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Azalea Health & Rehab Center

3800 Independence Boulevard, Wilmington, NC 28412 · For profit - Corporation · 80 certified beds · (910) 392-3110 Medicare & Medicaid certified

Call the home — (910) 392-3110 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$24,470 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 2 serious findings 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 (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,470 in federal fines (most recent 2024-07-19)
  • its independent health-inspection rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
1124 Gallery Park Ln · (910) 341-1600 · Call to confirm hours
Pharmacy
3860 Carolina Beach Rd · (910) 444-0241 · Call to confirm hours
Grocery
Food Lion0.2 mi
3905 Independence Blvd · (910) 791-0339 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
3736 Carolina Beach Rd · (910) 392-4181

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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 improved from 1 to 2 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 rating2★
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 weight2.1%7.2%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.7%0.9%better
Long-stay residents with a urinary tract infection0.5%2.3%2.0%better
Long-stay residents with depressive symptoms11.8%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 injury2.4%3.5%3.3%better
Long-stay residents whose ability to walk worsened21.8%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.8%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine96.5%94.1%95.3%typical
Long-stay residents with pressure ulcers3.2%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control24.0%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine32.0%78.1%79.4%worse
Short-stay residents rehospitalized after admission21.1%22.9%22.6%typical
Short-stay residents with an outpatient ER visit18.1%12.9%12.0%worse

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

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

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

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

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

66.5% 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 245 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.5%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
28.6%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 28.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 126 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF66.5%CMS range 60.2–74.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.5–12.410.7%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 discharge28.6%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 discharge42.9%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 discharge27.8%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 identified82.3%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 setting87.0%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 discharge97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened1.3%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 hospitalization6.8%CMS range 4.5–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

0.66
RN hours/ resident / day
0.78
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.51
RN hoursweekends
51.3%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 78.2 residents a day — about 98% occupied, or roughly 2 beds 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.86 hrs/resident/day on weekends vs 3.49 on weekdays — 18% thinner on weekends. RN hours go from 0.73 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-05-30)
17
at the previous standard inspection (2024-04-02)

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.

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · J2024-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident, staff, and Nurse Practitioner interviews, the facility failed to prevent Resident #1 from being left unsupervised in the facility ' s transportation van when Transporter #1 left the resident in the van with the doors and windows closed and the engine turned off midday in the summer heat ([DATE]) for approximately 10 to 30 minutes. The temperature outside was between 92 and 94 degrees Fahrenheit (F). The facility staff did not identify Resident #1 was not in the facility until his family member arrived at the facility and was unable to locate him. Resident #1 indicated he was yelling for help, he was panicked, became short of breath, was scared, and thought he was going die. Resident #1 did not sustain any physical injures, but there was a high likelihood of suffering serious harm that included heat stroke (a medical emergency that can result in permanent disability or death). This deficient practice affected 1 of 4 residents reviewed for transport in the facility…

    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 · G2024-05-31 · 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 staff, Nurse Practitioner, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #2 spoke to Resident #1 in a manner that made her cry, feel nervous, anxious, and as if she was going to have a panic attack. Resident #1 was observed by staff crying inconsolably (unable to be comforted) following an interaction with NA #2. This deficient practice affected 1 of 3 residents reviewed for dignity and respect. Findings included: Resident #1 was admitted on [DATE] with anxiety, worsening generalized weakness, peripheral numbness, and recurrent falls. Review of Resident #1's 3/19/24 quarterly Minimum Data Set assessment indicated resident was cognitively intact with no hallucinations or delusions, no behaviors and was coded as frequently incontinent of bowel and bladder. Resident #1 required extensive assistance with bed mobility, transfers and toileting. Resident #1 received an antianxiety medication. Review of Resident #1's care plan which 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 · Past Non-Compliance
  • Potential for harm · E2025-05-30 · tag F0760 — failed to prevent significant medication errors — pattern
    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, and Physician and staff interviews, the facility failed to thoroughly review the hospital discharge summary and clarify physician orders for a newly admitted resident (Resident #231) resulting in the failure to transcribe and administer an intravenous (a catheter inserted into a vein for medication administration) antibiotic medication listed on the discharge summary. Penicillin G (antibiotic) was not administered from 03/29/25 through 03/30/25 resulting in 6 missed doses of the antibiotic treatment. This deficient practice occurred for 1 of 1 resident reviewed for significant medication errors. Findings included: Resident #231 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis (an infection in the bone), and discitis (an infection in the intervertebral disc space). Review of the Discharge summary dated [DATE] from the hospital on page 1 revealed Resident #231's discharge diagnoses was discitis / osteomyelitis of the thoracic region and to continue intravenous (IV)…

