Person Memorial Hospital
615 Ridge Road, Roxboro, NC 27573 · For profit - Limited Liability company · 56 certified beds · (336) 503-5707 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $43,074 in federal fines (most recent 2025-11-25)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure 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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 fell from 3 to 1 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 | 22.1% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.2% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.9% | 2.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 2.5% | 3.5% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.7% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 5.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.7% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 14.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.2% | 78.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.9% | 22.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.7% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.78 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.73 | 1.80 | 1.80 | worse |
‡ 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.
62.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.9% 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 35 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 62.1%CMS range 52.4–70.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.3–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 62.9% | 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 | 60.0% | 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 | 51.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 94.1% | 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 | 6.1%CMS range 3.8–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.76 | 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 56 beds and averages 46.9 residents a day — about 84% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.84 hrs/resident/day on weekends vs 3.20 on weekdays — 11% thinner on weekends. RN hours go from 0.85 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · J2025-11-25 · 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 observations, record review, and staff, Family Member, and Physician Assistant interviews, the facility failed to provide care in a safe manner when a resident rolled off the raised bed while incontinence care was being provided. The resident had a history of stroke with residual left side weakness. Nurse Aide #1 turned the resident away from her onto her left side with the resident holding the upper side rail with her right hand. While care was being provided Resident #1 stated she could not hold on anymore and rolled out of the bed landing on her knees and immediately complained of pain in her knees, back and legs. Resident #1 was transferred to the local hospital by emergency medical services (EMS) for evaluation and a CT scan (computed tomography scan) confirmed distal right femur (thigh bone just above the knee joint) fracture. It was determined that the resident required a higher level of care and she was transferred to a local trauma center for further evaluation and treatment. CT scans of 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 · E2025-12-17 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and staff and physician interviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as-needed (PRN) basis to 14 days and/or indicate the duration and rationale for extending the PRN order beyond 14 days. This occurred for 1 of 5 residents whose medications were reviewed (Resident #36). Findings Included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder.On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for anxiety. Lorazepam is a psychotropic and controlled substance medication.The resident's most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #36 was severely cognitively impaired with no behaviors or rejection…
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 · E2025-12-17 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff, consultant pharmacist, and physician interviews, the facility failed to act on recommendations made by the consultant pharmacist and failed to document a response to the pharmacist's findings and recommendations in the resident's medical record for 2 of 5 residents whose medications were reviewed (Resident #36, and Resident #4).Findings included:1. Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for anxiety. Lorazepam is a psychotropic medication and a controlled substance. Resident #36's Electronic Medical Record (EMR) indicated that the physician's PRN Lorazepam order (dated 5/9/25) remained active through the review date of 12/17/25. A review of Resident #36's Medication Administration…
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 before2025-12-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to maintain 2 of 2 double-door ovens and 1 of 1 grill clean and free of grease. The facility also failed to label and date leftover food in 1 of 1 reach-in refrigerator and 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents.Findings included:a. The initial kitchen tour was conducted with the Dietary Aide #1 on 12/14/25 from 9:25 AM to 9:50 AM. Observations of double-door oven #1 and double-door oven #2 on 12/14/25 at 9:35 AM revealed black burnt food stains inside the ovens. The oven floors had a black layer of crust that appeared to be burnt food. The oven doors had dark brown oil stains. b. Observation of the grill on 12/14/25 at 9:40 AM revealed the top grill plate had a thick black layer of burnt grease and food, along with some freshly cooked, yellow-colored leftover food.During an interview with the Dietary Aide#1 on 12/14/25 at 9:40 AM, he indicated the grill had been used earlier that morning and the thick burnt layer was due to cooking food that morning. He stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-19 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 of the 33 days reviewed for staffing. The findings included: A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 8/17/24 through 9/18/24 was conducted on 9/19/24. A. On 8/24/24 the daily staff posting indicated 1 RN working day shift (7 AM - 3PM). Daily posting also indicated 2 Licensed Practical Nurse (LPN) and 2 NA working night shift (11PM - 7 AM). Review of the nursing staff assignment sheet for 8/24/24 indicated the RN, Nurse #9, working from 7 AM - 7 PM. The RN, Nurse #9, was also assigned to work as a Nurse Aide from 11 PM to 7 AM. Review of the staff clock-in sheet revealed no RN working from 7 AM - 3 PM shift. Further review revealed there was no RN working for the period of 3 PM -11 PM. An RN, Nurse #9, had clocked in at 11:00 PM. There was only one NA clocked in at 11 PM. During an interview on 9/19/24 at 3:15 PM, Nurse #9 indicated she was a Registered Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-19 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews, the facility failed to post the daily nurse staffing information for residents and visitors on 1 of the 4 days of the survey period. The facility also failed to update the daily staffing information to reflect actual staffing changes for 6 of 33 days reviewed for posted nurse staffing information. Finding included: 1. On 9/15/24 (Sunday) during the facility initial tour at 9:20 AM and for multiple observations throughout the day including 1:30 PM and 3 PM, the daily nurse staffing sheet posted near the facility elevator was dated 9/13/24 (Friday). The posting was not updated to reflect the current date, census, and staffing information. During an interview on 9/17/24 at 8:09 AM, the scheduler stated she was responsible for posting the daily staff posting during the weekdays. The scheduler stated she completed the staffing form for the weekend and left the posting sheet in a folder near the nurse's station. She explained the weekend nurses were responsible for posting and updating the daily staffing sheets on the weekend. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-19 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin for 1 of 3 medication administration carts, failed to date opened multi-dose vials of insulin medication for 2 of 3 medication administration carts, and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (rehabilitation hall, short and long halls). Findings Included: 1a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Insulin Glargine. A review of the manufacturer's literature indicated to discard Glargine multi-dose vial 28 days after opening. 9/15/24 at 9:40 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this…
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 · D2024-09-19 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 residents (Residents #24) reviewed for grievances. Finding included: Resident #24 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident #24 was assessed as severely cognitively impaired. Review of the Grievance /Concern Form dated 6/24/24 indicated a concern that was reported by Resident #24's responsible party (RP) regarding bruising of the resident's left arm, left hand and right forearm. Action indicated was the management was notified, abuse investigation sheet completed, law enforcement was notified and the staff member in question was taken off of the schedule. The form indicated the grievance was under investigation. This was signed by Administrator indicating the grievance was received. There was no indication on the form that indicated the complainant, resident, or family was contacted to inquire if 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 · D2024-09-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to provide fingernails and toenails care for 2 of 2 residents, dependent on staff for activities of daily living (ADL) care. (Resident # 37 and Resident #24) Findings included: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. The assessment indicated that Resident #37 was dependent on staff for Activities of Daily Living (ADL) including personal hygiene, toileting and showers/ bathe self. Review of the care plan dated 6/27/24 indicated the resident was care planned for ADL self-care performance deficit due to impaired balance, activity intolerance, and confusion. Interventions for bathing and showering included checking nail length, trimming and cleaning on bath day and as necessary. The resident was totally dependent on staff to provide bed bath…
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 before2024-09-19 · 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, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interest and needs for 3 of 3 cognitively impaired residents reviewed for activities(Resident #22, Resident #27 and Resident #28). The findings included: 1.Resident #22 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident #14 was coded on the annual Minimum Data Set(MDS) dated 8/24/24 as having cognition impairment and she needed assistance with activities. The MDS also coded Resident 22 's activity interest as very important to participate in favorite activities to include music, religious service and outside events. The resident was coded for total assistance with transfers and locomotion. The annual activity assessment dated [DATE] revealed Resident #'22s preference with interest in listening to music, religious services, and outside events. A focus area on the care plan dated 8/25/24 revealed Resident #22 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 · E2023-08-23 · 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 resident and staff interviews and review of resident council minutes, the facility failed to provide regular resident council monthly meetings (February 2023, March 2023, April 2023, and May 2023) for 4 consecutive months. The findings included: Review of resident council meeting minutes revealed no evidence that resident council meetings were conducted from February through May 2023. The resident council meeting was held on 8/22/23 at 2:00 PM. There were 10 residents identified as alert and oriented who participated in the meeting. The members of the group reported they were regular attendees of the resident council meetings. The residents reported the facility did not have any activity staff for four months to hold resident council meetings (February through May 2023). An interview was conducted on 8/22/23 at 4:00 PM with the Activity Director. The Activity Director stated she started working in the activities department in June 2023. The Activity Director further stated there was no documentation resident council meetings were held from February 2023 through May 2023.…
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 11 citations
