The Laurels of Chatham
72 Chatham Business Park, Pittsboro, NC 27312 · For profit - Corporation · 140 certified beds · (919) 542-6677 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- it has 2 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,527 in federal fines (most recent 2024-04-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.7% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.4% | 7.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 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 | 2.1% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.2% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.7% | 21.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 5.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 17.0% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.9% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.3% | 78.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.5% | 22.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.8% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.58 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.24 | 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.
47.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.7% 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 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 47.0%CMS range 39.9–55.9 | 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 | 10.5%CMS range 7.6–14.5 | 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 | 61.7% | 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 | 61.7% | 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 | 59.6% | 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 | 94.7% | 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 | 93.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.7% | 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 | 9.5% | 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 | 6.4%CMS range 3.7–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 140 beds and averages 122.8 residents a day — about 88% 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 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 3.23 hrs/resident/day on weekends vs 3.92 on weekdays — 18% thinner on weekends. RN hours go from 0.37 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-07-08 · 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 record review, observation and interviews with staff and the Medical Director the facility failed to provide care safely to a dependent resident (Resident #117). On 02/14/25 Resident #117 was sitting on a bath bench in the shower room while Nursing Assistant (NA) #1 was washing her hair when Resident #117's body suddenly went limp, and she went unresponsive. NA #1 laid Resident #117 onto the shower bench, ran approximately 10 feet away from her to yell for help, leaving Resident #117 with no staff support resulting in the resident falling off the shower bench. Resident #117 sustained a laceration to her right eyebrow with significant bleeding and bruising and a skin tear to her right elbow. Resident #117 was prescribed an anticoagulant (blood thinner) daily for blood clot prevention. This deficient practice affected 1 of 5 residents reviewed for supervision to prevent falls. The findings included: Resident #117 was admitted to the facility on [DATE]. Her diagnosis included fracture of sacrum, aneurysm…
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.
- Actual harm · Gcited before2024-04-17 · 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, observations and interviews with the Orthopedic Physician Assistant, Orthopedic Nurse, Wound Physician Assistant, Medical Director, Hospice Aide, and staff, the facility failed to assess Resident #102's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint). This resulted in the development of an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by eschar (dry, dark scab of dead skin), slough (yellow tissue that is stringy and thick) and granulation tissue (part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries form around the edges of the wound) pressure ulcer to the right inner ankle. The facility also failed to transcribe and provide protective skin care to a recently healed pressure ulcer (Resident #92). This deficient practice affected 2 of 7 residents reviewed for…
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 before2025-07-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and Paramedic and staff interviews, the facility failed to maintain a resident's (Resident #117) dignity when her nude body was left uncovered until after Emergency Medical Services (EMS) arrived following a fall on the shower room floor. EMS covered the residents' body upon their arrival. A reasonable person would not want to be left with their nude body fully exposed and would have experienced feelings such as embarrassment or humiliation. This deficient practice affected 1 of 4 residents reviewed for dignity. The findings included: Resident #117 was admitted to the facility on [DATE]. Resident #117's 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was intact. Resident #117 required moderate assistance with shower/bath and transfers. Resident #117's incident report dated 02/14/25 at 9:20 PM, completed by Nurse #6, indicated Resident #117 had a fall while being assisted by Nurse Aide (NA) #1 in the shower room when she lost consciousness and collapsed onto…
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 · D2025-07-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was made after a resident was given new mental health diagnoses for 1 of 2 residents (Resident #68) reviewed for PASRR. The findings included: Review of Resident #68's medical record revealed the resident was originally admitted to the facility on [DATE] and a PASRR level I was completed. A level II PASRR was halted on 5/21/24 due to dementia being the primary diagnoses without a diagnosis of mental illness. The resident was diagnosed with unspecified psychosis not due to a substance or physiological condition on 10/03/24. He had been placed on Nuplazid (an antipsychotic medication) 34 milligrams with a start date of 09/30/24. There was no documentation regarding a new level II PASRR request in Resident #68's chart after the new mental health diagnosis. Review of Resident #68's most recent comprehensive Minimum Data Set (MDS) dated [DATE] assessed the resident to be…
