No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Siler City Center

900 W Dolphin Street, Siler City, NC 27344 · For profit - Corporation · 150 certified beds · (919) 663-3431 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse2 immediate-jeopardy citations$7,909 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,909 in federal fines (most recent 2025-09-08)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • about 27% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1002 W 3rd St · (919) 742-2209 · Call to confirm hours
Pharmacy
127 E Raleigh St · (919) 663-0177 · Call to confirm hours
Grocery
600 W Raleigh St · (919) 742-9888 · Call to confirm hours
Park
302 S Fir Ave · (919) 742-2699 · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 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 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased26.6%15.6%15.4%worse
Long-stay residents who lose too much weight4.9%7.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.7%0.9%better
Long-stay residents with a urinary tract infection0.6%2.3%2.0%better
Long-stay residents with depressive symptoms6.1%5.9%6.5%typical
Long-stay residents who were physically restrained1.6%0.0%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.8%3.5%3.3%better
Long-stay residents whose ability to walk worsened33.7%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.0%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine98.5%94.1%95.3%typical
Long-stay residents with pressure ulcers6.1%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control23.0%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.8%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.5%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine68.4%78.1%79.4%worse
Short-stay residents rehospitalized after admission20.9%22.9%22.6%typical
Short-stay residents with an outpatient ER visit14.6%12.9%12.0%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

42.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.0%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
0.22U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.0%CMS range 27.5–57.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.2–15.610.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified87.5%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay3.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs0.991.02Oct 2022–Sep 2024CMS 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

0.49
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.00
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.33
RN hoursweekends
38.7%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 150 beds and averages 140.1 residents a day — about 93% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.42 on weekdays — 13% thinner on weekends. RN hours go from 0.55 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2026-03-13)
6
at the previous standard inspection (2024-11-07)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews with the Responsible Parties (RPs), PACE (Program of All-Inclusive Care for the Elderly) Nurse Practitioner, psychiatric Nurse Practitioner and staff, the facility failed to protect a cognitively impaired male resident's right to be free from sexual abuse (Resident #2) perpetrated by a cognitively impaired male resident (Resident #1). On 9/1/25 Nurse Aide (NA) #1 overheard Resident #2 laughing from the hallway and proceeded to the room he shared with Resident #1 as this was an unusual behavior for Resident #2. When NA #1 stepped into the doorway of the room, she observed Resident #2 lying on his back in bed with his penis exposed on the left side of his brief as Resident #1 stood beside the bed grasping Resident #2's penis with his hand as he moved his hand in an up and down motion. The residents did not have the cognitive capacity to consent to sexual relations or express an adverse psychosocial outcome. A reasonable person would have been traumatized by being…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2023-08-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, police reports, resident, staff, and psychotherapist interviews, the facility failed to protect moderately cognitively impaired residents (Resident #135 and Resident #49) right to be free from sexual abuse from a cognitively intact resident (Resident #122). During the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M., Resident #122 entered Resident #135's room, while he was sleeping, lifted Resident #135's blanket and reached his hand into Resident #135's brief, and then stimulated Resident #135's penis. Resident #135 reported the sexual abuse to Nurse Aide (NA) #1 on 7/12/23 at approximately 4:00 A.M. Resident #135 explained Resident #122 had not been invited into his room and the physical touch was not consensual. Resident #135 reported the incident hurt me mentally and he made me sick. On the evening of 7/11/23 at approximately 11:00 P.M, Resident #49 was lying in bed watching television when Resident #122 entered Resident #49's room and manipulated Resident #49's penis through…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-08-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, resident, staff, Nurse Practitioner and Medical Director (MD) interviews, the facility failed to hold an anticoagulant for a resident (Resident #345) who had oral surgery resulting in significant bleeding and emergency treatment, the facility also failed to wait for a nurse to asses a resident for injuries prior to moving her up off the floor (Resident #106). This was for 2 of 2 residents reviewed for standards of care. The findings included: 1. Resident #345 was admitted on [DATE]. The resident's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact and required assistance with activities of daily living. The resident's medical record contained a visit summary from the dentist dated 4/14/2023. The summary noted the resident needed referral to oral surgeon for extraction (removal) of all maxillary teeth and recommended complete denture for maxillary and partial denture for mandibular. The summary noted the resident was on Eliquis (anticoagulant). 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 store a scoop in a manner that prevented it from becoming contaminated by direct contact with flour, maintaining a clean steam table hood, and ensuring plastic plate bases were dried before being stacked for 2 of 2 kitchen observations. This deficient practice had the potential to affect food served to residents. The findings included:1. The initial tour of the kitchen was on 2/23/26 at 10:17 AM with the Dietary Manager. A large bin of flour was observed by the prep table with the scoop stored in the container of flour.The Dietary Manager was interviewed on 2/23/26 at 10:17 AM. The Dietary Manager asked a kitchen aide to remove the scoop from the flour. The Dietary Manager explained the hook to hang the scoop was inside the container and when the lid to the container slid to the closed position, it often knocked the scoop back into the flour.2. At 10:19 AM on 2/23/26, a continuation of the tour revealed the underside of the steam table hood contained orange, brown residue and felt slick to touch. The Dietary Manager…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident, staff, and Medical Director interviews the facility failed to assess a resident's ability to keep steroid nasal spray at bed side for self-administration for 1 of 1 resident reviewed for self-administration of medications (Resident #138).The findings included:Resident #138 was admitted to the facility on [DATE].Physician order dated 4/15/25 revealed an order for fluticasone propionate nasal suspension (steroid nasal spray for allergies) 50 micrograms 2 sprays in both nostrils twice a day for allergies.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #138 was cognitively intact.Resident #138's care plan dated 2/17/26 did not include any goals or interventions for self-administering medications.Review of Resident #138's medical record did not show an assessment for self-administration of medication.Resident #138 was interviewed on 2/23/26 at 11:16am. During the interview an observation was made of Resident #138's prescribed bottle of nasal spray…

