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Ridge Valley Center for Nursing and Rehabilitation

1000 College Street, Wilkesboro, NC 28697 · For profit - Limited Liability company · 120 certified beds · (336) 838-4141 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Sep 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • about 19% 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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1918 West Park Dr · (336) 903-7850 · Call to confirm hours
Pharmacy
1300 Westwood Ln Ste A · (336) 667-9347 · Call to confirm hours
Grocery
303 S Cherry St · (336) 262-8422 · Call to confirm hours
Park
1030 Fletcher St · (336) 838-3951 · 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 1 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 held steady at 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 increased17.4%15.6%15.4%worse
Long-stay residents who lose too much weight13.7%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder2.8%0.7%0.9%worse
Long-stay residents with a urinary tract infection3.8%2.3%2.0%worse
Long-stay residents with depressive symptoms10.5%5.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.6%3.5%3.3%worse
Long-stay residents whose ability to walk worsened18.6%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication41.9%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine74.7%94.1%95.3%worse
Long-stay residents with pressure ulcers8.2%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control24.1%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.3%14.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine17.2%78.1%79.4%worse
Short-stay residents rehospitalized after admission34.2%22.9%22.6%worse
Short-stay residents with an outpatient ER visit21.7%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.731.781.67worse
Long-stay outpatient ER visits per 1,000 resident days5.041.801.80worse

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.

26.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

26.0%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
57.5%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 57.5% 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 40 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% 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 SNF26.0%CMS range 16.5–38.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.2–16.110.7%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 discharge57.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge32.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.7%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 setting96.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay0.0%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 worsened4.5%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 hospitalization7.2%CMS range 3.4–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 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

0.21
RN hours/ resident / day
0.44
LPN hours/ resident / day
2.52
Aide hours/ resident / day
3.18
Total nurse hours/ resident / day
0.15
RN hoursweekends
33.8%
Total nursing turnover
72.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 83.8 residents a day — about 70% occupied, or roughly 36 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.09 hrs/resident/day on weekends vs 3.21 on weekdays — 4% thinner on weekends. RN hours go from 0.23 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below 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

1
deficiencies at the latest standard inspection (2025-12-04)
10
at the previous standard inspection (2024-09-11)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2023-06-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, staff, and Medical Director interview the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors (Resident #31). Nurse #1 administered 38 units of insulin glargine (a long-acting insulin that lasts for 24 hours and does not have a peak onset of action) in error to Resident #31, a resident who did not have a diagnosis of diabetes. Resident #31's blood sugar dropped throughout the night and the resident was sent to the hospital due to a blood sugar level of 50 (normal range 90-100) requiring an overnight hospitalization. A serious set of symptoms of hypoglycemia can occur in people without diabetes including tremors, palpitations, anxiety, sweating, dizziness, weakness, increased risk for falls and fractures, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. The symptoms occur when the glucose level falls below 55 mg/dL, although this can be variable. There was high likelihood for serious harm.…

