The Greens at Pinehurst Rehabilitation & Living Ce
205 Rattlesnake Trail, Pinehurst, NC 28374 · For profit - Limited Liability company · 120 certified beds · (910) 295-1781 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $41,844 in federal fines (most recent 2023-09-28)
- its payroll-based staffing rating is low (2/5)
- about 18% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.9% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.8% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 5.9% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.1% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.3% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 75.9% | 94.1% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.2% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.3% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.5% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 1.6% | 78.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.0% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.5% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.12 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
50.5% 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 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.8% 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 72 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.5%CMS range 41.8–57.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.0%CMS range 10.0–17.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 48.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 93.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.5–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 95.0 residents a day — about 79% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.19 hrs/resident/day on weekends vs 3.69 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% 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
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2023-09-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, Physician Assistant (PA), Wound Nurse Practitioner, and Medical Director (MD), the facility failed to implement preventative measures for a resident assessed to be moderate to high risk for development of pressure ulcers. The resident developed a deep tissue injury to the sacrum, 2 deep tissue injuries to the left lateral foot, as well as a deep tissue injury to the left ankle. Deterioration of the sacral wound was not communicated to the MD or the PA. The resident was admitted to the hospital with septic shock for 1 of 8 residents (Resident #178) reviewed for pressure injuries. The findings included: Hospital discharge summary indicated Resident #178 was previously living in an assisted living environment for 100+ days prior to being seen in the Emergency Department on 7/24/2023 for acute onset mental status change thought to be caused by a urinary tract infection. The resident was discharged from the hospital to the skilled nursing facility for short term…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 2 of 5 residents who were reviewed for unnecessary medication (Residents #93 and #13). The findings included: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included dysfunction of the bladder, and retention of urine. A review of the Medication Administration Record (MAR) for Resident #93 from 12/24/25 to 12/30/25 revealed she did not receive an antibiotic medication. A quarterly MDS assessment dated [DATE] indicated Resident #93 had severely impaired cognition and was coded for an antibiotic during the seven-day assessment period. On 3/18/26 at 3:01 PM, an interview occurred with MDS Coordinator #2. She reviewed the 12/30/25 MDS and Resident #93's December 2025 MAR. MDS Coordinator #2 confirmed Resident #93 did not receive an antibiotic from 12/24/25 to 12/30/25 and that the antibiotic was coded in error on the MDS assessment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0645 — isolatedPASARR 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 obtain a Level II Preadmission Screening and Resident Review (PASRR) evaluation after the initial approval for nursing home placement expired for 1 of 1 resident reviewed for PASRR (Resident #3).The findings included: Resident #3 was admitted on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder, and post traumatic stress disorder.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or other related condition.Review of the admission record revealed Resident #3 was admitted with a Level II PASRR for short term admission that was issued on [DATE] and expired on [DATE]. There was no evidence within the medical record to indicate the facility had submitted a referral for another Level II PASRR evaluation to extend approval past the [DATE] expiration date.During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, and interviews with resident representatives, resident and staff, the facility failed to provide resident representatives and/or residents with the opportunity to participate in the care planning process for 2 of 3 residents reviewed for care plan participation (Residents #77 and #13). The findings included: 1.) Resident #77 was admitted to the facility on [DATE]. A review of Resident #77's 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. Review of Resident #77's electronic health record