Smithfield Manor Rehabilitation and Healthcare Cen

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.

53.7% 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 302 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.6% 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 152 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 160 beds and averages 140.4 residents a day — about 88% occupied, or roughly 20 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.04 hrs/resident/day on weekends vs 3.63 on weekdays — 16% thinner on weekends. RN hours go from 0.66 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

21 citations, most serious first. The 14 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-12 · 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 observation, record review, and interviews with the resident, staff, and the Medical Director, the facility failed to follow the manufacturer's instructions for wheelchair securement in a transportation van. On August 26, 2025, the Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. As the vehicle accelerated, the unsecured wheelchair tipped backward, causing Resident #1 to fall and strike her head and back on the floor of the van. She was transported to the hospital, where she was diagnosed with posterior (back) neck and upper back pain, a superficial laceration on the tip of her tongue, paraspinal (muscles located along the spine) tenderness in the upper thoracic (part of the body between the neck and the abdomen) region, and a superficial abrasion on her right hand. A computed tomography (CT) (non-invasive imaging test that uses x-rays and computer technology to create detailed images of the body'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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-04-19 · 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

  Based on observation, record review and interviews with staff, Nurse Practitioner, Medical Examiner and Physician, the facility failed to protect a resident's right to be free from neglect for 1 of 3 sampled residents reviewed for neglect (Resident #1). On 3/4/24, Nursing Assistant (NA) #1 disregarded Resident #1's physician orders and plan of care for the assessed need of 2 person assistance with Activities of Daily Living (ADL) care and provided care to the resident without assistance. During care, NA # left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated…

  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 before2024-04-19 · 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 observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur…

  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 · Gcited before2025-11-04 · 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 observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner on 10/26/25 when Resident #1 rolled out of bed while a nurse aide was providing care sustaining a left distal tibia and fibula fracture (two main bones in the lower leg). Resident #1 required surgical intervention to repair the fractures and was discharged back to the facility on [DATE] with a splint applied to her left leg. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (a disease that makes bones weak and brittle increasing the risk of fractures from falls), vitamin D deficiency, atrial fibrillation (an irregular heartbeat), and dementia. A review of Resident #1's Physician's orders revealed an order dated 7/6/2024 for Apixaban (anticoagulant medication) 5 milligrams (mg) by mouth twice daily for atrial fibrillation. An ADL…

  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 · Past Non-Compliance
• Potential for harm · E2026-04-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 observation, record review, and resident and staff interviews, the facility failed to provide staff and residents with washcloths and towels to complete Activities of Daily Living (ADL) care. This occurred for 5 of 5 residents residing on 2 of 4 halls reviewed for linens (East and [NAME] Halls). The findings included:Review of the facility's census dated 4/22/2026 revealed the East Hall census was 56 residents and the [NAME] Hall census was 53 residents.a. Resident #134 was admitted to the facility on [DATE] and was housed on the [NAME] Hall. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #134 was cognitively intact and had no rejection of care documented. The MDS documented Resident #134 required substantial/maximal assistance with bathing and toileting. Resident #134 was frequently incontinent of urine and always incontinent of bowel.Review of the facility's ADL documentation sheet showed Resident #134's shower days were Wednesday and Saturday.Review of Resident #134's ADL…

  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 · E2026-04-23 · 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 maintain kitchen equipment clean and in a sanitary condition to prevent the potential for cross contamination of food by failing to clean the shelf under the steam table for 2 of 2 steam tables observed. In addition, failed to clean the door handles for 2 of 2 reach-in refrigerators and 1 of 1 hot box/warmer and to clean 1 of 1 pellet plate warmer observed. These practices had the potential to affect food served to residents. T The findings included:Review of the undated AM (morning) [NAME] Cleaning Schedule revealed: Monday: Clean under both steamtables thoroughly including the legs.Review of the undated Dietary Aide #2 Daily Cleaning Schedule revealed: Monday: Clean pellet warmer and polish.During the tour of the kitchen with the Clinical Registered Dietitian on 4/20/26 (Monday) at 10:23 AM the following were observed:The two 5-foot shelves under the steam tables were observed covered with dark dried food particles and were sticky to touch.The two reach-in refrigerators door handles were noted with dried food…

  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 · D2026-04-23 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 resident's right to be free from misappropriation of narcotic pain medication (Oxycodone) for 1 of 1 resident reviewed for misappropriation of property (Resident #60).The findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses which included chronic pain. A physician's order dated 12/30/24 documented Oxycodone HCL oral tablet 5 milligrams (mg) one tablet by mouth every 6 hours as needed (PRN) for ankle pain. Resident #60's annual Minimum Data Set assessment (MDS) dated [DATE] revealed he was cognitively intact and had not received opioid (narcotic) pain medication. The pharmacy packing slips #1 and #2 dated 8/25/25 revealed 2 medication cards of Oxycodone (44 tablets on each medication card) were accepted and signed by Nurse Supervisor #2. A review of the narcotic countdown sheets (an inventory log used to record a running total for each controlled medication card) for Resident #60's PRN Oxycodone 5 mg…