    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 · Past Non-Compliance
  • Immediate jeopardy · Jcited before2023-06-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interviews, the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 2 of 2 residents observed (Resident #3 and Resident #105) during a medication pass on 06/06/23 at 9:05 AM. The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter. The facility had three residents in the building with a diagnosis of a bloodborne pathogen (microorganisms that cause disease and are present in human blood) (Resident #104, Resident #64 and Resident #76). This deficient practice had a high likelihood for transmitting bloodborne pathogens within the facility. Immediate Jeopardy began on 06/06/23 when Nurse #6 was observed during medication pass removing two glucometers from the medication cart and use them without disinfecting per manufacturer's guidelines. The immediate jeopardy is present and ongoing. Findings included: Review of the facility policy Glucometer Disinfection revised in October…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-04 · tag F0761 — failed to label and store drugs safely — pattern
    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 and staff interviews, the facility failed to remove 2 expired Bisacodyl suppositories, 10 expired omeprazole tablets in accordance with the manufacturer's expiration date, and 27 unidentifiable loose pills from the medication carts. The facility also failed to date 2 opened insulin pens per manufacturer's specification for 4 of 4 medication carts (A, B, C and D) reviewed for medication storage.The findings included: Review of the package inserts for insulin Glargine revealed it could be stored under refrigeration at 36 to 46 Fahrenheit (F) unopened until the expiration date. Once the insulin pen was opened and in use, it could be kept at room temperatures below 86 F for up to 28 days. Discarded the insulin after 28 days even if it still had insulin in it. a.During a medication storage audit conducted on 12/02/25 at 4:34 PM in the presence of Certified Medication Aide (CMA) #1, two (2) Bisacodyl rectal suppositories 10 milligrams (mg) that expired on 10/31/25 were found in the medication cart for A Hall and available for use. An interview was conducted with CMA…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews and staff interviews, the facility failed to identify the need for Enhanced Barrier Precautions (EBP) for Resident #2 with an unhealed surgical wound and failed to implement their infection control policy when Nurse #2 did not apply a gown when performing wound care for Resident #2. In addition, Nurse #2 failed to change gloves and perform hand hygiene after cleansing wounds and applying the ordered dressing on Resident #2 and Resident #3. This occurred for 1 of 1 staff member observed for infection control practices. The findings included:Review of the facility's Enhanced Barrier Precautions policy dated 2025 revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of EBP: b. An order for enhanced barrier precautions will be obtained for residents for unhealed surgical wounds.Review of the facility's Hand Hygiene policy dated 2025 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-08 · 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 observation, record review, and staff interviews, the facility failed to secure an opened tube and an opened container of topical ointment for 1 of 1 Resident reviewed for medication storage. (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3 with an intact cognition. During an observation conducted on 01/08/25 at 10:53 AM, an opened tube containing approximately 1.5 ounces of zinc oxide ointment 20 % (a topical ointment for treating or preventing skin irritation related to diaper rash) was found unattended on top of the over-bed table in Resident #3's room. A further observation revealed another opened container of zinc oxide ointment with the same strength with approximately 3 ounces remaining in the container left unattended on top of Resident #3's bedside table. An interview was conducted with Resident #3 on 01/08/25 at 10:55 AM. She stated the ointments were for her diaper rash and she…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · 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 and staff and resident interviews, the facility failed to treat a resident with respect and dignity when Nurse #3 told a resident (Resident #48) that he would not be sent out to the hospital after he yelled that he was uncomfortable and felt that no one was helping him. The facility also failed to treat a resident with respect and dignity when the facility failed to address unwanted facial hair on a resident (Resident #20) This was for 2 of 6 residents reviewed for treating residents with respect and dignity. The findings included: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, paraplegia, and chronic pain syndrome. A review of Resident #48's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #48 was cognitively intact with no delusions, behaviors, or rejection of care. During an interview with Resident #48 on 09/04/24 at 2:15 PM revealed he had been feeling bad on 08/21/24 with some pain in his upper back. Resident…

    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 · D2024-09-11 · tag F0578 — failed to honor advance directives / code status — isolated
    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, staff interview, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident's code status election was accurate throughout the medical record (Resident #25) and failed to ensure an advanced directive form was signed by the Resident or Responsible Party (RP) (Resident #60) for 2 of 3 residents reviewed for advanced directives (Resident #25 and Resident #60). The findings included: 1) Resident #25 was admitted to the facility on [DATE]. A review of a physician's order dated [DATE] revealed Resident #25 was a Do Not Resuscitate (DNR). A review of a Medical Orders for Scope of Treatment form (MOST) dated [DATE] revealed Resident #25 wished to be a DNR with a limited scope of treatment. A review of a care plan dated [DATE] revealed Resident #25 had an advanced directive and chose to be a DNR with an intervention that included to honor Resident #25's choice to be a full code. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 interview the facility failed to protect Resident #125 from being physically restrained by Nurse Aide #2 when Resident #125 had terminal agitation and was attempting to sit up in bed for 1 of 3 residents reviewed for employee to resident abuse. Nurse Aide #2 used her hand to push Resident #125's head back into the pillow in an attempt to keep him in the bed. The findings included: Resident #125 was admitted to the facility on [DATE] and expired on [DATE]. Resident #125's diagnoses included malignant neoplasm of lung and skin, and anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required supervision with transfers. There was no behaviors or rejection of care noted during the assessment reference period. The MDS also revealed that Resident #125 had a prognosis of less than 6 months to live and received hospice care. Review of an initial allegation report dated [DATE] at 4:25 AM read, staff reported that Nurse Aide…