    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 · Dcited before2026-03-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect the residents' right to be from physical abuse when Resident #86 hit Resident #14 with a grabber (handheld device used to assist in obtaining items out of reach) on 12/2/25 which resulted in an abrasion to Resident #14's forehead and Resident #86 hit Resident #54 with an open hand across the face while Resident #86 was receiving one-on-one (1:1) supervision on 12/24/25. This for 1 of 4 residents reviewed for abuse (Resident #86). The findings included:Resident #86 was admitted to the facility on [DATE] with diagnosis that included dementia, insomnia, psychotic disturbance, mood disturbance, mild cognitive impairment and anxiety.Review of Resident #86 Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired with no upper or lower extremity impairments, only required set up for mobility and had no physical or verbal behaviors directed towards others. Review of Resident #86 Minimum Data Set (MDS)…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to complete an accurate Minimum Data Set (MDS) assessment in the area of skin conditions for 1 of 11 residents who MDS assessments were reviewed (Resident #5).The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses of left patella fracture, atrial fibrillation (A-fib), congestive heart failure (CHF), hypothyroidism, and Alzheimer's disease. An admission progress note written on 10/08/25 at 2:46 PM by Nurse #8 stated Resident #5 had arrived at the facility via ambulance on a stretcher. She noted that Resident #5 had a dark spot to her coccyx, an open area to her spine, and redness to her left knee. A review of Resident #5's care plan dated 10/09/25 revealed she was found to be at risk for skin breakdown. The goal dated 10/9/25 stated Resident #5 would not show any signs of skin breakdown for 90 days. The interventions also dated 10/9/25 included to pat (do not rub) skin when drying, observe skin for signs and symptoms of skin breakdown…

    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 · D2026-03-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident, staff and Physician interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #7).The findings included:Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's physician's orders dated 6/25/2025 revealed an order that stated, Resident may not administer his own meds. A review of Physician's order dated 6/25/25 for Resident #7 revealed that staff were to monitor swallowing during medication pass and to document if resident coughed, complained of pain, or demonstrated difficulty when swallowing meds.An observation and interview were conducted on 2/24/26 at 2:50PM with Resident #7 in his room. It was observed that he had a medication cup containing 7 pills sitting on his bedside table. Observation of the hallway outside of resident's room revealed the nurse for this hallway (Nurse #2) was no longer passing medications on the hallway. Resident #7 said he would take…