indicated neither he nor his Resident Representative were included as attendees during care plan meetings conducted on 10/17/25, 1/13/26 and 3/2/26. An interview with Resident #77 on 3/16/26 at 12:14 PM revealed he had not been invited to a care plan meeting since residing at the facility. Resident #77 stated he was unaware the facility held care plan meetings until he heard others talking about them recently. Resident #77 indicated he would like to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with the Medical Director and staff, the facility failed to administer scheduled medications as ordered by the physician for 1 of 6 residents reviewed for medication administration (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included hypertension and constipation.A review of Resident #12's active physician orders for March 2026 revealed the following:An order dated 2/17/26 for Metoprolol Tartrate 25 mg. Give one tablet via G-tube two times a day for hypertension. Hold for heart rate less than 65 or systolic blood pressure less than 100.An order dated 2/17/26 for MiraLax 17 gm/scoop (grams per scoop) via G-tube two times a day for constipation.A review of the March 2026 Medication Administration Record (MAR) for Resident #12 revealed the following:Metoprolol Tartrate 25 mg was scheduled for 9:00 AM. Nurse #2 administered the medication at 12:07 PM on 3/16/26.MiraLax 17 gm/scoop was scheduled for 9:00 AM. Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to provide nail care for 1 of 2 dependent residents reviewed for activities of daily living (ADL) (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses including contracture of unspecified joint (left hand) and reduced mobility.A care plan revised on 1/2/25 indicated Resident #6 had an ADL self-care performance deficit with a goal that read Resident #6 would maintain her current level of function. According to the care plan, the resident was dependent on the assistance of one staff with personal hygiene.The significant change Minimum Data Set (MDS) assessment completed 2/14/26 documented Resident #6 as cognitively intact, without rejection of care behavior, and dependent on others for personal hygiene.Review of the bath skin review sheets for Resident #6 for the dates of 3/10/26, 3/14/26, and 3/17/26 revealed only toenail condition was listed.Resident #6 was observed 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.
- Potential for harm · D2026-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 observation, record review, and staff interviews, the facility failed to clean and dry the syringe used to administer medications and water flushes through a gastrostomy tube/G-tube (a tube that delivers liquid nutrition and medications directly to the stomach) before storing it in a dry plastic bag for 1 of 2 residents reviewed for G-tube feeding management (Resident #12). This deficient practice had the potential to cause bacterial growth and contamination.Findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included unspecified dysphagia (difficulty swallowing), gastrostomy status, and aphasia (communication impairment) following a cerebral infarction (stroke).An admission Minimum Data Set assessment dated [DATE] indicated Resident #12 was moderately cognitively impaired and received 51% of more of her total calories from enteral feedings. A review of the active orders revealed Resident #12 had an order for a tube feeding formula to be provided at 72/ml/hr.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and the Medical Director, the facility failed to prevent a significant medication error when Nurse #2 did not administer scheduled medication as ordered. Resident #12 was prescribed scheduled anti-seizure medications to be administered every morning at 8:00 AM and 9:00 AM and Nurse #2 administered the medications 3 and 4 hours late. This deficient practice had the potential to increase seizure activity and affected 1 of 1 resident reviewed for significant medication error (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included intractable epilepsy (a seizure disorder that is difficult to manage or treatment-resistant), without status epilepticus (a seizure lasting 5 minutes or multiple seizures occurring close together without the person regaining consciousness in between). An admission Minimum Data Set assessment dated [DATE] indicated Resident #12 had moderately impaired cognition and was coded 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.
- Potential for harm · D2026-03-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews with staff and the Nurse Practitioner, the facility failed to follow its infection control policies and procedures for hand hygiene when the Assistant Director of Nursing failed to change gloves and perform hand hygiene during wound care for Resident #12 and Resident #4. The deficient practice occurred for 1 of 4 staff observed for infection control practices (Assistant Director of Nursing). The findings included:The facility's undated policy titled Infection Control Guidelines for All Nursing Procedures states that alcohol based hand rub (60-95% ethanol or isopropanol) is the preferred method of hand hygiene when hands are not visibly soiled. The policy requires hand hygiene before donning gloves, before handling clean or soiled dressings or gauze, after