    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 · D2024-09-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 reviews, and staff and Nurse Practitioner (NP) interviews, the facility failed to develop and implement a person-centered care plan for a resident on one-on-one supervision for 1 of 4 residents reviewed for development and implementation of a comprehensive care plan (Resident # 51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses which included dementia, disorientation (a state of confusion), and hallucinations (seeing/hearing something that is not there). A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was severely cognitively impaired, had no behaviors, and no rejections of care. A review of the care plan dated 7/31/2024 revealed Resident #51 was at risk for elopement and wandering related to impaired safety awareness with interventions which included application of a wander guard and to address wandering behaviors. There was no care plan intervention related to one-on-one supervision. An observation was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and resident and staff interviews, the facility failed to trim a dependent female resident's facial hair for 1 of 6 residents (Resident #20) reviewed for activities of daily living (ADL). The finding included: Resident #20 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes mellitus, chronic obstructive pulmonary disease and respiratory failure. A review of Resident #20's care plan revised 06/19/23 revealed the Resident had a self-care ADL deficit related to decreased mobility and disease process. The goal to maintain her current level of function would be attained by utilizing interventions which included providing extensive assistance of one staff with personal hygiene (shaving). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and required substantial to maximal assistance of one staff for personal hygiene which included shaving. There was no documentation on the MDS 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 · D2024-09-11 · 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 review, staff, and Nurse Practitioner interviews the facility failed to assess Resident #125 before transferring him back to bed after he was found on the floor for 1 of 2 residents reviewed for falls. The findings included: Resident #125 was admitted to the facility on [DATE] and expired on [DATE]. Resident #125's diagnoses included malignant neoplasm of lung and skin, and anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required supervision with transfers. There was no behaviors or rejection of care noted during the assessment reference period. There was also no history of falls in the 6 months prior to admission or since admission to the facility. The MDS also revealed that Resident #125 had a prognosis of less than 6 months to live and received hospice care. Review of an initial allegation report dated [DATE] at 4:25 AM read, staff reported that Nurse Aide (NA) #2 handled Resident #125 roughly during the provision of care. 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 · D2024-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, Registered Dietitian (RD), Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to meet the recommended fluid needs for 1 of 2 residents (Resident #42) reviewed for nutrition. The findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), required the use of a gastrostomy tube (artificial opening in the stomach used for tube feeding) and tracheostomy. A physician order dated 07/21/24 read; flush tube with 30-60 milliliters (ml) of water before/after meds twice a day (120-240 ml). Review of the Registered Dietician (RD) nutritional assessment dated [DATE] revealed that Resident #42 required 1982-2379 ml of fluid per day. A review of the RD recommendations dated 7/25/2024 revealed Resident #42 was recommended to have free water at 30 ml per hour which totaled 720 ml (additionally 1094 ml of water were noted from the tube feeding formula). A review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-09-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Resident, and staff interviews, the facility failed to assess a resident for pain on admission and when there was a change in condition for 1 of 3 residents reviewed for pain management (Resident # 88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses which included a left femur (long bone in the upper leg) fracture (break), sternal body (breastbone) fracture, liver laceration (trauma to the liver that causes bleeding), L1 vertebral body (spinal bone in the lower portion of the back) fracture, right forehead laceration (tear), and metacarpal (hand bone) fractures. A review of an admission nurse's note, authored by Nurse # 3, dated 6/14/2024 revealed Resident #88 had arrived at the facility via Emergency Medical Services (EMS), was pleasant, and alert and oriented. Resident #88 had extensive bruising and staples in his left leg and had a femur fracture. Resident #88 had staples on his right forehead and had a cast on his right arm. Resident #88…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and staff, Nurse Practitioner and Pharmacist interviews, the facility failed to identify the lack of documentation of monitoring for side effects (Resident #35) for psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included Parkinson Disease, unspecific dementia without behavioral disturbance, psychosis, mood disorder and neurogenic disturbance with Lewy body dementia. A review of Resident #35's physician orders revealed orders for: Seroquel (an antipsychotic) 25 milligrams (mg) by mouth once a day for dementia dated 07/12/24, Nuplazid (an antipsychotic) 34 mg by mouth once a day for psychosis related to Parkinson Disease dated 07/13/24, and Seroquel 12.5 mg by mouth once a day for dementia dated 07/13/24. A review of Resident #35's Medication Administration Record (MAR) for 07/2024, 08/2024 and 09/2024 revealed the antipsychotic medications were intialed as…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 reviews, and resident and staff interviews, the facility staff failed to don appropriate Personal Protective Equipment (PPE) before entering residents' room under transmission-based precautions. The facility also failed to utilize hand hygiene after removing gloves for 2 of 4 residents reviewed for infection control (Resident #40 and Resident #74). The findings included: 1. Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 12/2023 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting wit toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility's Hand Hygiene policy dated 12/2023 revealed staff will perform proper…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-20 · tag F0657 — failed to keep the care plan current — pattern
    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 record review, resident and staff interviews, and observations the facility failed to develop a comprehensive care plan after the admission assessment and failed to ensure individualized care plans were updated and accurate for 5 of 10 residents (Resident #20, Resident #37, Resident # 60, Resident #64, and Resident #355). The findings include: 1. Resident #355 was admitted to the facility on [DATE] with the following diagnosis: respiratory failure, atrial fibrillation, diabetes mellitus, and anxiety disorder. Review of physician orders for Resident #35 revealed: - 3/30/23 for Insulin 20 units at bedtime due to type 2 diabetes mellitus - 3/30/23 for anticoagulation to be administered twice daily for atrial fibrillation - continuous oxygen at 3 L/minute via nasal cannula dated 3/30/23 - Quetiapine Fumarate an antipsychotic medication dated 3/30/23 to be administered twice daily. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #355 was cognitively intact. She required…

