NC State Veterans Home - Salisbury
1601 Brenner Ave., Building #10, Salisbury, NC 28145 · Government - State · 99 certified beds · (704) 638-4200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,444 in federal fines (most recent 2025-12-12)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 5 to 4 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 | 16.7% | 15.6% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.5% | 7.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 5.9% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.6% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.6% | 18.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.8% | 21.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.5% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 5.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 13.6% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.5% | 14.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 74.3% | 78.1% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.08 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.58 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 51.9% 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 27 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.3–16.2 | 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 | 51.9% | 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 | 33.3% | 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 | 48.1% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 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 | 8.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 99 beds and averages 83.2 residents a day — about 84% occupied, or roughly 16 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 4.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.81 hrs/resident/day on weekends vs 5.19 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.39 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · J2025-12-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews with staff and the Physician's Assistant (PA), facility staff used a shared blood glucose meter located in the medication cart without cleaning and disinfecting it before and after each use. This occurred while there were two residents identified with a known bloodborne pathogen in the facility with 1 of the 2 residents requiring blood glucose monitoring. Shared blood glucose meters can be contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared blood glucose meter has a high likelihood of exposing residents to the spread of blood borne infections. This deficient practice affected 2 of 2 residents who were observed to have their blood glucose checked (Resident #26 and #37) and involved 2 of 2 nurses observed performing blood glucose checks (Nurse #2 and the Assistant Director of Nurses [ADON]).Immediate jeopardy began on 12/09/2025 when…
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 · D2025-12-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to honor a resident's request for a shower to be stopped when the resident told Nursing Assistant (NA) #3 to stop because he was man handling him. Resident #13 stated he was fearful of NA #3 and felt like no one was listening to him when he told staff about the incident. Additionally, the facility failed to maintain a resident's dignity by not placing a privacy/ dignity cover over his urine collection bag exposing his urine which was visible from the hallway to other residents, staff and visitors. This occurred for 2 of 3 residents reviewed for dignity (Resident #13 and Resident #3).The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included chronic pain and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was moderately cognitively impaired. The MDS documented the resident as having behavioral symptoms not directed towards others for 4-6 days…
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 · D2025-12-12 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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 review, and staff, Consultant Pharmacist and Physician interviews, the facility failed to ensure Resident #2 had a diagnosis for the use of antipsychotic medication and the as needed (PRN) antipsychotic medication, Haldol, used to regulate mood, behaviors, and thoughts, had a stop date of 14 days. The facility also failed to ensure Resident #1 had a diagnosis for the use of antipsychotic medication and antidepressant medication. This occurred for 2 of 5 residents reviewed for unnecessary medications (Resident #2, and Resident #1).The findings included:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included mild dementia with agitation, brief psychotic disorder and anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired. The MDS documented Resident #2 had physical behavioral symptoms directed towards others for 1 to 3 days during a 7-day period. The resident was not documented as receiving an antipsychotic…
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 · D2025-12-12 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident, Resident Representative, Physician Assistant, and Psychiatric Nurse Practitioner interviews, the facility failed to follow and implement their abuse policy and procedures in the areas of protecting and reporting to the Administrator for 1 of 3 residents reviewed for abuse (Resident #13). Resident #13 told Nursing Assistant (NA) #3 that the NA was treating him roughly and man handling him and to stop care. NA #3 did not stop the care. NA #9 heard Resident #13 state that NA #3 treated him roughly and was man handling him during his shower. Neither NA #3 or NA #9 reported the incident to administration or the charge nurse on duty allowing NA #3 to finish his shift and to return to work the next day. This failure resulted in a lack of protection for other residents. The findings included:The facility's policy Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property reviewed on 12/7/22 stated any allegation, suspicion, or identified…
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 · D2025-12-12 · 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 observations, record review, and staff and physician interviews, the facility failed to administer lidocaine 4% external pain patches per the Physician order for 1 of 6 residents reviewed for medication regimen review (Resident #34).The findings included:Resident #34 was admitted to the facility on [DATE] with diagnoses of pain in right hip and low back pain.A review of Resident #34's physician orders revealed an order dated 08/13/2025 for four (4) 4% Lidocaine adhesive patches to the skin daily. Special Instructions on order read: Apply to bilateral hips/ bilateral lower back daily.A review of Resident #34's Medication Administration Record (MAR) revealed Nurse #8 signed the MAR for the four Lidocaine patch administration on 12/11/2025. The MAR specified for four (4) 4% Lidocaine adhesive patches to the skin daily. Special Instructions on order read: Apply to bilateral hips/ bilateral lower back daily.A record review and interview with Nurse #6 on 12/11/2025 at 11:00 am revealed that she had only…