handling used dressings or contaminated equipment, and after removing gloves. The facility's enhanced barrier precautions protocol states staff are to wear gloves and a gown with high-contact resident activities such as wound care and to perform hand hygiene before and after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 date leftover food items stored for use in the dry goods storage area and in 1 of 1 walk-in coolers. This practice had the potential to affect food served to residents. The findings included: a. An observation on 12/2/24 at 9:35 AM of the dry goods revealed the following concerns: - an open and undated bag of corn flakes placed in transparent wrapping. - an undated bag of leftover brown sugar stored in a plastic bag that was not sealed. b. An observation of the walk-in cooler on 12/2/24 at 9:45 AM revealed the following concerns: - an undated leftover package of sliced cheese stored in transparent wrapping - an undated leftover package of sliced ham stored in transparent wrapping - a stainless-steel container with cooked mixed vegetables that had not been dated An interview with the Dietary Manager on 12/2/24 at 10:00 AM indicated that she was new in the position. She stated she was responsible for making sure food items were dated and stored properly. An interview with [NAME] #2 on 12/3/24 at 11:10 AM revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of accidents (Residents #63, #64 and #17). This was for 3 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A review of Resident #63's medical record revealed he had a fall on 9/20/24 with a minor injury since the quarterly MDS assessment on 8/9/24. The annual MDS assessment, dated 11/9/24, indicated Resident #63 had severe cognitive impairment and was not coded for any falls since the last assessment. On 12/5/24 at 9:50 AM, an interview occurred with the MDS Coordinator, who reviewed the MDS assessment dated [DATE] as well as Resident #63's medical record. The MDS Coordinator confirmed Resident #63 had a fall since the last assessment on 8/9/24 and should have been coded for a fall with minor injury. She stated it was an oversight. An interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-12-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on manufacturer's recommendations, observations, record review and staff, and Consultant Pharmacist interviews, the facility failed to discard expired medications in 1 of 2 medication carts (Masters Hall Medication Cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 12/04/24 at 1:50 PM of the Masters Hall medication cart in the presence of Nurse #1. The observation revealed the following expired medications: a. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 09/10/24. The manufacturer's recommendation was to discard 6 weeks after opening. b. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision) with an opened date of 10/16/24. The manufacturer's recommendation was to discard 6 weeks after opening. c. One opened bottle of Latanoprost eye drops used to treat glaucoma (a condition in which increased…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure Nursing Assistants (NAs) received annual Dementia training. This was for 4 (NA #1, NA #2, NA #3 and NA #4) of 5 NAs reviewed for staffing. The findings included: a.NA #1's date of hire was 06/22/10. Review of NA #1's Education/In-services records indicated no record of Dementia training since 06/07/23. b.NA #2's date of hire was 02/02/16. Review of NA #2's Education/In-services records indicated no record of Dementia training since 06/07/23. c.NA #3's date of hire was 12/20/99. Review of NA #3's Education/In-services records indicated no record of Dementia training since 06/06/23. d.NA #4's date of hire was 12/19/22. Review of NA #4's Education/In-services records indicated no record of Dementia training since 06/07/23. An interview was conducted with the Director of Nursing (DON) on12/05/24 at 10:01 AM. She explained the current Staff Development Coordinator (SDC) had been out on medical leave since October 2024 however she had requested to step down from her current position of SDC upon returning. The DON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 record review, observations and interviews with staff, Dishwasher Repairman, and Regional Dietary Director, the facility failed to label opened food items stored in 1 of 1 walk in coolers, 1 of 1 reach in coolers, and 1 of 1 walk in freezers and failed to maintain water temperature during the wash and rinse cycles of the high-temp dishwasher according to manufacturer ' s instructions for 3 of 4 observations. This practice had the potential to affect food served to residents. Findings included: 1. During the initial tour of the kitchen on 09/25/23 at 09:18 AM in the presence of the Dietary Manager (DM) the following were observed: a. Located in the reach-in refrigerator available for use was one ham and cheese sandwich without a label. The DM verified the sandwich did not contain a label and she discarded the item. b. Located in the walk-in refrigerator available for use were two trays containing 64 single serving individual cups with a white substance with no label. The DM identified the white substance as sour cream and stated that it should have been labeled and 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.
