PruittHealth-Raleigh
2420 Lake Wheeler Road, Raleigh, NC 27603 · For profit - Corporation · 150 certified beds · (919) 755-0226 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,152 in federal fines (most recent 2025-05-08)
- about 24% 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 | 12.6% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.1% | 7.2% | 5.4% | typical |
| 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 | 2.2% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 5.9% | 6.5% | better |
| 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 | 4.4% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.2% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.6% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 5.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.3% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.2% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.4% | 78.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.6% | 22.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.3% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.62 | 1.78 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 1.80 | 1.80 | typical |
‡ 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.
58.3% 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 189 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.4% 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 106 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 58.3%CMS range 49.3–64.9 | 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 | 11.9%CMS range 9.2–14.9 | 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 | 43.4% | 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 | 39.6% | 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 | 36.8% | 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 | 96.4% | 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 | 100.0% | 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 | 92.6% | 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 | 0.0% | 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 | 2.2% | 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 | 6.9%CMS range 4.2–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 150 beds and averages 143.6 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.63 on weekdays — 18% thinner on weekends. RN hours go from 0.61 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jdisputed · IIDR2025-05-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to protect Resident #1's right to be free of neglect for 1 of 3 residents reviewed for accidents. On 4/25/25 at approximately 4:30 PM during transportation back to the facility from a medical appointment in the contracted transport van the resident's wheelchair flipped backwards landing horizontal on the floor of the van. Resident #1's head hit the van floor and her back sustained impact when the wheelchair backrest (the support structure for the user's back) hit the floor. The Contracted Transport Driver was not qualified to complete a clinical assessment of injury. He asked the resident if she was okay, set the wheelchair upright, secured the wheelchair in the van, and continued the trip back to the facility. The resident reported during the entire ride back to the facility the Contracted Transport Driver repeatedly stated that he was going to be fired for what happened. Upon return to the facility, the Contracted Transport Driver notified facility…
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.
- Immediate jeopardy · Jcited beforedisputed · IIDR2025-05-08 · 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, interviews with staff, resident, Contracted Transportation Company, and the Physician, the Contracted Transport Driver failed to have Resident #1 assessed for injury by a qualified professional prior to moving the resident following a fall in the transportation van and to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. Resident #1 returned to the facility on 4/25/25 at approximately 5:30 pm and notified staff that her wheelchair had flipped backwards while being transported back to the facility and the Contracted Transport Driver lifted her and her wheelchair up from the floor and returned her to the facility. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. The resident was transferred to the hospital where she was identified with a fracture at the superior endplate (flat surface at the top of each vertebra) of the L1 (lumbar spine region,…
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.
- Immediate jeopardy · Jcited beforedisputed · IIDR2025-05-08 · 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 and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to ensure a resident was safely secured in the contracted transport van during the return trip from an appointment back to the facility. On 4/25/25 the Contracted Transport Driver failed to secure Resident #1's wheelchair in accordance with the manufacturer's instructions prior to departing with the resident from the dialysis clinic. During travel, Resident #1's wheelchair flipped backwards landing with the backrest of wheelchair (the support structure for the user's back) on the floor of the van. Resident #1 remained in the wheelchair during the fall resulting in her head hitting the van floor and her back sustaining impact when the backrest of the wheelchair hit floor. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. Staff reported the resident was moaning and crying out and that they had never seen 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 · Dcited before2026-01-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #141).The findings included:Resident #141 was admitted to the facility on [DATE].An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #141 to be cognitively intact.During an observation on 1/12/2026 at 11:03 am revealed Resident #141 in bed, the overhead light was on, but no string was attached to overhead light. The light was attached to the wall, behind Resident #141's head.During an interview on 1/12/2026 at 11:04 am with Resident #141, the Resident stated that the string on her overhead light had been broken since she was admitted to the facility in December. Resident #141 stated that she slept with the light on all night and that she was able to sleep fine with the light on. Resident #141 further indicated that although the light being on did not bother…