    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 · E2023-06-20 · 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, record review and staff interviews, the facility failed to ensure leftover food items stored ready for use were labeled and dated and failed to remove expired food items in 1 of 1 walk-in freezer, 1 of 1 reach-in refrigerators and 1 of 2 nourishment rooms (the Intermediate Care Facility nourishment room). These practices had the potential to affect food served to residents. Findings included: An initial tour of the kitchen was conducted on 06/04/23 at 10:45 AM with Dietary Aide #1. The walk-in freezer was observed to contain an unlabeled and undated bag of frozen riblettes which had been opened and tied back and two bags of opened frozen fried squash that were not labeled and dated. Observation further revealed in the walk-in cooler a container of diced ham that was labeled and had the discard date of 06/01/23. The observation of the reach-in refrigerator revealed a bag of lettuce in a plastic bag not labeled and dated, with a hole in the bag, and appeared to be brown. During this observation, Dietary Aide #1 was interviewed and revealed foods in the walk-in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigations that occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], a focused infection control survey of [DATE] and the recertification and compliant investigation survey that occurred on [DATE]. This failure was for six deficiencies that were originally cited in the areas of Notification of Change (F580), Resident Assessment (F641), Tube Feeding Management (F693), and Infection Prevention and Control (F880) and were subsequently recited on the current recertification, revisit, and complaint investigation survey of [DATE]. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F580: Based on record…

    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 · D2023-06-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Medical Director interview the facility failed to notify the physician after a non-diabetic resident was administered 38 units of insulin glargine (a long-acting insulin) in error by Nurse #1. This was for 1 of 1 resident reviewed for notification (Resident #31). Findings included: Resident #31 was admitted into the facility on [DATE] with diagnoses which included hypertension and asthma. Resident #31 did not have a diagnosis of diabetes mellitus. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring limited assistance of one staff member for most activities of daily living (ADL). Resident #31 was coded as not receiving insulin. A nursing progress note dated 05/14/23 at 2:07 AM written by Nurse #1 revealed she had made a medication error by administering Resident #31 38 units of insulin glargine a long-acting insulin. The note revealed Nurse #1 gave the resident peanut butter cookies, apple juice, ice cream and orange juice.…