    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 · D2025-05-30 · 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 observations, record review and staff interviews the facility failed to hold a blood pressure medication according to the physician ordered parameters and administered the blood pressure medication unnecessarily to 1 of 5 residents reviewed for unnecessary medication administration (Resident # 55). Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including high blood pressure. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #55 was cognitively intact. A physician order written on 12/28/24 revealed an order for Metoprolol Succinate Extended Release (a medication used to treat high blood pressure), 25 milligrams (mg) one tablet once a day. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm/Hg). Review of the April 2025 Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressure. On 04/12/25,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 review and interviews with staff and Nurse Practitioner, the facility failed to have a complete and accurate medication administration record related to a blood pressure medication. This was for 1 of 5 residents (Resident #55) reviewed for unnecessary medications. Findings included: Resident #55 was admitted to the facility on [DATE]. Diagnoses included high blood pressure. A physician order written on 12/28/24 revealed an order for Metoprolol Succinate Extended Release (a medication used to treat high blood pressure), 25 milligrams (mg) one tablet once a day. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm/Hg). Review of the April 2025 Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressure. On 04/19/25, Resident #55's blood pressure was recorded as 105/60 mm/Hg and the medication was signed off as given by Nurse #3. Review of the May Medication…

    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 before2024-07-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 review and staff interviews the facility failed to maintain complete and accurate medical records by not ensuring Nurse #1 documented the vital signs in the medical record for 1 of 5 residents (Resident #1) reviewed for medical record accuracy. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included debility and dementia. A progress note written by the Nurse Practitioner as a late entry on 07/08/24 at 1:10 PM for 07/05/24 at 3:50 PM documented she had been notified by staff and nursing that [Resident #1] was left on the facility van upon return from an appointment for a period of time up to 10 minutes. Nursing requested that she evaluate [Resident #1]. An interview was conducted with the Nurse Practitioner on 07/15/24 at 3:55 PM. She stated she had assessed Resident #1 when he was brought back into the facility after he had been left in the van unsupervised. She stated her assessment did not include vital signs but recalled she had instructed Nurse…

    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 · F2024-04-02 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact 74 of 74 residents who received oral nutrition. The findings included: An interview was conducted with the Dietary Manager (DM) on 03/25/24 at 11:45 AM. He stated that two of his kitchen staff called out that morning, leaving one kitchen aide and himself to prepare both breakfast and lunch, as well as clean-up. He revealed he was struggling to obtain and maintain staff, due to other facilities paying more. The DM disclosed having an understaffed kitchen staff meant meals were not served on time according to the schedule, but dietary staff were doing the best they could. An interview was conducted on 03/25/24 at 12:43 PM with the Dietary Manager (DM). He stated due to kitchen budget cuts he was having to schedule the kitchen staff short, months in advance, which he said, it is what it is. He stated that the dietary department needed staff, which was why there was only 1 dietary aide and himself…

    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 · Fcited before2024-04-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, staff interviews and review of manufacturer's instructions, the facility failed to: 1) store the hand-held plastic scoops outside of 2 of 3 dry food bins holding flour and sugar 2) wash dishes in hot water and sanitize dishes in the facility's three-compartment sink per Food and Drug Administration Food Code recommendations in a quaternary sanitizing solution of at least 50-parts per million (ppm) and maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and maintain a clean and sanitized kitchen area for food preparation. These practices had the potential to affect 74 of 74 residents' food quality and kitchen sanitation safety. Findings included: 1. During the initial tour of the facility on 3/25/24 at 11:00 AM, an observation was made of the flour and two sugar bins. Hand-held plastic scoops were stored directly in the food items. An interview was conducted with the Dietary Manager (DM) on 03/25/24 at 11:10 AM. He stated it was his expectation that hand-held plastic scoops be stored in a closed container outside of…

    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 · F2024-04-02 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and to close and/or replace all missing doors to the dumpsters that contained waste for 1 of 2 dumpsters reviewed. These failures had the potential to attract pests and rodents. Findings included: An observation of the dumpster area with the Dietary Manager (DM) on 03/26/24 at 12:20 PM revealed scattered debris, branches, and leaves around the sides and back area of the dumpster enclosure area. Both the right dumpster sliding door and the right half of the gate to the dumpster enclosure area were both missing, leaving trash contents and large amounts of debris to build-up around and behind the dumpsters, open to the elements, available to pests and rodents. An interview was conducted with the Dietary Manager on 03/26/24 at 12:30 PM. He stated it was the responsibility of the Environmental Services Department to keep the dumpster area clean and trash can lids closed. An interview was conducted with the Environmental Services Department -Assistant…