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 before2025-07-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 and Medical Director, the facility failed to thoroughly assess Resident #117, who had a do not resuscitate order and was prescribed an anticoagulant (blood thinner) daily for blood clot prevention, after she went unresponsive during a shower and after a fall that resulted in injury. On [DATE] Resident #117 was sitting on a bath bench in the shower room while Nursing Aide (NA) #1 was washing her hair. Resident #117 took a deep breath, her body suddenly went limp, and she went unresponsive. NA #1 laid Resident #117 onto the shower bench, ran approximately 13 feet away from her to yell for help, leaving Resident #117 with no staff support resulting in the resident falling off the shower bench. In the minutes after the medical event and fall and before emergency medical services (EMS) arrived, Nurse #6 did not perform a head-to-toe assessment, check vital signs including pulse from the carotid artery, check range of motion or assess pain. Resident #117 was not turned…
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 · D2025-07-08 · 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 record review, observations and staff interviews, the facility failed to administer water flushes via a feeding tube at the physician ordered flow rate for 1 of 1 resident reviewed with tube feedings (Resident #101). The findings included: Resident #101 was originally admitted to the facility on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition, cognitive communication deficit, dysphagia (difficulty swallowing) and presence of a feeding tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 had moderate cognitive impairment with no behaviors noted. He was coded as receiving 51% or more of his total calories through a tube feeding and an average fluid intake of 501 cubic centimeters (cc) per day or more by tube feeding. Resident #101's active care plan, last reviewed 5/19/25, revealed a focus area for an enteral feeding tube to meet nutritional needs. The interventions included providing water as ordered. Resident #101's active physician…
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 · D2025-07-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, record review, and staff interviews, the facility failed to follow sterile technique when Nurse #5 failed to apply sterile gloves for suctioning while providing tracheostomy care for 1 of 2 residents observed for tracheostomy care (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, diffuse traumatic brain injury with loss of consciousness of unspecified duration, and tracheostomy. A review of the annual Minimum Data Set assessment tool dated 4/7/25 indicated Resident #38 was severely cognitively impaired. She was coded for using oxygen, a tracheostomy, and suctioning. A review of Resident #38's orders revealed an order dated 7/1/24 to deep suction the tracheostomy as needed for increased secretions and every shift. An observation was conducted on 7/2/25 at 10:50 AM of Nurse #5 as she provided suctioning and tracheostomy care for Resident #38. Nurse #5 washed her hands, applied clean gloves, and opened 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.
- Potential for harm · Dcited before2025-07-08 · 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, Nurse Practitioner and staff interviews, the facility failed to hold a blood pressure medication as ordered by the physician for 1 of 6 residents whose medications were reviewed (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure. Review of Resident #32's physician orders included an order dated 7/20/24 for losartan potassium-hydrochlorothiazide (a medication for high blood pressure which is also a diuretic) 50-12.5 milligrams (mg) one tablet by mouth every day. Hold for systolic blood pressure (SBP-the top number in the blood pressure reading) less than 110. The March 2025 Medication Administration Record (MAR) was reviewed and revealed Resident #32 had received losartan potassium-hydrochlorothiazide, despite the SBP below 110 on the following dates: 3/4/25 SBP was 105 administered by Nurse #1. 3/9/25 SBP was 101 administered by Nurse #1. 3/12/25 SBP was 109 administered by…
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 · E2024-04-17 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff and resident interviews, the facility failed to resolve resident council concerns regarding call bell responses on night shift. (Resident #s 23, 41, 77), and failed to provide the residents a private resident council meeting without staff interference for 2 of 4 months reviewed (March 2024 and April 2024). Findings included: 1. Resident council meeting minutes/concern form dated 3/5/24 documented by the Activity Coordinator for new business revealed residents had to wait a long time on night shift for staff to answer call lights. The facility response was call bells were to be answered within 3 to 5 minutes. It was everyone's responsibility to answer call bells. If you cannot assist a guest, leave the light on. Resident council meeting minutes/concern form dated 4/2/24 documented by the Activity Coordinator for new business (brought forward from the month before) revealed the Nursing Assistants (NA) on night shift 11:00 pm to 7:00 am do not provide care and round regularly. Old business from last month's minutes: residents are waiting a long time for…
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 before2024-04-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff and resident interviews, the facility failed to provide stool incontinence care on night shift for a dependent resident which caused him to feel angry (Resident #59) and failed to communicate with a resident. A reasonable person expects to be provided communication during care and understand what to expect (Resident #15). This deficient practice affected 2 of 3 residents reviewed for dignity. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with the diagnosis of liver failure. Resident #59's Minimum Data Set, dated [DATE] documented the resident had an intact cognition, was understood and understands others. The resident required staff assistance of one with all activities of daily living. The resident was incontinent of stool. Resident #59's care plan dated 3/29/24 documented he had an activity of daily living deficit. The resident was incontinent of stool and the interventions were to check during routine rounds and as needed for…