- Potential for harm · Ecited before2023-08-23 · tag F0679 — failed to provide activities — patternProvide 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, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interests and needs to enhance the quality of life for 1 of 2 residents reviewed for activities (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE]. The diagnoses included cognitive and communication deficits. The annual Minimum Data Set (MDS) dated [DATE] coded Resident #45's cognition as moderately impaired. The resident's activity preferences indicated the following were very important: religious services, going outside for fresh air, listening to music, keeping up with the news and being around animals. He was also coded for total assistance with transfers and locomotion. The activity assessment completed by the former Activity Director, Activity Director #2, dated 4/5/23 revealed Resident #45's preference in group activities with interest in religious devotion, music, sports, bingo, community outings, pet therapy outdoor…
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 before2023-08-23 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (200 short hall and 200 long hall). Findings Included: 1. On 8/20/23 at 9:10 AM, an observation of the long hall medication administration cart on 200 hall with Nurse #2 revealed in the second draw of the medication cart there were noted one white loose capsule and two blue round shape loose pills. On 8/20/23 at 9:20 AM, during an interview, Nurse #2 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #2 did not clean the cart before her shift. On 8/24/21 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items or…
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 before2023-08-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents. The findings included: During a kitchen tour on 8/20/23 at 9:50 AM, the following observations were made with the Dietary Manager: a. The 8- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were substantial amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The fryer had dried…
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 · E2023-08-23 · 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, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey on 1/7/22 in order to achieve and sustain compliance. This was for a recited deficiency on a recertification survey on 8/23/23. The deficiency was in the area of medication storage and kitchen sanitary condition. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: The tag was cross referenced to: F761: Based on observations and staff interviews, the facility failed to remove expired multi-dose vial of insulin, stored in 1 of 3 medication administration carts (200 hall); failed to discard several loose pills that were identified in the medication cart's draw for 1 of 3 medication administration carts (200 hall). During the previous recertification surveys on 1/7/22, the facility failed…
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 · D2023-08-23 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete Minimum Data Set (MDS) assessments within the regulated time frame for 2 of 8 reviewed for resident assessment (Resident # 63, and Resident # 210). Finding included: 1.Resident #63 was admitted to the facility on [DATE] with diagnoses that included heart failure and depression. A review of Resident #63's admission MDS assessment dated [DATE] revealed the MDS was incomplete and was still in progress as of 8/22/23. The admission MDS assessment was due on 8/16/23. Review of the discharge return not anticipated MDS revealed the Resident #63 was discharged on 8/23/23. During an interview on 8/22/23 at 2:55 PM, the MDS Nurse stated she was hired on 8/14/23 and was in the process of completing all pending and incomplete MDS assessments. She indicated the assessments should be completed within 14 days from the admission date. During an interview on 8/23/23 at 6:06 PM, the Administrator stated the MDS assessments should be completed and…
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 before2023-08-23 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 schedule a Registered Nurse (RN) for at least 8 consecutive hours (hrs.) a day for 1 of 30 days reviewed. (7/23/23). Findings included: Review of the facility daily staffing schedules from 7/20/23 through 8/20/22 revealed the following: On 7/23/23 the staffing sheets indicated the facility census was 54 and 0 (zero) RN on duty. During an interview on 8/22/23 at 11:00 PM, the staff scheduler stated on 7/23/23 there was no RN assigned to the building, however she was made aware that if there was no RN on the schedule then the hospital RN supervisor would be counted as the RN for the nursing home. During an interview on 8/22/23 at 4:00 PM, The Director of Nursing (DON) stated when she was hired, she was informed that the hospital RN supervisor could be counted as the RN for the facility when there was no RN on the schedule. On 8/23/23 at 12:25 PM, the DON gave the surveyor the Job description for Person House Supervisor RN (Hospital). In the document the following was highlighted and read as follows. Nursing care:…
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 · D2023-08-23 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, the facility failed to complete performance evaluations of nurse aides at least once every 12 months and provide in-service education based on the outcome of these reviews for 2 of 2 Nurse Aides (NA) (NA #3 and NA #5). The findings included: During an interview on 8/23/23 at 10:00 AM, NA #3 stated she was hired 4 years ago. NA #3 stated she does not recollect having any performance evaluation for a long time. During an interview on 8/23/23 at 10:30 AM, NA #5 stated she was hired 5 years ago. NA #5 indicated she does not recollect any performance reviews completed annually. During an interview on 8/23/23 at 11:02 AM the Human Resource Staff (HR) stated the staff performance reviews were conducted by the appropriate department. The HR department did not maintain these files. On 8/23/22 at 4:50 PM, the Director of Nursing (DON) and Unit Manager were interviewed. Both DON and Unit Manager indicated they were unsure how staff performance was reviewed or assessed annually. The DON stated she was unable to find any documentation related to annual performance…
