Sanford Health & Rehabilitation Co

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

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.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 122 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.3% 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 78 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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.

Staffing

How full it usually is: this home is certified for 131 beds and averages 102.1 residents a day — about 78% occupied, or roughly 29 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.30 hrs/resident/day on weekends vs 4.04 on weekdays — 18% thinner on weekends. RN hours go from 0.29 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · J2022-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. a. On 11/29/2022 at 8:45 AM Medication Aide (MA) #4 was observed during medication administration. When approaching the MA's medication cart there were three pills in a clear medication cup and a nicotine patch sitting on the cart. MA#4 pulled medications for another resident and left the cart to administer those medications. The three pills in the medication cup and the nicotine patch were left unattended on her medication cart. At the time the medications were unattended, Resident #59, a severely cognitively impaired resident, was observed sitting in his wheelchair next to the medication cart. Immediately after completing the medication administration, MA #4 was interviewed. She stated the three pills and nicotine patch were for another resident who refused their medications. She further stated she should not leave medications on the cart unattended. Instead, she should have disposed of the medications or secured them in the locked cart until she had time to dispose of them. On 11/30/2022 at 4:08PM 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-06-13 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication administration when two blood pressure (BP) medications, Isosorbide mononitrate and hydralazine were not administered per orders for Resident #1. This resulted in Resident #1 ' s BP to drop to 82/50 causing a near syncope event that required a visit to the emergency room for further evaluation. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, hypertension (HTN) (high blood pressure), acute cerebral vascular accident (CVA) (an interruption in the flow of blood to cells in the brain), coronary artery disease (CAD) with history of two myocardial infarctions (MI) (heart attack), and coronary artery occlusion. The most recent Minimum Data Set (MDS) coded as an admission assessment on 06/02/24 revealed Resident #1 was cognitively intact. No behaviors coded and no…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-12-01 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and resident and staff interview, the facility failed to promote dignity by failing to address resident's repeated request for incontinence care (Resident #60) and by ignoring resident's request and allowing a resident to lay in a wet pad (Resident #51) for 2 of 3 sampled residents reviewed for dignity (Residents #60 & #51). The facility's failure to promote dignity made Resident #60 angry and made Resident #51 feel deserted. The findings included: 1. Resident #60 was admitted to the facility 9/5/2022 with diagnoses that included cerebral infarct (stroke). Resident #60's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, had clear speech, understood others and could be understood by others. She was coded as requiring extensive assistance for all activities of daily living and dependent upon staff for toileting during the assessment period. The resident's comprehensive care plan, last revised 11/18/2022, had a focus for assistance with…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-04 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit follow up documents for completion of a Preadmission Screening and Resident Review (PASRR) level I screen to determine appropriate placement for 1 of 3 residents sampled for PASRR (Resident #46). The findings included: A review of the diagnosis list for Resident #46 included diagnoses of psychotic disorder 05/24/2023 and bipolar disorder 06/12/2023. A review of the North Carolina Medicaid Long Term Care Facility Level (FL)2 Form dated 01/22/2024 revealed diagnoses including psychotic disorder 05/24/2023 and bipolar disorder 06/12/2023. Resident #46 was admitted to the facility on [DATE] with diagnoses including psychotic disorder and bipolar disorder. A review of the North Carolina PASRR level I screen submitted 02/28/2024 revealed diagnoses including bipolar disorder, and psychotic disorder. The screen requested additional information to include the most recent history and physical (H&P), FL2 signed by physician, psychiatric notes 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-24 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff, resident, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility failed to obtain Physician orders for the care and maintenance of a peripherally inserted central catheter(PICC) intravenous line for 1 (Resident #33) of 1 residents reviewed for intravenous (IV) therapy. The findings included: Resident #33 was originally admitted on [DATE] with a diagnosis of Methicillin-resistant Staphylococcus Aureus (MRSA) infection following a right total knee replacement (TKA). Review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact and not coded for the use of an antibiotic (medication prescribed to treat bacterial infections). Review of Resident #33 electronic medical record (EMR) indicated she transferred to the hospital on 1/8/24 for scheduled knee procedure. She was readmitted on [DATE] with orders for an IV antibiotic. Resident #33 was care planned on 1/15/24 for the use of a PICC line. Interventions…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Medical Director interviews, the facility failed to obtain Physician orders for continuous oxygen (Resident #73). This was for 1 of 2 residents reviewed for respiratory care. The findings included: Resident #73 was admitted to the facility on [DATE] with diagnosis that included gastrointestinal hemorrhage, hypertension, and peripheral vascular disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact and was not coded for receiving oxygen therapy. Review of Resident #73's nursing progress notes dated 01/11/24 revealed Resident #73 was sent to the emergency room (ER) due to vomiting. She returned to the facility on 2L of oxygen (O2) via nasal cannula. The O2 was removed during transfer to the bed from the wheelchair causing her O2 saturation to drop to 86%. O2 was reapplied via nasal cannula raising her O2 sats to 95% on 2L. Review of Resident #73's nursing progress notes dated 01/12/24 revealed no new…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-24 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record reviews, the facility failed to secure unused narcotic medications for disposition (the process of returning unused medications) resulting in possible diversion (the transfer of a controlled medication from a lawful to an unlawful channel of distribution or use). This was for 1 of 1 discharged resident (Resident #92) reviewed for pharmacy services. The finding included: Resident #92 