    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 · F2024-04-02 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and staff interviews, the facility failed to provide effective leadership and implement effective systems to ensure the facility was able to obtain 60-gallon, 30-gallon, and 10-gallon plastic can garbage liners, toilet tissue, paper towels, and 30 ml. plastic medication cups to meet residents' needs. This failure result affected 74 of 74 residents reviewed for Administration. Findings included: Review of facility's grievances revealed an anonymous grievance filed 09/05/23 regarding; The facility ran out of supplies often. The workers were having to ration trash bags, straws, and medication cups due to the facility not obtaining the supplies. The complainant did not know what the facility was doing to obtain the supplies but said that staff had a difficult time finding supplies to work with. An interview was conducted on 03/26/24 at 3:00 PM with the Medical Records/Central Supply Manager (CSM). She stated the supply delivery truck comes once a week. CSM looks in each of the three supply rooms to assess the needs of the residents then asks the residents/staff…

    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 · Fcited before2024-04-02 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following a Focused Infection Control survey and complaint investigation completed on 06/23/23, a recertification survey and complaint investigation completed on 12/09/22, a Focused Infection Control survey and complaint investigation completed on 06/03/22, a recertification survey and complaint investigation completed on 09/23/21, and a revisit survey and complaint investigation completed on 04/28/21. This was for 5 deficiencies cited in the areas of Quality of Care (684), Nutrition/Hydration Status Maintenance (692), Labeling and Storing Drugs & Biologicals (761), Sufficient Dietary Support Personnel (802), and Food Procurement, Store, Prepare, and Serve (812). These deficiencies were subsequently recited during the recertification and complaint investigation survey of 04/02/24. The continued failure during six federal surveys of record shows a pattern 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-02 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services (Resident #18 and Resident #66) and failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (form 10123) prior to discharge from Medicare Part A skilled services (Resident #324) for 3 of 3 residents reviewed for beneficiary protection review. The findings included: 1. Resident #18 was admitted to the facility 9/26/23 and admitted to Medicare Part A services. Resident #18's Medicare Part A skilled services ended on 10/22/23 and she remained in the facility. The SNF ABN reviewed revealed Resident #18's name, the date services were to end, and the estimated cost of the services. There were no options checked for the decision made about continuing Medicare Part A services. An interview was conducted with the facility…

    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
Show the remaining 21 citations
  • Potential for harm · Ecited before2024-04-02 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    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, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to obtain physician ordered weights for 7 of 7 residents (Resident #274,#5, #31, #24,#47, #48, #26 ) and provide a nutritional supplement for 1 of 1 resident (Resident #274) reviewed for nutrition. Findings included. 1.a) Resident #274 was admitted to the facility on [DATE] with diagnoses including in part; protein calorie malnutrition, and congestive heart failure. A physicians order dated 03/15/24 for Resident #274 revealed to obtain daily weights for congestive heart failure. A care plan dated 03/16/24 revealed Resident #274 was nutritionally impaired and was at risk for dehydration and weight fluctuations related to recent surgical correction of gastric volvulus, congestive heart failure, feeding tube placement, variable oral intake, diuretic use, obesity, chronic obstructive pulmonary disease, and edema. Interventions included in part; to monitor weights per order. The Minimum Data Set…

    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 · E2024-04-02 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews with the staff, Administrator and Regional Nursing Consultant, the facility failed to prevent the Director of Nursing (DON) from having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents for 7 of 7 days reviewed. Findings included: Review of the facility assignment sheets for 11/8/23 on the 3:00 PM-11:00 PM shift for 200 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/1/24 on the 3:00 PM-11:00 PM shift on the top of the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/12/24 on the 11:00 PM to 7:00 AM shift for the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/23/24 on the 7:00 AM to 7:00 PM shift on the top of the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/30/24 on the 3:00 PM to 11:00 PM shift for the 100 hall the Director of Nursing was assigned. Review of the Medication Administration 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-02 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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, Registered Dietician, and Nurse Practitioner interviews the facility failed to provide physician ordered low concentrated sweets therapeutic diets to 2 of 2 diabetic residents (Resident #34 and Resident #48) reviewed for nutrition. Findings included. Resident #34 was admitted to the facility on [DATE] with diagnosis including diabetes and long-term insulin use. A physicians order for Resident #34 dated 10/16/23 revealed LCS (Low Concentrated Sweets) diet. Regular texture with thin consistency. A care plan dated 10/27/23 revealed Resident #34 was at risk for impaired nutritional status in part due to type 2 diabetes. Interventions included to encourage compliance with dietary guidelines, encourage a healthy lifestyle and provide diet according to the physicians order. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #34 was cognitively intact. She had no rejection of care and received a therapeutic diet. During an interview on 03/26/24 at…

    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 · E2024-04-02 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, staff and Registered Dietician interviews, the facility failed to provide packed meals for a dialysis resident who left the facility at 6:30 AM and did not return until lunchtime three days a week for 1 of 1 resident reviewed, Resident #279. This deficiency had the potential to affect all five residents residing at the facility who received hemodialysis. Findings included: Resident #279 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease and dependence on renal dialysis. Review of a Medicare 5 day Minimum Data Set (MDS) assessment revealed Resident #279 had intact cognition. He received hemodialysis and had a midline intravenous access line. Review of the care Plan dated 3/21/24 for Resident #279 revealed the following focus area: Resident at risk for nutritional decline, dehydration, and weight fluctuations related to, in part, end stage renal disease with hemodialysis. The goal was for Resident #279 to be free of signs and symptoms of dehydration,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Nurse Practitioner interviews the facility failed to administer a topical antibiotic ointment prescribed for treatment to the nasal area following a dermatology procedure and to administer antibiotic ophthalmic drops according to the physicians order for 2 of 2 residents (Resident #48, and Resident #43) reviewed for quality of care. Findings included. 1.Resident #48 was admitted to the facility on [DATE] with diagnosis including malignant melanoma of the skin, and diabetes. A physicians order dated 03/08/24 revealed Triple Antibiotic External Ointment (Neomycin-Bacitracin-Polymyxin). Apply to nose topically two times a day for Post-operative dermatology for 3 Days. During an interview on 03/25/24 at 1:00 PM Resident #48 was observed lying in bed. He was alert and oriented to person, place, and time. He stated he had a recent procedure to remove a skin cancer on his nose and he continued to be followed by a dermatologist. He stated an antibiotic cream was prescribed to apply to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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, and staff interviews the facility failed to implement the treatment protocol for a newly acquired nephrostomy tube (a catheter surgically placed through the back and into the kidney to drain urine that is blocked). The treatment included monitoring the insertion site for signs and symptoms of infection, providing daily dressing changes to the insertion site, monitoring and recording urine output, and monitoring the tube for kinks or obstruction. This resulted in the nephrostomy tube and insertion site not being monitored for 8 days following hospitalization. There was no negative outcome. This occurred for 1 of 1 resident ( Resident #5) reviewed for catheter care. Findings included. Resident #5 was initially admitted to the facility on [DATE]. Resident #5 was readmitted on [DATE] following hospitalization with diagnoses including septic shock secondary to urinary tract infection, bacteremia (bacteria in the blood stream), and moderate to severe right hydronephrosis with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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, observation, and staff, Registered Dietician and Nurse Practitioner interviews, the facility failed to follow a physician order for the method of administration of the enteral feeding (nutrition taken through a tube directly into the stomach) and the calculated amount of water flush. 2) Implement the enteral feeding tube policy upon admission resulting in the residents gastrostomy tube not being flushed every six hours when not in use with 30 milliliters of water for 4 days following admission. This occurred for 2 of 2 residents (Resident #26, and Resident #274) reviewed for management of enteral feeding tubes. Findings included: 1.) Resident #26 was admitted to the facility on [DATE] with diagnoses which included in part: dysphagia (impaired swallowing) and aphasia (impaired communication) following stroke. In addition, Resident #26 had gastrostomy status listed as a diagnosis. Review of Resident #26's 1/6/24 quarterly Minimum Data Set (MDS) assessment indicated resident had severe…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · 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 observation, and staff, Corporate Nursing Consultant and Administrator interviews the facility failed to: store an opened bottle of lorazepam in the locked box of the medication refrigerator and label a bottle of lispro insulin with an opened date for 1 of 1 medication storage rooms observed for medication storage (Hibiscus Pharmacy Room). 1. An observation of the Hibiscus Pharmacy Room (Medication Storage Room on 100 hall) with Nurse #12 in attendance revealed the nurse unlocked the room. In the Pharmacy Room there was a refrigerator which was unlocked. An unlocked box was observed in the refrigerator. The box contained two 30 milliliter bottles of lorazepam concentrate 2 milligrams per milliliter labeled for Resident # 53. One of the bottles was sealed. The other bottle was opened with liquid observed in the bottle. An interview on 3/25/24 at 3:30 PM with Nurse #12 revealed the box should be locked but it was not. Nurse #12 attempted to lock the box and discovered the key was broken in half with one half in the lock and the other half on the key ring. Nurse #12 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 · Fcited before2022-12-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews the facility failed to remove expired items from 1 of 1 dry goods storage area, failed to label and date items in 1 of 1 reach-in coolers, 1 of 1 walk-in refrigerators, 1 of 1 walk-in freezers and 1 of 2 nourishment rooms. This practice had the potential to affect the food served to the residents. The findings included: 1. Initial observation of the kitchen reach in cooler on 12/5/22 at 10:50 AM revealed items which were opened with no use by label: - a container of nectar thick apple juice - a container of nectar thick water - a container of nectar thick iced tea - a container of nectar thick cranberry juice - a container of honey thick water - a container of honey thick iced tea - a container of honey thick cranberry juice 2. Initial observation of the dry storage on 12/5/22 at 10:55 AM revealed: - a plastic bag filled with packets of instant thickened coffee with an expiration date of 9/17/22 3. Initial observation of the walk-in refrigerator on 12/5/22 at 11:05 AM revealed the following items with a date not specified as opened or…