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 · D2025-12-12 · 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 resident and staff interviews, the facility failed to complete a smoking safety screen in August 2025 for 1 of 1 resident reviewed for smoking (Resident # 48).The findings included:An undated facility policy titled, Tobacco, Vapes, and Alcohol Use in the North Carolina State Veterans Home, stated Staff will evaluate each resident's ability to safely use cigarette lighters, lit cigarettes, cigars, pipes, and Vape devices to determine if a resident can be permitted to use these without direct supervision (independently) or if the resident must be directly supervised in order to safely use them. Resident #48 was admitted to the facility on [DATE] with diagnoses which included tobacco use, cerebral vascular accident, and vascular dementia.A review of Resident #48's Nursing Quarterly Assessment that included the smoking safety screen dated 5/19/25 indicated the resident was a supervised smoker and did not have the ability to hold his own cigarette or extinguish it.Review of Resident #48'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 · D2025-12-12 · 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 record review, observations, staff, and Physician Assistant interviews, the facility failed to keep a urinary catheter collection bag from touching the floor to reduce the risk of infection for 1 of 3 residents reviewed for urinary catheters (Resident #51).The findings included:Resident #51 was admitted to the facility on [DATE] with diagnoses which included stage four kidney disease, and obstructive and reflux urinary disease.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Resident #51 was coded for an indwelling urinary catheter.Resident #51's care plan revised 11/21/2025 indicated Resident #51 had a goal that she would not develop any complications or injury associated with urinary catheter usage.An initial observation was conducted on 12/08/2025 at 9:19 am of Resident #51 while she was sitting up in her chair in the dining area. Her urinary catheter collection bag was observed to be laying on the floor under her chair. It had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Consultant Pharmacist, and the Physician Assistant, the Consultant Pharmacist failed to identify drug irregularities related to the indicated use and scheduled stop date of an as needed (PRN) antipsychotic, and the indicated use of an antidepressant for 2 of 5 residents (Resident #2 and Resident #1) reviewed for drug regimen review.The findings included:1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included mild dementia with agitation, brief psychotic disorder and anxiety. A physician order dated 11/3/25 revealed Resident #2 was ordered Haldol lactate solution (antipsychotic) 5 milligrams (mg)/1 milliliter (ml), administer 2 mg intramuscular (IM) every 4 hours PRN for agitation. The order indicated the end date was 1/3/26.A monthly pharmacist Medication Regimen Review (MRR) dated 12/5/25 read per hospice, haloperidol 2 mg IM every 4 hours PRN agitation for 60 days. The pharmacist review did not document any recommendations…
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 · D2025-12-12 · 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 observations, record review, and staff and interviews, the facility failed to maintain an accurate medical record related to documentation of medication administration for 1 of 2 residents reviewed for accurate medical records (Resident #34).The findings included:Resident #34 was admitted to the facility on [DATE] with diagnoses of pain in right hip and low back pain. A review of Resident #34's physician orders revealed an order dated 08/13/2025 for Lidocaine (an over-the-counter pain reliever) adhesive patch, medicated; 4%; amount: 4; apply to skin. Special Instructions on order read: Apply to bilateral hips/ bilateral lower back daily.a. An observation and interview with Nurse #6 and Resident #34 on 12/10/25 at 12:00 pm revealed Nurse #6 had two lidocaine patches in her hand. Nurse #6 proceeded into Resident #34's room and when she returned from the room, she said that she had placed the two patches on Resident #34's low back and no patches were placed to Resident's bilateral hips. A review 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 · D2025-12-12 · 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 (1) document that education of the influenza vaccine was provided for Resident #20 and (2) failed to obtain Resident #72's signature on the influenza vaccine consent/refusal form prior to administering the influenza vaccine. This occurred for 2 of 5 residents reviewed for immunizations.Findings included:1. Resident #20 was re-admitted to the facility on [DATE].Review of the facility's document titled, Resident Influenza (Flu) Vaccine Consent/Refusal Form, revealed Resident #20 consented to receive the influenza vaccine and signed the form on 6/12/25. A Vaccine Information Statement (VIS) form for the influenza vaccine was not attached to the consent form.The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 was cognitively intact.Review of Resident #20's electronic medical record (EMR) revealed Resident #20 received the influenza vaccine at the facility on 11/4/25. The vaccine education section did 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 · E2024-08-08 · 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 observation and staff interviews, the facility failed to remove unlabeled items from 2 of 2 nourishment rooms. These practices had the potential to affect food served to residents. Findings included: An observation and interview conducted with Dietary [NAME] #1 on 08/05/24 at 11:10 AM revealed the nourishment room located on the second floor had a bottle of 12 fluid ounce (fl. oz) lactose free milk 20 fl. oz orange Gatorade, and an opened half full 20 fl oz. bottle of cherry coke located in the refrigerator that were unlabeled. Dietary [NAME] #1 further revealed they were not sure if the items belonged to a resident or nursing staff but should not have been located the refrigerator unlabeled. Dietary [NAME] #1 indicated it was nursing staffs' responsibility to label items that belong to residents and staff items were not allowed in the nourishment rooms. An observation and interview conducted with the Dietary [NAME] #1 and Nurse #2 on 08/05/24 at 11:20 AM revealed the nourishment room located on the first floor had two push-up ice cream cones and two 16 oz. containers 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.