was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #92 ' s physician orders revealed an order initiated on [DATE] and discontinued on [DATE] for oxycodone 5 milligrams (mg) tablet, take one tablet by mouth every 8 hours as needed for moderate pain. An attempt to interview the Weekend Supervisor was made on [DATE] at 1:02 PM without success. Weekend Supervisor ' s statement revealed he reported on [DATE] about 5:30 AM the door to the medication room on 100 hall was propped open. When he entered the room, the pharmacy tote's secure tags (tags applied to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-01-24 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure 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 observations, record review and staff interviews, the facility failed to label multi-dose medications with the date they were opened on 1 of 3 medication carts reviewed (the 300 Hall Medication Cart). Findings included: An observation was conducted on 01/21/24 at 3:25 PM of the nurse ' s medication cart on the 300 Hall in the presence of Med Aide #1 and Unit Manager #1. The observation revealed no opened date on the following multi-dose medications: a. Two 10ml (milliliter) multi-dose vials of Humalog insulin with no open date. (Manufacturer ' s recommendation to discard 28 days after opening). first use b. two 10ml (milliliter) multi-dose vial of Novolog insulin with no open date. (Manufacturer ' s recommendation to discard 28 days after opening). c. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5 milligram (mg)/3mg per 3 milliliter (ml) inhalation vials. (Manufacturer ' s recommendation that once the foil pouch is opened, use vial within one week). d. One multi-dose 10ml bottle of Latanoprost 0.005% solution eye drops. (Manufacturer'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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-24 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, and record reviews, the facility failed to provide effective leadership and implement effective systems to thoroughly investigate possible diversion (the transfer of a controlled medication from a lawful to an unlawful channel of distribution or use) of missing narcotic medications from 100 hall medication room. The finding included: An attempt to interview the Weekend Supervisor was made on 01/23/24 at 1:02 PM without success. The Weekend Supervisor ' s statement revealed he reported possible narcotic diversion on 08/20/23 about 5:30 AM. He reported that the door to the medication room on 100 hall was propped open, upon entering the room, a pharmacy tote's secure tags (tags applied to both ends of the tote to secure it shut) were cut and sitting on top of the tote. Upon further review of the tote, it was noted that the narcotic sheet that was in the tote was missing along with a bubble pack containing 16 Oxycodone 5mg tabs. A phone interview was conducted with the Staff Development Nurse on 01/23/24 at 1:24 PM. She stated she was made aware…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-01-24 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews, observations, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey on 5/6/21. This was for one deficiency that was cited in the area of Respiratory/Tracheostomy care and Suctioning. In addition, two additional deficiencies were cited during the annual recertification and complaint survey on 12/1/22 in the areas of Respiratory/Tracheostomy care and Suctioning and Label/Store Drugs and Biologics. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: The citations are cross referenced to: 1) F695- Based on observations, record review, and staff and Medical Director interviews, the facility failed to obtain Physician orders for continuous oxygen (Resident #73). This was for 1 of 2 residents reviewed for respiratory care. During the facility's annual…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-12-01 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and resident and staff interview, the facility failed to provide nail care to residents who needed extensive assistance and/or were dependent for activities of daily living (ADL) for 4 of 6 sampled residents reviewed for ADL care (Residents #3, #51, #18 & #67). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, and he had no behavior of rejection of care. The assessment further indicated that Resident #3 needed extensive assistance from the staff with personal hygiene. Review of Resident #3's active care plan, last reviewed on 9/27/22 was conducted. The care plan problem was resident requires assistance from the staff with activities of daily living (ADL) related to weakness and overall deconditioning and dementia. The goal was resident will have his needs met daily. The approaches included prefers to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-12-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, Wound Nurse Practitioner and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 1 of 4 residents reviewed for pressure ulcers (Resident #56). The findings included: Resident #56 was admitted to the facility 2/22/21 with diagnoses that included adult failure to thrive and dementia. Resident #56's active physician orders included an order dated 9/29/22 for an alternating pressure air mattress to the bed. Nursing to check every shift to ensure properly functioning and/or settings are in place. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56 had severely impaired decision-making skills, one stage 3 pressure ulcer and a pressure reducing device to the bed. A review of Resident #56's active care plan, last reviewed 10/28/22, included a focus area for potential for further skin breakdown secondary to mobility deficits with incontinence. One…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-12-01 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, Program of All-Inclusive Care for the Elderly (PACE-a Medicare/Medicaid program for older adults and people over age [AGE] living with disabilities) Site Director interview and record review, the facility failed to obtain ordered psychological consultation due to a new diagnosis onset of dementia with behaviors to include hallucinations and delusions. This was for 1 (Resident #64) of 1 residents reviewed for behavioral, emotional and mood concerns. The findings included: Resident #64 was admitted on [DATE] with cumulative diagnoses of dementia without behaviors, anxiety and major depression. A nursing note dated 8/2/22 at 6:30 PM indicated that Resident #64 had an episode of delusion/hallucination by dialing 911 telling the dispatcher that she was told to dial 911 by someone calling her name on the loud speaker. PACE was notified of her new behaviors with no new orders. A nursing note dated 8/3/22 at 5:34 PM indicated that Resident #64 demonstrated hallucinations by referencing someone…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$10,527 in federal fines across 1 penalty.

• $10,527 — penalty dated 2024-06-13

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 SANSTONE HEALTH & REHABILITATION — 18 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 →

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 files one row per role, so the 7 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.

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC