Autumn Care of Myrtle Grove

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.

63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 226 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.4% 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 123 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 90 beds and averages 88.6 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.15 hrs/resident/day on weekends vs 4.03 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.74 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above 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

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

Inspection deficiencies

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

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

41 citations, most serious first. The 19 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-04-24 · 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 and interviews with staff, the Medical Director, and the Nurse Practitioner (NP), the facility failed to immediately notify the physician on 1/25/25 of a resident's (Resident #1) dislodged jejunostomy tube (j-tube [a tube surgically inserted into the small intestine to deliver nutrition and medications]). Nurse #1 did not communicate with the physician and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25 and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was surgically placed. This delayed physician notification had a high likelihood of resulting in serious harm for Resident #1 from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient…

  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
• Immediate jeopardy · Jcited before2025-04-24 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Nurse Practitioner (NP), Medical Director, staff, and Responsible Party (RP) interviews, the facility failed to ensure a resident (Resident #1) was provided with the necessary treatment to replace his dislodged jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). On 1/25/25, Nurse #1 did not identify the need for hospital treatment to replace the dislodged jejunostomy tube (j-tube) and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25, and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. This noncompliance created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis…

  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
• Immediate jeopardy · J2025-04-24 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Responsible Party, Nurse Practitioner, Medical Director and staff, the facility failed to have a system in place to train agency nurses and verify their competency to provide care for a resident with a jejunostomy tube (j-tube [a feeding tube placed in the small intestine]). On 1/25/25 when Resident #1's j-tube became dislodged, Nurse #1 did not identify the need for hospital treatment to replace the dislodged j-tube and she replaced it by inserting a urinary catheter tube into the j-tube site. Nurse #1 stated she assumed Resident #1's j-tube was a gastrostomy tube (tube placed in the stomach for nutritional support). Replacing a j-tube requires radiographic (x-ray) guidance or surgical placement and Nurse #1 performing this action at the facility created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due 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
• Immediate jeopardy · Jcited before2024-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff, residents, Nurse Practitioner, and family member the facility failed to protect a vulnerable male resident's (Resident #1) right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 10/17/24 Resident #2 was observed by Resident #1's family member to have his hand inside Resident #1's brief as Resident #1 laid in bed. Resident #1 was incapable of giving consent for sexual contact and was unable to protect himself. Following the incident, Resident #1's antidepressant was increased due to an increase in agitation and restlessness. A reasonable person expects to be protected from abuse in their home and would have experienced psychosocial harm with feelings such as intimidation, severe anxiety, agitation, humiliation, withdrawal, and fear. This deficient practice was reviewed for 1 of 3 residents for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to provide supervision to Resident #7, a severely cognitively impaired resident, who asked the Weekend Receptionist to sit on the porch. Resident #7 exited from the building without nursing staff's knowledge when the Weekend Receptionist unlocked the front door and let the resident out of the facility unsupervised at approximately 12:00 PM on 9/21/2024. The resident was outside unsupervised, until Nurse #5 who was inside the building observed Resident #7 self-propelling on the road in the facility's parking lot near the curb on the right side of the building around 1:15 to 1:20 PM. The distance was approximately 332 feet from the porch of the facility. Nurse #5 instructed Nurse Aide (NA) #3 to bring Resident #7 back into the facility. The resident had taken her sweater off and stated she was warm. According to the Weather Channel website, the temperature on 9/21/2024 was approximately 82 degrees 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-07-23 · 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, and staff, Nurse Practitioner and Physician interviews the facility failed to follow a physician order to hold a tube feeding (nutrition administered through a tube directly into the stomach) following an episode of vomiting for 1 of 1 resident (Resident #98) reviewed for tube feeding. The tube feeding that was ordered to be held was administered to Resident #98 on 1/24/24 through 1/25/24. The Nurse Practitioner observed the resident lying flat in bed, with the tube feeding running, vomit on his body, and respiratory distress symptoms that included elevated respirations, shortness of breath and decreased oxygen level. Resident #98 was hospitalized from [DATE] through 2/14/24 with a diagnosis of septic shock (widespread infection) secondary to aspiration pneumonitis (lung infection due to material from the stomach entering the lungs) and acute hypoxic respiratory failure (inadequate oxygen in the blood). Findings included: Resident #98 was admitted on [DATE] with diagnosis…