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 · D2026-01-15 · 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 staff interviews, the facility failed to ensure medications were administered according to the physician's orders and manufacturer's instructions for method of administration for 1 of 10 residents reviewed for medication administration (Resident #118). Findings included:Resident #118 was admitted to the facility on [DATE] with diagnoses that included Parkinsons disease, dementia and weakness.On 11/29/2025, the admission Minimum Data Set (MDS) assessment revealed Resident #118 was severely cognitively impaired. Eating and oral hygiene required substantial/maximal assistance. On 12/25/2025 a physician order stated that the resident takes medications whole in applesauce. A review of January 2026 active medications orders included Aspirin 81 milligrams (mg) delayed-release 1 tablet once a day, Carbidopa-levodopa 25-100 mg 2 tablets at 6:00 am, 10:00 am and 4:00 pm and Bisacodyl (stimulant laxative) 5 mg delayed-release 1 tablet at bedtime. Review of Resident #118's January 2026 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 · D2026-01-15 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to provide an ongoing resident centered activities program in the memory care unit of the facility for 1 of 1 resident reviewed for activities (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included dementia and depression. She resided on the memory care unit of the facility (a locked unit for individuals with dementia). The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Resident #27's assessment of daily and activity preferences revealed it was important for her to have reading material, listen to music, be around pets, keep up with news, be around groups of people, go outside and participate in religious services. Resident #27's care plan last reviewed on 11/18/25 revealed no goals or interventions related to activities. Review of the Kardex (resident care guide) for Resident #27 revealed no mention of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with the Pharmacy Consultant and staff interviews, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy which resulted in the controlled medication being diverted from the medication cart for 1 of 1 resident reviewed for pharmacy services (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] and discharged on 1/7/25. Review of a certificate of inventory and destruction form with no date completed by Nurse #2 revealed she had started a return to pharmacy of 11 tablets of 5 mg oxycodone HCL for Resident #13 discharged on 1/7/25. Review of the facility reported incident investigation dated 1/23/25 revealed the narcotic count for the 100-hall medication cart was not correct the evening of 1/18/25 during narcotic reconciliation completed by the off going Nurse #1 and oncoming Nurse #2. The 100-hall medication cart was found to be missing one narcotic count sheet for oxycodone HCL…
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 before2025-06-25 · 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, staff interviews, the facility failed to ensure the medical record was accurate regarding administration of Oxycodone Hydrochloride (HCL) (an opioid medication which is a controlled substance) for 1 of 1 resident (Resident #13) reviewed for accuracy of medical records. The findings included: A physician's order for Resident #13 dated 12/6/24, read Oxycodone HCL 5 mg to be administered 1 tablet every 6 hours as needed for moderate to severe pain. A review of the narcotic controlled substance count record for Resident #13 revealed Nurse #1 signed out one Oxycodone HCL 5 mg on the following dates: - 12/8/24 at 9:30 am - 12/11/24 at 8:45 am - 12/12/24 at 8:00 am - 12/17/24 at 1:30 pm - 12/20/24 at 3:00 pm - 12/22/24 at 9:00 am - 12/22/24 at 6:00 pm - 12/24/24 at 8:00 am A review of the Medication Administration Record (MAR) for Resident #13 revealed no documentation by Nurse #1 for the Oxycodone HCL 5 mg on the following dates: - 12/8/24 at 9:30 am - 12/11/24 at 8:45 am - 12/12/24 at 8:00 am - 12/17/24 at 1:30 pm - 12/20/24 at 3:00 pm - 12/22/24 at 9:00 am -…