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 before2024-04-17 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to honor a resident's right to refuse care when Nursing Assistant (NA) #5 attempted to dress the resident in a gown despite the resident's (Resident #15) physical and verbal behaviors resisting this care. This deficient practice affected 1 of 2 residents reviewed for choices. Findings included: Resident #15 was admitted to the facility on [DATE] with the diagnoses of seizure disorder and psychotic disorder with delusions. Resident #15's quarterly Minimum Data Set, dated [DATE] indicated the resident had severely impaired cognition. The resident had verbal behaviors 1 to 6 times per week during the 7-day look back period. The resident required assistance of one staff member for dressing. The resident was coded for refusal of care. Resident # 15's care plan had a need for crying spells and yelling out. The interventions were to approach in a quiet, calm manner, encourage participation in activities of daily living, report changes in mood…
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 · D2024-04-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews with the Orthopedic nurse, Orthopedic Physician Assistant, Responsible Party (RP) , and staff, the facility failed to notify the orthopedic provider of a newly acquired pressure ulcer caused by a knee immobilizer and that the knee immobilizer was not being worn as ordered for Resident #102's fractured distal femur (the area of the leg just above the knee joint). The facility also failed to notify the RP of the addition and increase of medication prescribed for Resident #173. This was for 2 of 2 residents reviewed for notification. The findings included: 1) Resident #102 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, bullous pemphigoid (an autoimmune disorder that causes itchy raised rashes and large blisters) and psoriasis. The hospital Discharge summary dated [DATE] indicated Resident #102 was to wear the well-padded knee immobilizer which could be removed for hygiene. A review of Resident #102's physician…
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 19 citations
- Potential for harm · Dcited before2024-04-17 · 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 record review, observation, and staff and resident interviews, the facility failed to provide dependent residents nail care (Resident #s 59 and 92) and failed to provide hair care and facial hair shaving (Resident #59) for 2 of 7 residents reviewed for activities of daily living. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with the diagnoses of post-traumatic stress disorder and depression. Resident #59's Minimum Data Set, dated [DATE] documented an intact cognition and no behaviors or rejection of care. The resident required staff assistance of one for bathing and personal care. Resident #59's care plan dated 3/29/24 documented he had an activity of daily living deficit and could refuse care, needs assistance with all activities of daily living, and to keep his nails trimmed. A review of Resident #59's Nursing Assistant (NA) documentation for personal care, including facial and nail care, were documented yes for each day for 4/1/24 through 4/16/24. On 04/15/24 at 11:47am…
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 before2024-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews with the Medical Director, Orthopedic nurse, Orthopedic Physician Assistant and staff, the facility failed to apply a right knee immobilizer for a resident with a fractured distal femur (the area of the leg just above the knee joint) as ordered (Resident #102). In addition, the facility transferred a resident with an obvious deformity and pain to the right hip/leg after a fall. (Resident #30). This was for 2 of 3 residents reviewed for well-being. The findings included: 1) Resident #102 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur. The hospital Discharge summary dated [DATE] indicated Resident #102 was to wear the well-padded knee immobilizer which could be removed for hygiene purposes. A review of Resident #102's physician orders included an order dated 3/2/24 to 3/19/24 for right knee immobilizer to be worn at all times. Remove for hygiene, replace padding if removed every shift. The admission Minimum Data…
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 before2024-04-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on record review and staff interviews, the facility failed to have complete and accurate medical records in the areas of wound care (Residents #273 and #274). This was for 2 of 7 closed records reviewed. The findings included: 1) A review of Resident #273's February 2024 Treatment Administration Record (TAR) revealed wound care to the left great toe amputation site was not signed as completed or refused by the resident on 2/8/24 and 2/15/24. A phone interview was completed with Nurse #6 on 4/16/24 at 2:51PM. She was assigned to care for Resident #273 on 2/8/24. Nurse #6 stated she recalled completing wound care as ordered for Resident #273 but must have gotten busy and forgot to sign off as completed. A phone interview occurred with Nurse #7 on 4/16/24 at 9:11 AM, who was assigned to care for Resident #273 on 2/15/24. Nurse #7 stated she completed wound care to her left great toe area as ordered but must have forgotten to sign off as complete. On 4/17/24 at 10:03 AM, an interview was conducted with the Director of Nursing (DON) who stated she expected documentation to be…
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 before2024-04-17 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and staff interviews, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification survey dated 2/9/23 in order to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 4/14/24. The deficiencies were in the areas of dignity (550), activities of daily living, pressure ulcer, and accurate medical records. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: F550: Based on record review, observation, and staff and resident interviews, the facility failed to provide stool incontinence care on night shift for a dependent resident which caused him to feel angry (Resident #59) and failed to communicate with a resident. A reasonable person expects to be provided communication during care and understand what to expect (Resident #15). This deficient practice affected 2 of 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-17 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 staff, Physician and Consultant Pharmacist interviews and record review, the Consultant Pharmacist failed to identify the lack of documentation for the monitoring of side effects for a resident prescribed antipsychotic medications. This was for 1 (Resident #173) of 7 residents reviewed for unnecessary medications. The findings included: Resident #173 was admitted on [DATE] with cumulative diagnoses of Alzheimer's Disease, dementia with behaviors, and Bipolar Disease. Review of Resident #173's admission Physician orders included an order dated 8/13/23 for Zyprexa (antipsychotic) 2.5 milligrams (mg) every 6 hours as needed for psychotic disorder x 14 days until 8/27/23. Resident #173 was care planned on 8/14/23 for a risk for adverse reactions and side effects related to receiving multiple psychotropic medications which included an antipsychotic. Interventions for the antipsychotic included to observed for sedation, headaches, dizziness, diarrhea, anxiety, tremors, orthostatic hypotension, blurred vision,…