  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
• Actual harm · G2025-12-03 · 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 interviews, the facility failed to protect a cognitively impaired resident (Resident #1) with agitated behaviors from being physically restrained by an employee during care when Nurse #1 was witnessed by two other employees (Nurse Aide #1 and Nurse Aide #2) to hold Resident #1's arms down to restrict her hand and arm movements. Resident #1 screamed while being restrained by Nurse #1 and sustained bruising and pain in her bilateral hands and wrists that was relieved with as needed medications for pain following this incident. Resident #1 also had scratches to the right forearm and wrist. This occurred for 1 of 1 resident reviewed for physical restraints. Findings included:Resident #1 was admitted on [DATE] with diagnosis which included severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder and depression, and chronic pain with peripheral neuropathy. A review of Resident #1's physician orders revealed orders dated 10/9/25…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-26 · 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 and staff, Nurse Practitioner and Physician interviews, the facility failed to comprehensively assess a resident and failed to identify or recognize the significance of external rotation and shortening of the leg, severe pain, and inability to bear weight after a fall. The resident had external rotation (an outward rotation of the thigh and knee away from the body), was unable to bear weight and experienced pain from 3/4/25 (the day after a fall) through 3/10/25 at which time he was sent to the emergency room and identified with a comminuted right intertrochanteric femur fracture (most common type of hip fracture which the long bone of the thigh breaks into multiple pieces caused by a fall and is characterized by severe pain in the hip, inability to bear weight on the affected leg, and shortening and external rotation of the leg). The resident underwent intermedullary nailing of the right femur (a procedure in which a metal rod is inserted into the long thigh bone to stabilize 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
• Actual harm · G2025-03-26 · 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 and staff, resident, family, Nurse Practitioner and Physician interviews, the facility failed to provide thorough and ongoing pain assessments that included identifying the source of the pain and to evaluate a resident's pain regimen when the prescribed medication was not effectively managing the resident's pain. The resident was discharged from the hospital on 3/3/25 after being admitted for pain control following a total knee replacement. The initial pain assessment on admission to the facility indicated a pain rating of 5 (on a 0 to 10 scale with 10 being the worst pain imaginable). The resident experienced a fall on 3/3/25 in the evening. The following day (3/4/25), Resident #2 experienced increased pain with a pain level ranging from 6 to 10 through 3/10/25. On 3/10/25 the resident was evaluated at the hospital and was identified with a comminuted right intertrochanteric femur fracture (most common type of hip fracture which the long bone of the thigh breaks into multiple pieces…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect a resident's right to be free from neglect when Resident #1, a resident with severely impaired cognition and known behavioral symptoms, requested as needed pain medication from Nurse #1 and the nurse disregarded the resident's pain and withheld the medication in response to the resident spitting at her when she (the nurse) entered the resident's room. This occurred for 1 of 3 residents reviewed for abuse and neglect.Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder and depression, chronic pain with peripheral neuropathy. Review of Resident #1's physician orders revealed orders dated 10/9/25 for acetaminophen 325 milligrams (mg) administer 2 tablets every 6 hours as needed and tramadol 50 mg administer one tablet every 6 hours as needed for pain. Review of Resident #1'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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to follow its abuse policies and procedures in the area of immediately reporting an allegation of staff to resident abuse to the Administrator and in the area of protection. This occurred for 1 of 1 resident who was investigated for a staff to resident allegation of abuse (Resident #1). Findings included:Review of the facility resident abuse policy titled North Carolina Abuse Policy last reviewed on 7/2/2025 revealed in part; staff must report all allegations, suspicions and incidents of abuse and neglect to the Administrator/Abuse Coordinator immediately, but no later than 2 hours. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies. The investigation must be completed within five (5) working days of the alleged occurrence. The policy indicated that if a staff member was accused or suspected of abuse, the staff member will immediately be removed from the facility 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-21 · 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 review, staff and resident interviews, the facility failed to 1.) develop a person-centered comprehensive care plan as indicated by the Minimum Data Set (MDS) care area assessment to include a plan of care for a resident (Resident #9) admitted with a feeding tube. 2.) implement the use of bilateral fall mats as care planned to prevent injury in the event of a fall from bed (Resident #5) for 2 of 21 residents reviewed for care plan development and implementation. Findings Included: 1.) Resident #9 was admitted to the facility on [DATE] with diagnoses including gastrostomy (feeding) tube. The Minimum Data Set (MDS) admission assessment and care areas assessment dated [DATE] revealed Resident #9 was cognitively impaired and received tube feedings. The care area assessment indicated to initiate a care plan for Resident #9’s feeding tube. Review of Resident #9’s medical record from 9/18/24 through 8/21/25 revealed no care plan was developed to care for Resident #9’s feeding tube. During…