    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 · D2026-03-13 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interviews, the facility failed to keep the area around the trash compactor free from accumulated trash and debris for 1 of 1 trash compactor observed. This failure had the potential to attract pests and rodents.The findings included:An observation of the dumpster area occurred on 2/23/26 at 10:23 am with the Dietary Manager (DM). The observation revealed the facility had one trash compactor located in a fenced area behind the kitchen entrance. Directly in front of the trash compactor was a cement platform with a grassy area to the left side and back of the trash compactor. On the left side of the trash compactor in the grassy area there were four plastic bottles, six disposable cups, four disposable gloves, and seven straws.The DM was interviewed on 2/23/26 at 10:24 am. The DM explained the cement platform was cleaned weekly by a member of the kitchen staff but the trash and debris on the left side and back of the trash compactor did not get picked up. The DM stated she was not sure why the area was not attended to and commented that all departments…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · 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, observations, and resident and staff interviews the facility failed to maintain the resident's dignity by not emptying urinals prior to lunch and as needed. This was evident for 1 of 4 residents (Resident #41) reviewed for dignity. Findings include: Resident #41 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41's cognition was moderately impaired. He required moderate assistance with toileting and dressing and minimal assistance with transfers. He was occasionally incontinent of bowel and bladder. Resident #41 had range of motion impairment to both sides of his upper extremities. An observation and interview were conducted with Resident #41 in his room on 11/04/24 at 10:39 AM. Resident #41 was observed laying on his bed watching TV. Two urinals were noted on the nightstand with urine in them. One with approximately 400 milliliters (ml) of yellow urine and one with approximately 250 ml of yellow urine. He stated the staff emptied them…

    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 · Dcited before2024-11-07 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with resident and staff, the facility failed to assess and obtain a physician's order for the self-administration of medications found at bedside for 1 of 1 resident (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes type 2, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #58 was cognitively intact and displayed no behaviors or rejection of care. A review of Resident #58's medical record did not reveal an order to self-administer medications. On 11/4/24 at 10:30 AM, an observation was made of medications in a medication cup sitting on Resident #58's over the bed table. Resident #58 stated that the medication had been sitting there since his breakfast was delivered and that staff did not normally leave his medication sitting on the over the bed table. Resident #58's breakfast plate…

    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 · D2024-11-07 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, the facility failed to deliver resident mail unopened for 3 of 7 residents reviewed for mail delivery (Resident #29, Resident #91, and Resident #100). The findings included: a. Resident #29 was admitted to the facility on [DATE]. Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. An interview on 11/05/24 at 10:24 AM with Resident #29 revealed that he had received opened mail that was addressed to him. He stated that it had happened on more than one occasion but was unable to give specific dates. Resident #29 stated the mail that was opened was related to his financial status. b. Resident #91 was admitted to the facility on [DATE]. Resident #91's annual MDS assessment dated [DATE] revealed Resident #91 was cognitively intact. An interview on 11/05/24 at 10:26 AM with Resident #91 revealed that she had received opened mail that was addressed to her. She stated that it had happened on more than one occasion…

    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 · D2024-11-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to administer water flushes via a feeding tube at the physician ordered flow rate for 1 of 2 residents reviewed with tube feedings (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and presence of a feeding tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 rarely made herself understood and had severely impaired decision-making skills. She was coded as receiving 51% or more of her total calories through a tube feeding and an average fluid intake of 501 cubic centimeters (cc) per day or more by tube feeding. A review of Resident #22's active physician orders included an order dated 10/17/24 to flush the feeding tube with 110 milliliters (ml) of water every 3 hours during continuous feedings. Resident #22's active care plan, last reviewed 10/25/24, revealed a focus area for an enteral…