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 · D2024-04-17 · 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 staff and Physician interviews and record review, the facility failed to identify the lack of documentation for the monitoring of side effects for a resident prescribed antipsychotic medications. This was for 1 (Resident #173) of 7 residents reviewed for unnecessary medications. The findings included: Resident #173 was admitted on [DATE] with cumulative diagnoses of Alzheimer's Disease, dementia with behaviors, and Bipolar Disease. Review of Resident #173's admission Physician orders included an order dated 8/13/23 for Zyprexa (antipsychotic) 2.5 milligrams (mg) every 6 hours as needed for psychotic disorder x 14 days until 8/27/23. Resident #173 was care planned on 8/14/23 for a risk for adverse reactions and side effects related to receiving multiple psychotropic medications which included an antipsychotic. Interventions included to observed for sedation, headaches, dizziness, diarrhea, anxiety, tremors, orthostatic hypotension, blurred vision, extrapyramidal (impaired motor control) side effects 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 · Ecited before2023-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, family member, resident and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #66, #28, #114, #40, #116 and #58) and failed to assist with shaving (Resident #84). In addition, the facility failed to assist a resident with bathing (Resident #33). This was for 8 of 12 residents reviewed for Activities of Daily Living (ADLs). The findings included: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact and displayed no behaviors or rejection of care. He required total assistance from staff for bathing and personal hygiene. Resident #66's active care plan, last reviewed 1/20/23, included the following areas of need: - ADL self-care performance deficit and requires assistance with ADLs and mobility related…
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 before2023-02-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 review, observations, and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 3 of 12 residents reviewed for pressure ulcers (Resident #58, #87, and #14). The findings include: Review of the operational manual for the alternating air mattress revealed the following: Weight Setting Selection: The pressure of the mattress can be adjusted by choosing the patients ' corresponding weight setting using the weight setting buttons (+) and (-). Use the weight setting buttons to select the desired level. Pressure levels will range from 20 to 60 millimeters of mercury (mmHg). 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included post traumatic seizures, contractures of the left elbow, right lower leg, ankle, hip, and knee, left lower leg, ankle, hip, knee and wrist, and adhesive capsulitis of the right and left shoulders. Resident #58's active physician orders included an order 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 · Dcited before2023-02-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to provide a dignified dining experience by providing residents with disposable food containers and plastic utensils during three observed meals (Resident #89 and Resident #31) and referring to a resident who needed assistance with meals as a feeder (Resident #75). This was for 3 of 9 residents reviewed for dignity. Based on the reasonable person concept residents would expect to utilize regular plates and utensils regardless of how fast they eat and would not expect to be identified as a feeder. Requiring a resident to utilize disposable food containers and plastic utensils while other residents were not or being labeled a feeder has the potential for a reasonable person to experience a negative psychosocial outcome. The findings included: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated…
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 · D2023-02-09 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews with staff, Responsible party, the facility failed to transfer a resident to the hospital when the Responsible Party's (RP) made the request for 1 of 1 (Resident #119) reviewed for choices. The findings included: Resident #119 was admitted to the facility on [DATE] with diagnosis that included dementia and fracture after a fall. The resident's admission Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living. The resident's medical record included a progress note dated 1/28/2023 by Nurse #10. The progress note indicated Resident #10 was found on the floor next to her bed. The nurse assessed the resident for injuries, notified the RP and the Medical Director, and placed the resident on neurological observations. Then at 2:35PM Nurse #10 documented a progress note that read in part, guest with continued labored breathing yet no signs or symptoms of pain. MD notified of clinical…
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 before2023-02-09 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to honor a resident's choice related to showers (Resident #66) for 1 of 2 residents reviewed for choices. The findings included: Resident #66 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact and displayed no behaviors or rejection of care. He required total assistance from staff for bathing and personal hygiene. Resident #66's active care plan, last reviewed 1/20/23, included a focus area for ADL self-care performance deficit and requires assistance with ADLs and mobility related to decline in mobility and dementia. A review of Resident #66's nursing progress notes from 9/1/22 to 1/8/23 revealed no refusals of showers documented. A review of the facility's shower schedule indicted Resident #66 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.