Show the remaining 6 citations
- Potential for harm · D2024-08-08 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff and resident interviews, the facility failed to honor residents' preference for eating in the dining room in the evenings for 1 of 1 resident reviewed for choices (Residents #58). Findings included: Resident # 58 was admitted to the facility on [DATE] with diagnoses which included hypertension and muscle weakness. Review of the Resident #58's significant change Minimum Dat Set (MDS) dated [DATE] revealed the resident was alert and oriented. The MDS further revealed Resident #58 was independent and required setup for eating. The MDS further revealed resident #58 was coded for wheelchair use. An interview conducted with Resident #58 on 08/05/24 at 2:40 PM revealed he enjoyed eating dinner meals in the 200-hall dining room with friends but was told by staff on multiple dates that he could not eat in the dining room due to shortage of staff. Resident #58 indicated this often occurred on weekends and sometimes throughout the week. An interview conducted with Nurse Aide (NA) #4 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews the facility failed to provide shaving for 1 of 4 residents (Resident #4) reviewed for personal hygiene. Resident #4 was dependent on staff for personal hygiene. Findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses of stroke and hemiplegia. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #4 was dependent on staff for showering and required moderate assistance with personal hygiene such as shaving. Resident #4's Care Plan, which was updated on 6/10/2024, stated he was dependent for personal hygiene and bathing and staff would provide assistance as needed. A Nurse's Progress Note by Nurse #1 written on 8/3/2024 at 12:03 pm indicated Resident #4 took his scheduled shower. Review of Resident #4's shower and personal hygiene documentation on 8/3/2024 at 6:47 pm indicated he was given a shower. During an observation and interview with Resident #4 on 8/5/2024 at 12:03 pm he was observed to have a full…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-23 · 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, record review and staff interviews, the facility failed to provide nail care for 1 of 3 residents who were reviewed for being dependent on staff for personal care (Resident #215). Findings included: Resident #215 admitted to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #215 was moderately cognitively impaired and required extensive assistance with personal care. Resident #215's Care Plan dated 2/16/2023 indicated he required extensive to total assistance with all activities of daily living except eating due to deterioration related to Parkinson's disease. On 2/20/2023 at 11:25 am Resident #215 was observed in bed with the head of the bed elevated. Resident #215's fingernails were approximately 1/4 inch long. He stated his fingernails had not been cut since he arrived at the facility, but he would like for them to be cut. Resident #215 stated he was not able to cut his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-23 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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 hospice admission, plan of care, and hospice visits notes in the electronic medical record for 1 of 1 resident reviewed for hospice care (Resident #31). Findings included: The Hospice Nursing Home Agreement dated 2/10/2011 read in part: .(the) facility and Hospice shall each prepare and maintain complete and detailed clinical records .(that) shall document completely, promptly, and accurately all services provided to and the events concerning each Hospice patient and all services provided . Resident #31 was admitted to the facility on [DATE] with diagnoses to include dementia and stroke. A physician order dated 4/20/2022 ordered a hospice evaluation. A consent for hospice was signed on 4/25/2022 and Resident #31 was admitted to hospice services. The significant change Minimum Data Set (MDS) dated [DATE] noted that hospice services had been initiated and Resident #31 had a life expectancy prognosis of less than 6 months. A review 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.
- No harm found · C2025-12-12 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all required state agencies and advocacy groups, including the State Survey Agency, Adult Protective Services, State Long-Term Care Ombudsman Program, and the Resident Advocacy Network, Home and Community Based Service Programs, or Medicaid Fraud Control Unit information. These observations occurred on 4 of the 5 days of the onsite recertification survey.The findings included: An observation completed on 12/08/2025 at 10:51 AM of the front hallway bulletin board revealed no signage in place for the State Survey Agency, Adult Protective Services, State Long-Term Care Ombudsman Program, and the Resident Advocacy Network, Home and Community Based Service Programs, or Medicaid Fraud Control Unit information. The first-floor nurses station wall had a Resident Rights poster with the current local Ombudsman's contact information. The second-floor nurses station wall had a Resident Rights poster with the previous local Ombudsman's contact…
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 · B2025-12-12 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 resident representatives and staff, the facility failed to explain the arbitration agreement to a resident's representative prior to having them sign the agreement. This occurred for 2 of 5 residents reviewed for arbitration (Resident #1 and Resident #66).The findings included:A review of the facility's undated arbitration agreement read that the residents or resident representatives acknowledge they had read and understood the agreement and that it had been explained in plain language.a. Review of Resident #1's arbitration agreement dated 10/7/25 revealed neither box was checked indicating if the resident/resident Representative accepted or declined the agreement. The agreement was signed by Resident #1's Representative.Resident #1 was admitted to the facility on [DATE].Resident #1's Representative was interviewed by telephone on 12/11/25 at 5:00pm. The Representative discussed sitting next to the facility's admission Coordinator during Resident #1's pre-admission…
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
$12,444 in federal fines across 1 penalty.
- $12,444 — penalty dated 2025-12-12
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NC DEPT OF MILITARY AND VETERANS AFFAIRS NC DIVISION OF VETER AFFAIRS | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 03/31/2009 |
| STEPHENS, NICOLE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/07/2019 |
| WESTBROOK, TERRY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 06/26/2019 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.3M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 345531. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, 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.