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 before2024-11-15 · 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 4. Resident # 44 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment, had no behaviors, and needed supervision for ambulating around the unit. The MDS also documented that Resident #44 required a trunk restraint (a restraint on the torso that prevents a resident from getting up out of a chair) once during the observation period. Review of Resident #44's physician's orders from 7/1/24-11/14/24 did not reveal an order for a restraint. Review of Resident #44's progress notes from 7/1/24-11/14/24 did not reveal notes that she had any behaviors or any indications of a need for a restraint. The notes did not document that a restraint was used. In an interview on 11/12/24 at 12:22 PM, Nurse #4, Resident #44's regular charge nurse, said Resident #44 never had a restraint. In an interview on 11/15/24 at 1:20 PM, Nurse #5 said she completed the MDS for Resident #44. She said she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, family and staff interviews, the facility failed to offer the resident the right to participate in the person-centered planning process for 2 of 5 residents reviewed for care plans (Residents #96 and Resident #21). Findings included: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, and depression. Resident #96's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact and required substantial to dependent assistance with most activities of daily living (ADL). Resident #96's care plans were noted as last reviewed or revised on 11/11/24. Review of Resident #96's record did not indicate care plan meetings had been conducted. On 11/12/24 at 10:32 AM an interview was conducted with Resident #96 who deferred all questions to her Family Member. Her Family Member stated early in Resident #96's admission he had participated in a care plan meeting, but it had been a while since he…
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 · D2024-11-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record reviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #5) reviewed with urinary catheters. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), obstructive and reflux uropathy (when urine cannot drain through the urinary tract and urine backs up into the kidneys), artificial openings of urinary tract (a medical condition where a surgical procedure has created an opening in the urinary system to allow urine to exit the body when the normal pathway is blocked or damaged), and urinary tract infection (UTI). Resident #5's care plan dated 10/3/2024 revealed focus areas for catheter care and at risk for infection. Interventions included not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-29 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to obtain the resident's consent before depositing and withdrawing the resident's personal funds into and from his non-transferring personal funds account. This was for 1 of 1 resident (Resident #52) reviewed for personal funds. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). A review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. A review of Resident #52's current Resident Fund Management Service authorization and agreement to handle resident funds dated 6/29/21 revealed Resident #52 provided his written consent for a non-transferring account (no-automatic transfer of deposits to pay for care costs). This consent was witnessed by the facility Regional Financial Counselor. A review of Resident #52's personal check #480 dated 10/10/22 revealed it was made out 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 · E2023-09-29 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to deliver a residents personal mail unopened. This was for 1 of 1 residents (Resident #52) reviewed for privacy of communication. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). A review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. On 9/25/23 at 3:09 PM in interview Resident #52 stated he was still able to take care of his finances including his tax refunds himself and it was important for him to continue doing this. He went on to say he used the facility address as his mailing address because he was residing in the facility when he completed his tax refund forms. Resident #52 stated he was expecting 2 tax refund checks for the tax forms he completed, and he never received them. He went on to say this worried him. He stated he had contacted the Internal Revenue…
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 17 citations
- Potential for harm · Ecited before2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 2. The facility's Smoke Free Policy dated 2014 stated fire igniting materials and smoking materials should not be kept in a resident's possession. Resident's igniting smoking materials would be maintained at the nurse's station for safety of smokers. The policy also stated residents who were grandfathered-in would be assessed for risk and hazards prior to smoking in designated areas and shall be supervised as necessary based on the smoking observation form located in the electronic medical record. The smoking observation form was completed at least quarterly if questions indicated the resident smoked or had a history of smoking. Resident #12 was admitted to the facility on [DATE], and diagnoses included multiple sclerosis (an unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body). Resident #12's care plan initiated on 03/17/2022 and reviewed on 9/26/2023 indicated Resident #12 was care planned as a smoker and was noncompliant…
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 · E2023-09-29 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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, resident interviews and staff interviews, the facility failed to provide breakfast meal trays at a regular scheduled mealtimes comparable to normal breakfast mealtimes in the community for 3 of 8 halls (100, 200 and 300 Halls). Findings included: A meal schedule was provided on 9/25/2023. Meal delivery times were recorded scheduled in 15-mnute intervals for the seven different halls (Memory unit, 700, 600, 500, 400, 300, 200, and 100-hall) between the following times: · Breakfast - 7:00 AM - 8:30 AM 1. On 9/27/2023 at 9:10 a.m., breakfast meal trays were observed not served to residents on the 100-hall and 200-hall On 9/27/2023 at 9:15 a.m., the Dietary Supervisor was observed working on the serving line and stated breakfast meals trays were delayed due to a call out in the dietary department that morning. She stated all halls except for the 100-hall and 200-hall had received their breakfast meal trays, and the dietary staff were currently working on preparing the 200-hall…