  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 before2025-08-21 · 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 maintain an environment that was free from accident hazards when a mechanical lift that was not in use was left in the hallway (600 hall) by a staff member (Nurse Aide #3) which resulted in a cognitively impaired resident with poor safety awareness and a history of falls with injury to trip over the lift while ambulating in the hallway causing a fall with minor injury of blood on her left nostril. This occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #11). Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's with dementia and agitation, and a history of falls. A care plan revised 3/14/25 revealed Resident #11 was at risk for falls due to a history of falls with injury, other risk factors included weakness, use of psychotropic medications, impaired memory, confusion and incontinence. The goal of care was to minimize the risk of falls and minimize…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-21 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, and staff interviews, the facility failed to discard four expired insulin pens according to the manufacturer's guidelines and record an opened date on an insulin pen on 1 of 4 medication carts (700 hall medication cart) that were reviewed for medication storage. Findings Included. Review of the manufacturer's guidelines for Insulin Lispro (Humalog) pens and Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. An observation of the 700-hall medication cart on 8/20/25 at 11:00 AM revealed the following:Insulin Lispro (Humalog) pen with an opened date of 6/12/25 and expiration date of 7/10/25. Insulin Lispro (Humalog) pen with an opened date of 7/7/25 and expiration date of 8/5/25. Insulin Lispro (Humalog) pen with an opened date of 6/18/25 and expiration date of 7/16/25. Insulin Glargine (Lantus) pen with an opened date of 7/1/25 and expiration date of 7/29/25. Insulin Glargine (Lantus) pen with no opened date and 60 of 300 units had been administered. During an interview on 08/18/25 at 11:01 AM Medication Aide #1 stated 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 · Dcited before2025-08-21 · 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 review, and staff interviews, the facility failed to follow the infection control policy and procedures when 1.) Medication Aide #1 entered a resident's room (Resident #73) who was on Contact Precautions due to a wound infection without donning personal protective equipment (PPE) to include gloves and a gown. 2.) Nurse Aide #1 did not don PPE for Enhanced Barrier Precautions (EPB) to include a gown when providing high-contact resident care activities for Resident #26 who had a surgical wound dressing and a lower leg dressing. This occurred for 2 of 4 staff members reviewed for infection control practices. Findings Included. 1.The facility’s Infection Control Policy revised 5/19/25 revealed Contact Precautions were intended to prevent the transmission of infectious agents which were spread by direct or indirect contact with the resident or resident’s environment. Contact Precautions were indicated in the presence of excessive wound drainage, urine or fecal incontinence or other discharges that could not be contained and suggest an increased potential for…

  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 · E2025-04-24 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff and resident interviews, the facility failed act upon concerns that were reported by the resident council and communicate the efforts to address concerns that were reported during Resident Council Meetings for 6 of 6 months (November 2024, December 2024, January 2025, February 2025, March 2025 and April 2025) reviewed. Findings included: a. The Resident Council meeting minutes dated November 27, 2024, recorded by the Activity Director indicated a concern expressed at the previous month's meeting regarding the meal tickets not matching what was served. The minutes indicated a concern form was filed. The November meeting minutes did not indicate that a response was provided to the council regarding the concern form and any follow-up that the facility completed. The meeting minutes were signed by the Administrator on 11/27/24. b. The Resident Council meeting minutes dated December 13, 2024, recorded by the Activity Director indicated a concern was expressed at the previous month's meeting regarding the taste of the food. The minutes indicated 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-24 · tag F0880 — failed to prevent and control infections — pattern
  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 review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. Nurse #2 and Nurse #3 provided tracheostomy (an opening surgically created in the neck to insert a tube into the trachea (windpipe) allowing for air to enter the lungs directly) care which included tracheal suctioning (a procedure to remove excess secretions from the airway). Nurse #2 also administered a tube feeding through a gastrostomy tube (a feeding tube placed directly into the stomach). The nurses donned gloves and a mask but no gown during the procedures. This occurred for 2 of 2 staff members (Nurse #2, and Nurse #3) who were observed for infection control practices. Findings included: The facility's Infection Control Policy revised 03/15/25 revealed Enhanced Barrier Precautions (EBP) were intended to prevent transmission of multi-drug-resistant organisms (MDRO's) via contaminated hands and clothing to high-risk residents. Enhanced Barrier Precautions…

  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 · D2025-04-24 · tag F0622 — isolated
  Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
  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 communicate all required information to the hospital for 1 of 1 resident (Resident #1) reviewed for hospital transfers. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of left middle cerebral artery (stroke), dysphagia (difficulty swallowing), and aphasia (absence of speech). The physician's orders for Resident #1 dated 1/14/25 included a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had no speech. A nurse's progress note written by the Director of Nursing on 1/25/25 at 2:00 PM indicated that she received a call from the floor nurse that Resident #1's jejunostomy tube (j-tube) fell out. Nurse #1 was advised to call the Provider on…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-24 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and the Medical Director's interviews the facility failed to hold a fast-acting insulin (insulin that begins working within 15 minutes after administration) as ordered by the physician for a blood sugar level less than 150. Resident #4 was administered 2 units of sliding scale insulin with a blood sugar of 103. This occurred for 1 of 1 resident (Resident #4) reviewed for unnecessary medications. Findings included. Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes. A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter. Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #4 was nonverbal and unable to assess cognition. He received insulin. Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4…

  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

“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

$141,604 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $37,196 — penalty dated 2025-12-03
• $87,607 — penalty dated 2025-03-26
• $8,400 — penalty dated 2024-11-01
• $8,401 — penalty dated 2024-11-01
• Medicare payment denial — starting 2025-04-23 for 21 days

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 SABER HEALTHCARE GROUP — 126 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 25 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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