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 before2025-12-17 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors on 1 of the 4 days during the survey period (12/14/25). The facility failed to provide upon demand the posted daily nurse staffing sheets for 10 of the 45 daily nurse staffing sheets reviewed (11/8/25, 11/13/25, 11/16/25, 11/17/25, 11/18/25, 11/20/25, 12/2/25, 12/3/25, 12/12/25, and 12/13/25). In addition, of the 35 daily nurse staffing sheets reviewed the facility failed to complete 3 daily nurse staffing sheets with information related to Nursing Assistants (11/2/25, 11/9/25, and 11/29/25). Findings included:a. On 12/14/25 (Sunday), during the initial tour of the facility at 9:05 AM daily nurse staffing sheet posted near the facility elevator was dated 12/11/25 (Thursday). The daily nurse staffing sheet was not updated to reflect the current date, census, and staffing information. The daily nurse staffing sheet posted dated 12/11/25 remained during another observation at 11:00 AM on the same day.During an interview on 12/15/25 at…
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 · C2024-09-19 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, residents and staff interviews, the facility failed to post the notice of location and make accessible the facility survey results for residents in a wheelchair. This was observed on 4 of 5 days of the survey. The findings included: During initial tour on 9/15/24 at 9: 10 AM, an observation was made of the survey results located in a small hall area near the eye wash station. On a large bulletin board was a black caddy with the survey book, which was not wheelchair accessible. The caddy was in the center of the bulletin board out of reach of residents in wheelchairs. There was no signage posted throughout the facility regarding the availability and location of the recent survey results. Multiple observations were conducted from 9/15/24 to 9/18/24. Observations were made on 9/15/24 at 9:58 AM, on 9/16/24 10:30 AM, on 9/17/24 10:00 AM and on 9/18/24 at 11:02 AM. Observations revealed there was no notice posted in the facility regarding the availability and location of the recent survey results. The location of the survey remained unreachable for residents in…
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 · B2023-08-23 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to transmit Quarterly and Annual Minimum Data Set (MDS) assessments within the required time frame for 6 of 8 residents (Resident # 45, Resident # 44, Resident #19, Resident #24, Resident #46, and Resident # 49) reviewed for Resident Assessments. Findings included: a. Resident #45 was admitted on [DATE]. A review of resident's most recent MDS assessment revealed an Assessment Reference Date (ARD) of 7/5/23 and was coded as a quarterly assessment. The MDS was completed on 7/19/23 and indicated as accepted on 7/24/23. b. Resident #44 was admitted on [DATE]. A review of resident's most recent MDS assessment revealed an ARD of 7/12/23 and was coded as a quarterly assessment. The MDS was completed on 7/21/23 and indicated as accepted on 7/25/23. c. Resident #19 was admitted on [DATE]. A review of resident's most recent MDS assessment revealed an ARD of 7/12/23 and was coded as a quarterly assessment. The MDS was completed on 7/24/23 and indicated as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-08-23 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews, the facility failed to post the daily nurse staffing information to residents and visitors for 2 of the 4 days of the survey period. Finding included: On 8/20/23 during facility initial tour and multiple observations throughout the day including at 9:20 AM and at 1:30 PM, the daily nurse staffing sheet posted near the facility elevator was dated 8/18/23. The posting was not updated to reflect the current date, census, and staffing information. On 8/21/23 multiple observations at 9:00 AM; 12:45 PM and 3:30 PM revealed no daily nurse staffing information was posted near the elevator. During an interview on 8/22/23 at 10:20 AM, the Unit Secretary stated she was responsible for completing the staffing information, once she receives the information of assigned staff from the scheduler. The sheets were displayed beside the elevator. The Unit Secretary indicated on Fridays she completed the staffing form for the weekend and places them behind the Friday posting. The weekend charge nurse was responsible for changing the sheets over the weekend. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$43,074 in federal fines across 5 penalties. 1 Medicare payment denial on record.
- $16,153 — penalty dated 2025-11-25
- $4,545 — penalty dated 2023-10-02
- $13,635 — penalty dated 2023-09-11
- $4,545 — penalty dated 2023-08-28
- $4,196 — penalty dated 2023-08-21
- Medicare payment denial — starting 2025-11-25 for 1 days
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 LIFEPOINT HEALTH — 8 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 | 1 of 5 | 4.1 | -3.1 vs chain |
| Health inspection | 2 of 5 | 4.0 | -2.0 vs chain |
| Staffing | 1 of 5 | 3.4 | -2.4 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 7 homes this chain runs (chain average 4.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
CMS ownership filings flag an owner of this facility as an investment firm. That’s a fact worth knowing about who ultimately profits from the home. Read the inspection and staffing record above on its own merits.
- DSB ACQUISITION LLC — investment firm · 97.00% share · 5% Or Greater Indirect Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DLP HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2011 |
| DLP PARTNER LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2011 |
| HISTORIC LIFEPOINT HOSPITALS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2011 |
| LEGACY LIFEPOINT HEALTH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2014 |
| LIFEPOINT HOLDINGS 2 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2011 |
| LIFEPOINT HOSPITALS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2011 |
| BROWN, ELLIOTT | Individual | CORPORATE OFFICER | — | since 04/02/2026 |
| LAWRENCE, CHARLOTTE | Individual | CORPORATE OFFICER | — | since 03/24/2022 |
| MONTE, CHRISTOPHER | Individual | CORPORATE OFFICER | — | since 10/01/2011 |
| POLITE, ELMER | Individual | CORPORATE OFFICER | — | since 12/14/2020 |
| POPPELL, MARCUS | Individual | CORPORATE OFFICER | — | since 11/16/2018 |
| SENSING, PHILLIP | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 05/04/2026 |
| BEARD, BERTRAND | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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 345004. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, 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.