxygen therapy. Physician orders dated 8/25/2025 included an order for oxygen at three liters per minute via nasal cannula every shift. Resident #49's care plan last updated on 8/26/2025 documented Resident #49 was at risk for respiratory complications and was receiving oxygen at 3 liters per min. via nasal cannula every shift. On 9/14/2025 at 1:25 PM, Resident #49 was observed lying in bed receiving oxygen at 3 liters per minute via nasal…

  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 · E2025-10-01 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  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 staff, Consultant Pharmacist, and the Nurse Practitioner, the facility failed to address irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews (Residents #75, #113, #1, and #2) and to maintain documentation of the monthly drug regimen reviews within the facility and readily available for review (Resident #75). This deficient practice affected 4 of 5 residents reviewed for unnecessary medications. The findings included: 1.Resident #75 admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease with esophagitis, anxiety, polyneuropathy, and depression with psychosis. The admission Minimum Data Assessment (MDS) dated [DATE] indicated Resident #75 had moderate cognitive impairment with no display of behaviors coded. The MDS was coded for Resident #75 receiving antipsychotic medications on a routine basis. Resident #75's physician's orders revealed the following: Order dated 10/25/2024 documented a…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-10-01 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Pharmacy Consultant #1 and Nurse Practitioner and Cardiologist interviews, the facility failed to prevent a significant medication error when a resident was administered blood pressure medication with a blood pressure recorded below the parameters ordered by the physician for 1 of 6 residents whose medication regimens were reviewed (Resident #113). Finding included: Resident #113 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and heart failure. Resident #113 was discharged from the facility on 9/2/2025. A review of Resident #113's blood pressure recorded in the electronic medical record from 6/6/2025 to 7/31/2025 ranged from 101/50 mmHg to 164/43 mmHg. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 was cognitively intact and was coded for hypertension. Resident #113's quarterly MDS dated [DATE] was coded for orthostatic hypotension (sudden drop in blood pressure when a person stands up…

  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 · E2025-10-01 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to secure medications in an unlocked medication cart for 1 of 4 medications carts (medication cart #1) and to discard an unlabeled open vial of insulin from a refrigerator in a medication room (Nursing Station #2 medication room) and secure the locked refrigerated controlled medication black box to a permanent structure in 2 of the 3 medication rooms (Nursing Station #1 medication room and Nursing Station #3 medication room) reviewed for medication storage. Findings include: 1. On 8/14/25 at 10:55 AM, a continuous observation began of an unlocked medication cart #1 located at Nursing Station #3. There was no nursing staff observed at medication cart #1 or at Nursing Station #3 and the lock on medication cart #1 was observed extending outward. Resident #80 was observed walking past the unlocked medication cart #1 and Resident #73 self-propelling his wheelchair past the unlocked medication cart #1. At 10:57 AM, Resident #60 was observed…

  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 before2025-10-01 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen reviewed (Resident #39, and Resident #91) and medications (Resident #113) for 3 of 15 residents whose medical records were reviewed.1. Resident #113 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and heart failure. Physician's orders dated 7/25/2025 included Coreg 12.5 milligrams (mg) twice a day for blood pressure; hold for systolic less than 150 millimeters of mercury (mmHg). A review of Resident #113's July and August 2025 Medication Administration Record recorded Nurse #8 administered Coreg 12.5 mg with a blood pressure recording less than 150 mmHg: on 7/27/2025 with a blood pressure reading of 144/69 mmHg, 8/2/2025 with a blood pressure reading of142/63 mmHg, 8/3/2025 with a blood pressure reading of 146/66 mmHg, 8/8/2025 with a blood pressure reading of 142/78 mmHg, 8/9/2025 with a blood pressure…

  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

“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

$171,721 in federal fines across 4 penalties.

• $26,449 — penalty dated 2025-12-18
• $51,415 — penalty dated 2025-10-01
• $30,518 — penalty dated 2025-02-12
• $63,339 — penalty dated 2024-10-03

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 GENESIS HEALTHCARE — 184 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

CMS files one row per role, so the 18 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

11 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 87% 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 $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in NC