    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
Show the remaining 9 citations
  • Potential for harm · Dcited before2024-11-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Medical Director and staff interviews, the facility failed to hold blood pressure medication as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #95). The findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses that included low blood pressure (hypotension). A review of Resident #95's active physician orders included an order dated 10/7/24 for Midodrine (a blood pressure medication) 10 milligrams (mg) one tablet by mouth three times a day for low blood pressure- take if systolic blood pressure is less than 120. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #95 was cognitively intact. The October 2024 and November 2024 Medication Administration Records (MARs) were reviewed and revealed Resident #95 had received Midodrine despite the systolic blood pressure (SBP) being greater than 120. - 10/9/24 at 1:00 PM the SBP was 122 and at 5:00 PM the SBP was 124. - 10/21/24 at 9:00 AM…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-02 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews with resident, staff, and Medical Director, the facility failed to discontinue a resident's antiepileptic medication per neurologist recommendation for 2 months in 1 of 6 residents (Resident #95) reviewed for unnecessary medications. The findings included: Resident #95 was admitted to the facility 6/8/2021 with diagnoses that included a history of seizures. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. Resident #95's comprehensive care plan was last revised 6/22/2023 and included a focus for risk of seizure activity. An interview was conducted with Resident #95 on 7/17/2023 at 9:38AM. He stated he knew the seizure medication had been discontinued by the neurologist and he made the nurses aware. The nurses told him they did not have a copy of the after-visit summary. Resident #95 stated he gave the summary to the nurse at the nurse station when he returned to the facility on 5/4/2023. He finally became frustrated and refused 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 · Ecited before2023-08-02 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to date sliced fruit stored inside the reach in refrigerator and the Dietary Manager (DM) and dietary aide #1 failed to wear hair coverings for 2 of 5 staff working in the kitchen. These practices had the potential to affect food served to residents. The findings included: During a kitchen tour on 7/16/23 at 11:20 AM with the DM there was observed in the reach in refrigerator sliced peaches in a metal container with clear wrap covering it. There was no date observed. The DM stated they were to be served at lunch today and that was why they were inside the reach in cooler. He stated they should have been labeled. In the cooler, there was observed a metal container of sliced carrots covered with clear wrap on a metal rack stored underneath a metal pan with a cooked pork roast covered with clear wrap. The DM stated the vegetable should be stored above the meat. The DM's head appeared clean shaven and absent of a hair covering during the tour. He stated he forgot his hat in the car and should be wearing it. During a lunch…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-02 · tag F0867 — failed to act on quality-improvement findings — pattern
    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, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 03/17/22 and during a complaint investigation on 6/12/23. This was for 4 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment, Care Plan Timing and Revision, Free of Accident Hazards/Supervision/Devices, Food Procurement, Store/Prepare/Serve-Sanitary, which were previously cited on 03/17/22, and Free of Accident Hazards/Supervision/Devices was cited on 06/12/23. All 4 of these deficient practice areas were recited on the current recertification, follow up, and complaint survey of 8/2/23. The duplicate citations during three federal surveys of record shows a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1) F584-Based on observations and staff interviews, 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 and staff interviews, the facility failed to 1) replace 2 bed side commodes with visible rust on the legs and frame for 2 of 6 resident bathrooms (room [ROOM NUMBER] and 106) and 2) failed to repair or replace broken Packaged Terminal Air Conditioner (PTAC) air filters for 1 out of 12 resident rooms (room [ROOM NUMBER]) reviewed for comfortable, clean, and homelike environment. The findings included: 1) On 07/16/23 from 11:22 AM through 11:41 AM and on 07/17/23 from 10:42 AM through 10:51 AM the following were observed: - room [ROOM NUMBER] ' s bathroom had a bedside commode over the toilet. All four legs and the metal frame of the bedside commode had visible rough texture of rust located on the metal surface. Small pieces of light colored rust and paint crumbled off when touched. The room was occupied with continent residents that utilize the bedside commode. The surface was not smooth and not cleanable. - room [ROOM NUMBER] ' s bathroom had a bedside commode over the toilet. All four legs…

    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 · D2023-08-02 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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 and staff and resident interviews, the facility failed to implement their policy for reporting an allegation of sexual abuse to the state agency within 2 hours for 1 of 3 residents reviewed for alleged sexual abuse investigations (Resident #49). Findings included: The facility abuse policy, last revised 10/24/22, read in part, Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. (Refer to External Abuse reporting Requirements table). 7.1 Enter allegations into PCC Risk Management Portal. 7.2 Report allegation involving abuse physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. 7.3 Report allegation to the appropriate state and local authority(s) involving neglect, exploitation, mistreatment (including injuries of unknown source), suspected criminal activity and misappropriation of patient property not later than two (2) hours after 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 and record review, the facility failed to revise the comprehensive care plan in the area of transfer status for 2 (Resident #106 and Resident #30) of 30 residents reviewed for care plan revision. The findings included: Resident #106 was admitted on [DATE] with cumulative diagnoses of Congestive Heart Failure and acute/chronic renal failure. Review of Resident #106's Activities of Daily Living (ADL) care plan dated 5/25/22 read she was an total assistance of 2 for transfers using sit to stand lift. Her annual Minimum Data Set (MDS) dated [DATE] indicated Resident #106 was cognitively intact, experienced no falls, requiring extensive staff assistance of 2 for transfers. Review of Resident #106's July 2023 Physician orders did not include an order for Resident #106's transfer needs. Review of a nursing note dated 7/15/23 at 11:37 AM read Resident #106 was being transferred from the bed to her wheelchair with 1 staff assistance when her knee gave out and she was lowered to the floor. Review…

    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 · D2023-08-02 · 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 Based on resident, staff, Medical Director (MD) and Therapy Director interviews and record review, the facility failed to transfer a resident using a sit to stand lift (a mechanical lift that assist a resident with limited mobility in standing up from a seated position) as care planned and according to the physical therapy discharge summary (Resident #106). The facility also failed to transfer a resident requiring a total mechanical lift (portable total body lift used to minimize physical effort) for transfers resulting in a fall without injury (Resident #30). This was for 2 of 8 residents reviewed for accidents. The findings included: 1. Resident #106 was admitted on [DATE] with cumulative diagnoses of Congestive Heart Failure and acute/chronic renal failure. Review of Resident #106's comprehensive care plan read she was a total staff assistance of 2 for transfers using sit to stand lift on 5/26/22. Review of Resident #106's latest Physical Therapy (PT) Discharge summary dated [DATE] read she continued 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
  • No harm found · B2024-11-07 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 4. Resident #132 was admitted to the facility on [DATE]. Resident #132's medical record revealed he was transferred to the hospital on [DATE]. There was no documentation that written notices of transfers were provided to the RP for the reasons for the transfers. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #132's Resident #132 was cognitively intact. An interview was conducted with Nurse #6 on 11/07/24 at 4:23 PM. She indicated Resident #132 called 911 himself for transport to the hospital due to him not feeling well. He did not notify staff he was calling 911. She stated emergency medical services (EMS) arrived, took face sheet, list of medications, and DNR form and transported Resident #132 to the hospital per his request. She notified his power of attorney (POA), Hospice, and the Director of Nursing (DON) of the transfer. On 11/5/24 at 3:10 PM, the Director of Nursing (DON) was interviewed and stated a copy of the face sheet, any Do Not Resuscitate (DNR) information,…

    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 plan 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$7,909 in federal fines across 1 penalty.

  • $7,909 — penalty dated 2025-09-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GENESIS HEALTHCARE — 184 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 →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 1 of 53.5-2.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

Showing 40 of 183; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
REGENCY HEALTH SERVICES, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/02/2015
FC GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
SUN HEALTHCARE GROUP, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/15/2009
SUNBRIDGE HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2009
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 03/02/2015
BERG, MICHAELIndividualCORPORATE OFFICERsince 12/01/2008
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 01/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 01/01/2024
ALVAREZ, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/19/2023
HOFFMAN, BYRONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2025

CMS files one row per role, so the 17 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$14.7M
Net patient revenuemost recent cost report
+5.7%
Operating marginrevenue minus expenses
$3.8M
Related-party expense27% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 2%Other / private 15%

About 83% 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 $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$273per resident / day
operating cost
$8,294per month
≈ monthly operating cost
$289per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

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 345143. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.

What to do next