  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 · Dcited before2026-04-23 · 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 and staff interviews, the facility failed to accurately code the physician's documented clinical contraindication of a gradual dose reduction (GDR) of psychotropic medications (Resident #2) and appliances in the bowel and bladder section for 2 of 27 residents reviewed for Minimum Data Set (MDS) assessment accuracy (Resident #91).The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia and schizoaffective disorder. A review of the psychiatric provider note dated 3/11/26 revealed an attempted dosage reduction to the psychotropic regimen was likely to impair the resident's function and exacerbate underlying psychiatric conditions. The quarterly MDS dated [DATE] for Resident #2 indicated a GDR had not been documented by the physician as clinically contraindicated. An interview was conducted with MDS Nurse #1 on 4/22/26 at 11:55 AM who stated the physician documented GDR as clinically contraindicated was marked no on the quarterly 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-23 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff and Medical Director interviews, the facility failed to observe a resident to ensure they had taken their medications during medication administration which resulted in a cup of pills being found on the resident's bed for 1 of 1 resident observed with medications at the bedside (Resident #83).Findings included:Resident #83 was admitted to facility on 2/2/2024 with diagnoses that included peripheral vascular disease, atrial fibrillation, hypertension, chronic pain syndrome, hypothyroidism, hyperlipidemia, generalized anxiety disorder, and bipolar disorder with a history of depression.Based on record review, Resident #83 was prescribed a medication regimen that included anticoagulant (Apixaban), beta blocker (Metoprolol), diuretic (Furosemide), thyroid replacement (Levothyroxine), psychotropic medications (Sertraline, Aripiprazole, Alprazolam), and opioid pain management (Oxycodone), as well as additional medications for constipation, electrolyte balance, and nutritional…

  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 · Dcited before2026-04-23 · 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 record review and staff interviews, the facility failed to provide care in a safe manner when the resident rolled off of the bed and onto the floor during incontinence care. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #121).Findings included:Resident #121 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, atherosclerotic heart disease, and dementia.A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #121 had moderate cognitively impairment and no behaviors or rejection of care. Resident #121 had functional limitations in range of motion to both lower extremities. She was dependent on staff assistance for toileting and required substantial/maximum assistance for rolling left to right on the bed.A Fall Risk Evaluation dated 02/26/2025 identified the resident as high risk for falls indicating the need for ongoing fall prevention interventions and monitoring. Items checked that…

  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 · D2026-04-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident #123).The findings included: Resident #123 was admitted to the facility on [DATE] with diagnoses which included retention of urine and obstructive uropathy (a condition by a blockage in the urinary tract that prevents urine from flowing normally). Review of Resident #123's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #123 was coded for an indwelling urinary catheter. An initial observation was conducted on 4/22/26 at 5:40 am of Resident #123 as he was lying in his bed. A urinary catheter drainage bag was observed to be hanging off the bed frame on the resident's right side of the bed (with a solid, blue-colored side of the bag facing the door). The entire bottom of the urinary catheter drainage bag was resting on the floor.…

  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 · D2026-04-23 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interviews, the facility failed to ensure agency personnel was adequately trained and competent before providing care of residents for 1 of 8 agency personnel reviewed for training requirements (Nursing Assistant #9).Findings included:This tag was cross referenced to:F689 Based on record review and staff interviews, the facility failed to provide care in a safe manner when the resident rolled off of the bed and onto the floor during incontinence care. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #121).A phone interview with Nursing Assistant (NA) #9 on 4/21/2026 at 1:10 pm NA #9 stated that she worked for an agency and this was her first time working with Resident #121. NA #9 further stated that she was not aware that Resident #121 was not on her assignment until NA #10 told her. NA #9 stated that she had not received any training from facility regarding fall prevention or what to do after a fall.A interview with Director of Nursing (DON) on 4/22/2026 at 3:03 pm revealed that nursing staff were expected 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-23 · 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, manufacturer's instructions, and staff and Pharmacist interviews, the facility failed to remove one (1) open bottle of zinc sulfate, (1) multi-dose lispro insulin injector pen, and one (1) multi-dose glargine insulin injector pen that were expired in 1 of 4 medication carts reviewed for medication storage and labeling (Upper East Medication Cart).The findings included: An observation of the Upper East medication cart on 4/3/26 at 7:50 am with Nurse #1 revealed one (1) open bottle of floor stock zinc sulfate (a supplement) 50 milligrams (mg) tablets with a manufacturer's expiration date of 2/2026 circled in red and an illegible handwritten open date on the side of the bottle, one (1) open insulin lispro injector pen with a handwritten open date of 3/8/26 with no handwritten expiration date, and the manufacturer's expiration date of 4/10/27, and one (1) open insulin glargine injector pen with a handwritten open date of 3/5/26 with no handwritten expiration date, and the manufacturer's expiration date of 3/18/27. The lispro injector and insulin glargine pens were…

  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 · E2025-01-24 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to have a process that provided an opportunity to formulate an advance directive (Resident's #'s 292, 73, 287, 54) and have accurate advance directive documentation throughout the medical record (Resident #54) for 5 of 15 residents reviewed for advance directives. Findings included: 1a. Resident #292 was admitted to the facility on [DATE] with diagnoses including spinal cord disease and chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #292 was cognitively intact. Physician orders dated [DATE] included an order for cardiopulmonary resuscitation (CPR). There was no documentation in Resident #292's medical record that education regarding the formulation of advance directives and/or an opportunity to formulate an advance directive was offered. b. Resident #73 was admitted to the facility on [DATE] with diagnoses…

  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

“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

$263,607 in federal fines across 3 penalties.

• $16,985 — penalty dated 2025-09-12
• $4,147 — penalty dated 2025-02-26
• $242,475 — penalty dated 2024-04-19

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 VENZA CARE MANAGEMENT — 25 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 43 rows in the source record cover these 33 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

25 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.

This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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