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 · E2023-09-29 · tag F0867 — failed to act on quality-improvement findings — patternSet 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 interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the complaint surveys of 2/10/21and 10/27/21. The deficiencies were in the areas of ADL Care Provided for Dependent Residents (677), Quality of Care (684), Free of Accident Hazards/ Supervision/Devices (689), Sufficient Nursing Staff (725), Resident Records-Identifiable Information (842), Increase/Prevent Decrease in ROM/Mobility (688) and Free from Abuse and Neglect (600). The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: The tag is cross-referenced to: F677: Based on observations, record review, and staff interviews the facility failed to keep dependent residents' fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #19). During the complaint survey of 10/27/21, the facility…
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 · D2023-09-29 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 complete a self-administration of medication assessment, obtain a physician's order, and care plan self- administration of medication before leaving medication at the resident's bedside. This was for 1 of 1 residents (Resident #17) reviewed for self-administration of medication. Findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic pain. A review of Resident #17's annual Minimum Data Set (MDS) assessment dated [DATE] revealed her vision was adequate. She was cognitively intact. A review of Resident #17's current comprehensive care plan last revised 8/17/23 revealed she was not care planned to self-administer medication. A review of Resident #17's medical record on 9/25/23 revealed no self-administration of medication assessment indicating Resident #17 would self-administer medication. A review of Resident #17's medical…
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 before2023-09-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observations, record review and resident and staff interviews the facility failed to accommodate a resident's request to try the new type of television (TV) the facility had when he was no longer able to use the control buttons on his old TV to change the channels. This was for 1 of 1 resident (Resident #52) reviewed for the accommodation of needs. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis paralysis of all four limbs. A review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was dependent on 1 person for personal hygiene including combing hair, brushing teeth, and shaving. He had functional limitation in range of motion of both upper and lower extremities. He had no behaviors, delusions, or rejection of care. A review of Resident #52's current comprehensive care plan last revised on 8/12/23 revealed a focus area for activities of daily living (ADL) decline related to paralysis of bilateral lower and right…
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 · D2023-09-29 · 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 staff interviews the facility failed to keep dependent residents' fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. His active diagnoses included metabolic encephalopathy, cerebral infarction due to embolism of left middle cerebral artery, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #19's minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He had no rejection of care. He required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. Review of Resident #19's care plan dated 7/20/23 revealed Resident #19's was care planned for activities of daily living decline related to cerebrovascular accident and weakness. The interventions included to notify the physician of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-29 · 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, staff, and wound care Physician interviews the facility failed to assess and receive Physician orders for a resident who had a wound to the back of her right leg. This occurred for 1 of 1 resident (Resident #248) reviewed for wound care. Findings included: Resident #248 was admitted to the facility on [DATE] with multiple diagnoses that included adult failure to thrive and wound to right posterior leg. A review of Resident #248's hospital discharge record dated 7-6-23 revealed the resident was discharged with multiple decubitus ulcers on her legs and thigh. There were no treatment orders provided in the discharge summary. An admission note written by Nurse #2 on 7-6-23 at 7:17pm documented Resident #248 arrived to the facility at 6:35pm on 7-6-23 from the hospital. The documentation included diagnoses but no mention of the resident's wound. Nurse #2 was interviewed on 9-28-23 at 1:45pm. The nurse confirmed she had been assigned to Resident #248 when she was admitted on [DATE] and had…