    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 · D2023-06-20 · 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, observation, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for discharge status (Resident #102), range of motion limitations (Resident #211), and accumulative diagnoses (Resident #210) for 3 of 28 residents whose MDS were reviewed. The findings included: 1. Resident #102 was admitted on [DATE] and discharged from the facility on 3/31/23. A review of the Social Worker Discharge summary dated [DATE] indicated Resident #102 was scheduled for discharge back to the community with spouse on 3/31/23. Home health services had been set up. A review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #102 was marked as a having a planned discharge to an acute hospital. In an interview with the MDS Coordinator on 6/7/23 at 3:32 PM, after reviewing the discharge summary she reported discharge status should have been coded as return to the community on the 3/31/23 MDS assessment. She stated it was coded in error. A resident'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-20 · 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 observations, record review, resident and staff interviews, the facility failed to obtain orders for suprapubic catheter care for 1 of 1 resident reviewed for catheter use (Resident #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included paraplegia and neurogenic bladder. The Resident has had several discharges and returns with the most recent readmission being 5/6/23. Resident #64's care plan initiated on 11/29/22, revealed a focus for indwelling suprapubic catheter due to neurogenic bladder. The interventions included monitor and document intake and output, monitor/document for pain/discomfort due to catheter, and monitor/record/report to Physician for signs and symptoms of urinary tract infection (UTI). Resident #64's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was cognitively intact and had a catheter due to neurogenic bladder. Review of Resident #64's electronic medical record dated 3/1/23 through 6/7/23 revealed no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-20 · 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 observation, record review, staff and resident interviews the facility failed to ensure an opened bag of tube feed that was running through a feeding pump, had a date, time, and resident name on them for 1 of 3 residents reviewed for tube feeding. (Resident #89) Resident #89 was admitted to the facility on [DATE] with diagnoses of stroke, severe protein calorie malnutrition, and dysphagia. Review of Resident #89's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident had severe cognitive impairment and required extensive assistance from staff with activities of daily living (ADLs). The assessment was also marked for tube feeding while a resident. Resident #89 was receiving 25% or less total calories through tube feed and 500 cubic centimeter (cc)/ day or less average fluid intake. A review of the care plan dated 4/16/23 revealed a focus for nutritional risk due to history of stroke with dysphagia and the need for tube feeding. An intervention included tube feeding as ordered and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-07-17 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to maintain an accurate Treatment Administration Record (TAR) for 1 of 3 residents (Resident #1) reviewed for wound care.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and bilateral below knee amputations (BKKA).Review of Resident #1's medical record revealed a physician order start date of 06/18/25 to cleanse the left below knee amputation (BKA) incision with wound cleanser then apply a petrolatum dressing (a wound dressing made of a fine mesh gauze infused with petrolatum and 3% bismuth and tribromophenate blend) then secure with gauze wrap and ACE bandage daily and as needed. The medical record also included a physician order for a start date of 06/19/25 for the right BKA to cleanse the incision with wound cleanser then apply a petrolatum dressing then secure with gauze wrap and ACE bandage daily and as needed.Review of Resident #1's 06/2025 TAR revealed there was no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-06-20 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, which was the last day of the assessment period) for 2 out of 2 sampled residents (Resident #107 and #211). Findings include: 1. Resident #107 was admitted to the facility on [DATE]. A review of Resident #107's admission MDS assessment revealed an assessment reference date (ARD) of 3/28/23 and was signed as completed on 6/4/23. An interview with MDS Coordinator on 6/7/23 at 3:32 PM revealed the admission assessment was signed complete outside of the 14-day timeframe. The MDS Coordinator went on to say she was in the facility 3 to 4 days a week and had gotten behind. She reported she was working on getting assessments caught up and completed in the appropriate timeframe. During an interview with Administrator on 6/7/23 at 5:31 PM she stated she expected all MDS assessments to be completed in a timely manner. 2. Resident #211 was admitted to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2023-06-20 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, which was the last day of the assessment period) for 5 out of 32 sampled residents (Resident #10, #33, #36, #48, and #71). Findings included: a. Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's medical record revealed there had been a quarterly MDS assessment with an ARD of 3/28/23 marked as complete on 5/26/23, outside of the time frame specified in the Resident Assessment Instrument (RAI) manual. b. Resident #33 was admitted to the facility on [DATE]. Review of Resident #33's medical record showed the last quarterly MDS assessment completed was dated 1/11/23. There was a quarterly MDS assessment with an ARD of 4/13/23 that was still in process as of 6/7/23. c. Resident #36 was admitted to the facility on [DATE]. Review of Resident #36's medical record revealed the last quarterly MDS assessment completed was…

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

    Resident Assessment and Care Planning 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$10.4M
Net patient revenuemost recent cost report
-18.9%
Operating marginrevenue minus expenses
$2.4M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 5%Other / private 26%

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$398per resident / day
operating cost
$12,100per month
≈ monthly operating cost
$335per 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 345133. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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.

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