- Potential for harm · F2023-09-28 · tag F0867 — failed to act on quality-improvement findings — widespreadSet 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 reviews, observations, Pharmacy Consultant, Hospice Aide, Physician's Assistant, Wound Nurse Practitioner, Dishwasher Repairman, Regional Dietary Director, resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey on 9/20/21. This was for five deficiencies that were cited in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Free of Accident/Hazards/Supervision/Devices, Free from Unnecessary Psychotropic Medications, and Food Procurement/Store/Prepare/Serve-Sanitary. In addition, five additional deficiencies were cited during the annual recertification and complaint survey on 7/20/22 in the areas of Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers, Increase/Prevent Decrease in Range of Motion/Mobility, Residents are Free of Significant Medication Errors and Food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-28 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 interviews with staff, Physician Assistant (PA) and Medical Director (MD), the facility failed to provide scheduled antianxiety medication resulting in multiple missed days of a significant medication for 1 of 5 (Resident #26) reviewed for unnecessary medications. The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and psychosis and anxiety disorder. Resident # 26's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired and received antipsychotics and antidepressants 7 out of 7 days during the assessment period. Resident #26's medical record contained an after-visit summary by the Mental Health Nurse Practitioner dated 8/23/2023. The summary indicated the resident had been on 0.5mg of lorazepam as needed for anxiety for 14 days. Staff reported Resident #26 showed reduction in anxiety behaviors with the lorazepam. The Mental Health Nurse Practitioner…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, resident and staff interviews, and record review, the facility failed to apply a left lower extremity (LLE) brace as ordered. This was for 1 (Resident #44) of 1 resident reviewed for range of motion (ROM). The findings included: Resident #44 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident (CVA) and multiple contractures. Resident #44's annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, no behaviors, extensive assistance with all of her activities of daily living and she was coded for impairment to both upper and lower extremities. Review of Resident #44 September 2023 Physician orders included an order dated 8/22/23 and reordered on 9/25/23 that read she was to wear a knee brace on her LLE for 4 hours a day, or as tolerated while lying supine in the bed for contracture management. Resident #44 was care-planned for a self-care performance deficit which included the new intervention dated 8/23/23 to wear the knee brace on her LLE for 4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and Hospice Aide #1 interviews along with record review, the facility failed to provide care safely which resulted in a fall without injury when Hospice Aide #1 left Resident #68's on his side in bed to retrieve a washcloth and failed to ensure two staff were presence for bed mobility. This was for 1 (Resident #68) of 8 reviewed for accidents. The findings included: Resident #68 was admitted on [DATE] with a diagnosis of cerebral ischemia. Review of Resident #68's Fall Risk assessment dated [DATE] indicated he was a moderate risk for falls, no history of falls and required the presence of 1-2 staff. Review of the incident report read Resident #68 sustained a fall on 7/27/23 when Hospice Aide #1 independently positioned him on his side and stepped away from the bedside to retrieve a washcloth resulting in a fall with no injury. The new intervention implemented was to ensure Resident #68 was repositioned on his back when not providing ADL care. Review of Resident #68's Fall Risk Assessment completed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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, Physician Assistant and staff interviews, the facility failed to transcribe pulse parameters for a heart medication for 1 of 5 residents whose medications were reviewed (Resident #73). The findings included: Resident #73 was initially admitted to the facility on [DATE] with diagnoses of hypertension, presence of a cardiac implant and atrial fibrillation. A physician's progress note dated 7/26/23 indicated that Digoxin 125 micrograms (mcg) was being provided daily for atrial fibrillation and should be held for a pulse rate less than 60. A review of the August 2023 physician orders revealed an order dated 7/26/23 for Digoxin 125 mcg 1 tablet by mouth daily for atrial fibrillation. Hold for pulse less than 60. Review of the August 2023 Medication Administration Record (MAR) from 8/1/23 to 8/21/23 indicated the pulse rate was being monitored when the Digoxin was administered. There were no days that Resident #73's pulse was below 60 and the Digoxin was held. A review of the medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Pharmacy Consultant, Physician's Assistant and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #73). This was for 1 of 5 residents whose medications were reviewed. The findings included: Resident #73 was initially admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, anxiety disorder, and depression. A review