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 · D2023-09-29 · 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 review and staff interviews the facility failed to place skin protection under the bridge (a section of a wound vac system used to connect the dressing to the vac) of a wound vac (Resident #8) and failed to complete weekly skin audits (Resident #397) for 2 of 4 residents reviewed for pressure ulcer care. Findings included: 1. Resident #8 was admitted to the facility on [DATE]. Resident #8's minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He was assessed to reject care daily. He required supervision with bed mobility, dressing, eating, toilet use, and personal hygiene. He was independent with transfers. Resident #8 had an indwelling catheter and was always continent of bowel. His active diagnosis included osteomyelitis of vertebra, sacral and sacrococcygeal region, neurogenic bladder, diabetes mellitus, hyperlipidemia, paraplegia, anxiety disorder, and pressure ulcer of the sacral region stage IV. He had one stage IV pressure ulcer which was present upon…
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 · D2023-09-29 · 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 and staff interviews the facility failed to provide restorative services for 1 of 2 residents reviewed for rehab and restorative (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. His active diagnoses included metabolic encephalopathy, cerebral infarction due to embolism of left middle cerebral artery, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #19's minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He had no rejection of care. He required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. He did not receive any restorative services during the lookback period. Review of Resident #19's occupational Discharge summary dated [DATE] revealed occupational therapy was discontinued due to Resident #19's ceased progress and limited participation. He was discharged to 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 · D2023-09-29 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews the facility failed to provide sufficient nursing staff to provide restorative services for 1 of 2 residents reviewed for therapy and restorative (Resident #19). Findings included: This tag is cross referenced to: Tag F688 - Based on record review and staff interviews the facility failed to provide restorative services for 1 of 2 residents reviewed for rehab and restorative (Resident #19). During an interview on 9/27/23 at 1:32 PM the Director of Nursing stated that providing care was the priority of the facility nurse aides. Nurse aides are education to provide range of motion exercises while in school. The Director of Nursing felt that there was not a staffing issue as there were enough staff to provide care and they could provide restorative services during that care. Due to this, she stated nurse aides needed to be educated as to which residents needed restorative services in order to complete the care with the current staffing levels. During an interview on 9/28/23 at 9:08 AM the Administrator stated she felt there were enough staff…
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 · D2023-09-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and record review, the facility failed to secure medications for 1 of 2 residents (Resident #500) observed with medications at bedside and failed to keep unattended medications in a locked medication cart for 1 of 4 medication carts observed (600-hall medication cart). Findings Included: 1. Resident #500 was admitted to the facility on [DATE]. Diagnosis included, in part, dementia. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #500 had severely impaired cognition. The Self-Administration of Medication assessment, dated 9/12/23, indicated Resident #500 was not appropriate to self-administer any medication. A review of the medical record revealed there was no order for Resident #500 to self-administer medication. An observation of Resident #500's room was completed on 9/25/23 at 11:49 AM. The resident was alert and sitting at the foot of the bed. A medication cup that contained ten pills was on the overbed table next to the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to have a complete and accurate medical record related to documentation of a resident's wound. This occurred for 1 of 1 resident (Resident #248) reviewed for wound care. Findings included: Resident #248 was admitted to the facility on [DATE] with multiple diagnoses that included adult failure to thrive, wound to posterior right thigh. A review of Resident #248's hospital discharge record dated 7-6-23 revealed the resident was discharged with multiple decubitus ulcers on her legs and thigh. There were no treatment orders provided in the discharge summary. The facility's admitting observation report for Resident #248 was initiated on 7-6-23 at 10:09pm and was completed by the Director of Nursing (DON). The skin assessment section documented Resident #248 as having no alterations of her skin. The Director of Nursing (DON) was interviewed on 9-28-23 at 3:49pm. The DON explained the process when a resident was admitted to the facility from the hospital.…
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 · D2023-09-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 administer the pneumococcal vaccine to 2 of 5 residents reviewed for immunization (Resident #144 & #70). Findings included: The facility policy for Pneumococcal Vaccinations with the revised date of 10/26/22 read in part all residents who reside in this healthcare center are to receive the pneumococcal vaccine within the current CDC (Centers for Disease Control and Prevention) guidelines unless contraindicated by their physician or refused by the resident or resident's family. 1. Resident #144 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated [DATE] indicated she was cognitively intact. Resident #144's vaccine information consent form signed by the resident dated 8/30/23 read in part that the resident would like to be offered the pneumococcal vaccine upon admission. Review of Resident #144's immunization records on 9/27/23 revealed no documentation of the pneumococcal vaccine being administered or refused. 