- Potential for harm · D2023-02-09 · 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 review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of cognition (Residents #89, #87 & #19), pressure ulcer (Resident #114) and diagnoses (Resident #28) for 5 of 31 residents whose MDS were reviewed. Findings included: 1. Resident #87 was admitted to the facility on [DATE]. The annual MDS assessment dated [DATE] indicated that Resident #87 had unclear speech, sometimes made self-understood and usually understood others. The Brief Interview for Mental Status (BIMS), used to screen and identify cognitive conditions, was noted as not completed because Resident #87 was rarely/never understood. The Social Worker (SW) Assistant was interviewed on 2/8/23 at 10:17 AM. The SW indicated that she was responsible for completing the BIMS assessment for the MDS assessment. She stated that she was new to the facility and was still learning the process. The MDS Nurse was interviewed on 2/9/23 at 10:50 AM. The MDS Nurse reported that 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.
- Potential for harm · D2023-02-09 · 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, observation and staff interview, the facility failed to transcribe the correct medication administration route for 1 (Resident #87) of 4 residents reviewed for gastric feeding tube and with orders for nothing by mouth (NPO). Findings included: Resident #87 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia (difficulty swallowing) following cerebro vascular disease and severe protein calorie malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #87 was receiving tube feeding. Resident #87 had a physician's order dated 11/10/22 for continuous enteral feeding at 60 milliliter (ml) per hour and NPO. On 11/11/22, the resident had an order for Melatonin 3 milligrams (mgs) 1 tablet by mouth at bedtime for insomnia. On 2/4/23, the resident had an order for Fluconazole (used to treat fungal infections) 150 mgs 1 tablet by mouth for infection. Resident #87 was observed on 2/6/23 at 11:24 AM. He was in bed and a continuous…
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 · D2023-02-09 · 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 record review, observations, and staff interviews, the facility failed to apply the right-hand palm guard (Resident #87) and bilateral elbow extension splints (Residents #58) as ordered for 2 of 3 residents reviewed for range of motion. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included contractures of the left elbow, right lower leg, ankle, hip, and knee, left lower leg, ankle, hip, knee and wrist, adhesive capsulitis of the right and left shoulders. Resident #58 had a physician ' s order dated 04/07/22 to position bilateral elbow extension (BUE) splints daily following AM care for up to 4 hours or as tolerated. Provide hygiene to BUE hand/creases of elbows with warm soapy water, rinse, and dry thoroughly. Provide slow gentle stretching to BUE at the shoulders, elbows, wrists, and hands as tolerated prior to application. Review of quarterly Minimum Data Set (MDS) assessment, dated 10-25-22, revealed Resident #58 ' s cognition was severely…
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 before2023-02-09 · 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, Medical Director and staff interviews, the facility failed to transcribe vital sign parameters for a blood pressure medication as ordered for 1 of 6 residents whose medications were reviewed (Resident #223). The findings included: Resident #223 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, anxiety disorder, and muscle weakness. A nursing progress note dated 9/28/22 read, in part, that therapy had reported that Resident #223 was not doing well because her blood pressure dropped during therapy. The physician was in the building and was updated on Resident #223's condition. An order was provided with new parameters for Metoprolol (a blood pressure medication) 12.5 milligrams (mg). Hold the medication if blood pressure is less than 110/70 or heart rate less than 60. Review of the September 2022 physician orders revealed an order dated 9/20/22 for Metoprolol 12.5 mg by mouth twice a day for Hypertension. The parameters of when to hold the medication…