of Resident #73's medical record revealed she was hospitalized from [DATE] to 8/28/23. Per the hospital Discharge summary dated [DATE], an order was present for Seroquel 25mg 1 tablet by mouth at bedtime 8:00 PM. A review of the active physician orders included an order dated 8/28/23 for Seroquel 25 mg 1 tab by mouth at bedtime for behaviors. The September 2023 Medication Administration Record (MAR) indicated Resident #73 received Seroquel at bedtime as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-03-19 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 7 out of 30 days reviewed (2/16/26, 2/22/26, 2/23/26, 2/25/26, 3/1/26, 3/8/26 and 3/15/26). The facility also failed to post the daily nurse staffing sheet for 1 out of 5 days observed (3/16/26). The findings included: 1. A review of the facility's daily posting for nursing staff for the past 30 days (2/16/26 to 3/16/26) as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 2/16/26 indicated that 9 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 2/16/26 documented that 7 NAs worked from 7:00 AM to 3:00 PM. b. The nursing schedule for 2/22/26 indicated that 8 NAs worked from 7:00 AM to 3:00 PM and 7 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/22/26 documented that 7 NAs worked 7:00 AM to 3:00 PM and 8…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-09-28 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 interviews, the facility failed to provide written notification regarding bed hold to the resident's responsible party when residents were hospitalized for 3 of 3 residents reviewed for hospitalization (Residents #43, #45 and #73). The findings included: 1) Resident #43 was initially admitted to the facility on [DATE]. Resident #43's medical record indicated she was transferred to the hospital on 8/7/23. On 8/11/23 she was readmitted to the facility. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 to be cognitively intact. On 9/27/23 at 11:09 AM, an interview occurred with Nurse #1 who stated she was unaware of a bed hold policy being sent when a resident went to the hospital by the nursing department. The Business Office Manager was interviewed on 9/27/23 at 11:15 AM and stated she was unaware of a bed hold policy having to be sent to the resident and/or Responsible Party (RP) when a resident was hospitalized . On 9/27/23 at 11:17 AM, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-09-28 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of bathing for 1 of 20 residents reviewed (Resident #6). The findings included: Resident #6 was admitted to the facility 6/21/22 with diagnoses that included muscle weakness, low back pain, and chronic pain. A review of the shower records from 7/16/23 to 7/22/23 revealed Resident #6 was provided a bed bath on 7/21/23. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 had moderately impaired cognition. The bathing section was coded as the activity did not occur during the seven-day look back period. On 9/25/23 at 12:30 PM, Resident #6 was interviewed. She explained that she preferred to have bed baths and sponge baths rather than showers. Resident #6 also stated that a sponge bath was provided daily before she got up to her wheelchair. She was able to wash some of her upper body but became fatigued very easily with pain in her joints. An interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-09-28 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise the care plan for an antidepressant medication (#73) and for bed mobility (Resident #68). This was for 2 of 20 residents reviewed. The findings included: 1) Resident #73 was initially admitted to the facility on [DATE] with diagnoses that included a history of a stroke, dementia, and depression. The medical record for Resident #73 was reviewed and indicated Venlafaxine (a medication used to treat depression) 75 milligrams (mg) by mouth twice a day was discontinued on 7/11/23. Resident #73's active care plan, last reviewed 8/14/23, included a focus area for uses antidepressant medication (Venlafaxine) related to depression. A review of the September 2023 Medication Administration Record revealed Resident #73 did not receive any type of antidepressant medication. On 9/28/23 at 9:45 AM, an interview occurred with the Minimum Data Set (MDS) Coordinator. After reviewing Resident #73's active care plan and medical record she confirmed 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$41,844 in federal fines across 1 penalty.
- $41,844 — penalty dated 2023-09-28
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 CCH HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.5 | +0.5 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 32 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PINEHURST OPCO, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 07/26/2018 |
| JEREMIAS, BARUCH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 07/26/2018 |
| PINEHURST NC INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 07/26/2018 |
| STARLIGHT HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 07/26/2018 |
| GORHAM, KELLY | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/26/2018 |
| STERN, JACOB | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/26/2018 |
CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345177. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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 →
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