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 before2024-11-15 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews with staff, the facility failed to complete the daily staff posting sheet for 4 of 4 days observed (11/12 through 11/15/24). The daily staff posting sheet did not include the resident census of the facility. The findings included: Observation on 11/12/24 at 2:00 p.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/13/24 at 9:15 a.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/14/24 at 8:15 a.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/15/24 at 8:15 a.m. revealed the daily staffing posting at the front desk did not include the census. In an interview on 11/15/24 at 3:27 p.m., the Staffing Coordinator said she did not know how to access the census for that day, so when she came in at 5 a.m., she would make rounds and fill out the accurate information and then wait for after the meeting to put in the census on the daily staffing posting. She would sometimes get busy helping residents…
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 before2024-11-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to have a complete and accurate medication and treatment administration record for 1 of 7 residents (Resident #399) reviewed for medical record accuracy. The findings included: Resident #399 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, high cholesterol, yeast infection of skin and nails, and non-pressure chronic ulcer of the right lower leg. Resident #399's physician orders revealed the following: - An order dated 11/02/23 for a pain evaluation every shift - An order dated 11/02/23 for atorvastatin (a statin medication used for high cholesterol) 80 milligrams (mg) one tablet at bedtime. - An order dated 11/02/23 for behavior monitoring. - An order dated 11/02/23 for miconazole nitrate (an antifungal) 2 % powder to apply twice a day to skin folds. - An order dated 11/03/23 for COVID-19 Monitoring twice a day. - An order dated 11/30/23 for oxycodone (used for pain) 5 mg one tablet twice a day. - An order…
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 · Ccited before2023-09-29 · 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 and staff interviews the facility failed to post the daily staffing sheet and post daily staffing census from May 2023 through September 2023 for 80 of 153 days reviewed for daily posted staffing. Findings included: A review of the daily posted staffing forms from May 2023 through September 2023 revealed no available posted staffing sheets and/or census information on the following days. - May 2023: There was no daily staff posting for 5-1-23, 5-2-23, 5-3-23, 5-4-23, 5-5-23, 5-6-23, 5-7-23, 5-8-23, 5-9-23, 5-10-23, 5-13-23, 5-15-23, 5-22-23, 5-27-23, 5-28-23, and 5-29-23. On 5-25-23 there was no census documented on the daily posted staffing sheet. - June 2023: There was no daily staff posting for 6-3-23, 6-4-23, 6-5-23, 6-10-23, 6-11-23, 6-13-23, 6-17-23, 6-18-23, 6-20-23, 6-24-23, 6-25-23, and 6-29-23. - July 2023: There was no daily staff posting for 7-1-23, 7-2-23, 7-3-23, 7-4-23, 7-5-23, 7-6-23, 7-7-23, 7-8-23, 7-9-23, 7-10-23, 7-11-23, 7-12-23, 7-13-23, 7-15-23, 7-16-23, 7-17-23, 7-18-23, 7-20-23, and 7-26-23. On the following days there was no…
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 before2023-09-29 · 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 review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Pre-admission Screening Resident Review (PASRR), contraindication of a gradual dose reduction of antipsychotic medication, antibiotic use, anticoagulant use, and sedative/hypnotic use for 3 of 51 resident MDS assessments reviewed (Residents #11, #70, and #44). Findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. a. Review of Resident #11's medical record revealed his PASSR Level II Determination dated 6/13/20 (no expiration date). Review of Resident #11's annual MDS assessment dated [DATE] indicated he did not have a level II PASSR. b. A pharmacy review dated 7/5/23 revealed a signed contraindication for a gradual dose reduction of Risperdal, an antipsychotic medication for Resident #11. Review of Resident #11's August Medication Administration Record revealed he received an antipsychotic medication every day of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$16,152 in federal fines across 2 penalties.
- $8,076 — penalty dated 2025-05-08
- $8,076 — penalty dated 2025-05-08
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 PRUITTHEALTH — 95 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 | 2.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; 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 |
|---|---|---|---|
| HESS-CAMPBELL, JILL | Individual | W-2 MANAGING EMPLOYEE | since 04/06/2022 |
| HOLLAND, ELIZABETH | Individual | W-2 MANAGING EMPLOYEE | since 03/08/2021 |
| JONES, KURTIS | Individual | W-2 MANAGING EMPLOYEE | since 02/03/2021 |
| LAPOINTE, KIMBERLY | Individual | W-2 MANAGING EMPLOYEE | since 01/03/2022 |
| PRUITT, NEIL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/27/2007 |
CMS files one row per role, so the 6 rows in the source record cover these 5 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.
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 $4.4M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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 2024. 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, FY2024). 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 345538. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.