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 · D2023-02-09 · 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 observation, interview with resident and staff, the facility failed to secure medication patches for 1 of 4 (Resident #16) residents observed for medication administration. The findings included: On 2/7/2023 at 9:30AM Nurse #9 was observed administering medication to Resident #16. The resident asked Nurse #9 to apply her patch while she was in the room. Nurse #9 reached down in the draw of the bedside table, next to Resident #9's bed and pulled out two boxes of Asper creme patches (Lidocaine, topical analgesic). Nurse #9 pulled out a patch, placed the boxes back in the bedside table drawer, and applied patch she removed to Resident #16. After exiting the resident's room, the state surveyor questioned Nurse #9 regarding the storage of medication in Resident #16's bedside table. Nurse #9 stated the resident did not have an order to self-administer the patch and the patches should be secured somehow if kept in the resident's room. She further stated the resident did not like the patches the facility had, therefore she had her family bring the patches into the facility for her.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on record review and staff interviews, the facility failed to maintain accurate medical records for wound care (Resident #123), and respiratory care (Resident #123). This was for 1 of 7 closed records reviewed. The findings included: 1a. Resident #123's physician orders included an order dated 3/23/22 for skin prep to the right foot blister every shift, monitor every shift for changes and report to physician and wound care nurse for treatment change. The April 2022 and May 2022 Treatment Administration Records (TARs) were reviewed and revealed the right foot blister wound care had not been documented as completed or refused by the resident for the following: - Day shift (7:00 AM to 3:00 PM) on 4/3/22, 4/6/22, 4/7/22, 4/9/22, 4/14/22, 4/22/22, 4/27/22, 4/29/22 and 5/1/22. - Evening shift (3:00 PM to 11:00 PM) on 4/8/22, 4/12/22 and 5/6/22. Review of the nursing progress notes from 3/1/22 to 5/9/22 did not reveal any refusals of wound care by Resident #123. On 2/8/23 at 10:17 AM, an interview occurred with the Nurse Unit Manager #1 who was familiar with Resident #123. She 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.
- Potential for harm · Dcited before2023-02-09 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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, 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 the annual recertification and complaint survey completed on 1/24/20. This was for 3 deficiencies that were cited in the areas of Accuracy of Assessments, Services Provided Meet Professional Standards, and Increase/Prevent Decrease in Range of Motion/Mobility. In addition, one further deficiency was cited during the annual recertification and complaint survey on 3/17/22 in the areas of Resident Records. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F641- Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of cognition (Residents #89. #87 & #19), pressure ulcer (Resident #114) and diagnoses…
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 · B2023-02-09 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to display accurate Posted Nurse Staffing Information as compared to the Staff Schedule/Assignment Sheets for 31 out of 31 days reviewed. The findings included: A review of the Staff Schedule/Assignment Sheets and timecard reports compared to the daily Posted Nurse Staffing Information sheets from 01/06/23 through 02/06/23 revealed discrepancies in the areas of actual hours worked and actual nursing staff who worked including the licensed Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), and the unlicensed Medication Aides (MAs), and Nursing Assistants (NAs). Review of the daily Posted Nurse Staffing Information sheets for 01/06/23 through 02/06/23 compared to timecard reports revealed there were no RNs noted on the Posted Nurse Staffing Information although RNs were working for the following days: 01/20/23, 01/25/23, 01/27/23, and 02/03/23. The number of licensed staff and actual hours worked of licensed staff on 1st shift were incorrect for the following days: 01/06/23, 01/07/23, 01/09/23, 01/10/23,…
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
$10,527 in federal fines across 1 penalty.
- $10,527 — penalty dated 2024-04-17
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 CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 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 | 2 of 5 | 2.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 80 homes this chain runs (chain average 2.8★, per CMS)
Showing 40 of 80; lowest-rated first.
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 | Since |
|---|---|---|---|
| QAZI, MOHAMMAD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 02/01/2016 |
| KHAN, ANIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2016 |
| STOBB, DAVID | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 02/01/2016 |
| LAUREL HEALTH CARE COMPANY | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2016 |
| JARRELL, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/03/2007 |
| SIMPSON TAROKH, LEANN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 15 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $829K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
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 345421. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.