    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 · E2022-12-09 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews the facility failed to provide a resident with privacy when Resident #50 was observed lying in bed with her buttock and lower body exposed with the door to the hallway open, the blinds to the window open, and the privacy curtain not pulled around the bed in a semi-private room. In addition, the facility failed to provide a privacy curtain for a resident who resided in a semi-private room with a roommate (Resident #20). The deficient practice affected 2 of 2 residents reviewed for privacy. The reasonable person concept was applied to example 1 as residents have an expectation of privacy in their home environment. The findings included: 1. Resident #50 was admitted to the facility on [DATE] with medical diagnoses which included in part advanced dementia with behaviors. Resident's 10/19/22 quarterly Minimum Data Set (MDS) assessment revealed that resident had severe cognitive impairment and exhibited no behaviors. Resident was always incontinent of bowel and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews the facility failed to maintain a clean and sanitary living environment by 1) not providing housekeeping services for 100, 200 and 300 halls 2) not replacing soiled privacy curtains in resident rooms (Rooms 101, 104, 106, 107, and 112); and 3) not eliminating a strong odor in room [ROOM NUMBER]. This deficient practice affected 3 of 3 halls observed. Findings included. 1). An observation conducted on 12/07/22 at 9:15 AM revealed no housekeeping staff on the 200 hallway, the floors in some of the resident rooms were littered with trash including napkins, food crumbs, and straws on the floor. Continuous observations conducted on 12/07/22 from 9:15 AM through 11:30 AM revealed no housekeeping staff or cleaning carts were observed on any of the halls in the facility. Continuous observations conducted on 12/07/22 from 12:00 PM through 12:30 PM revealed no housekeeping staff or cleaning carts on the halls. During an interview conducted on 12/07/22 at 1:00 PM Nurse aide #10…

    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 before2022-12-09 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    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 record review, staff, Registered Dietician, and Physician Assistant interviews the facility failed to obtain and record accurate weights and to identify and verify the accuracy of weights for 5 of 21 residents (Resident #26, #41, #52, #33, #58) reviewed for significant weight change. Findings included. 1). Resident #26 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (CHF), diabetes, and chronic kidney disease. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #26 required extensive assistance with activities of daily living. Resident #26 had weight loss and received a therapeutic diet. Resident #26's care plan dated 11/14/22 revealed a risk for nutritional decline, dehydration, and weight fluctuations related to diagnoses of chronic kidney disease, vitamin deficiency, cardiac disease, and the need for a therapeutic diet with variable oral intake, diuretic use, significant weight loss, and history of malnutrition. The goal of care was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff and residents interviews the facility failed to provide foods at a temperature according to residents' preferences and to maintain palatability for 4 of 8 residents reviewed for food palatability (Resident #59, Resident 215, Resident #6, and Resident #3). Findings included: Review of the Resident Council Meeting Minutes revealed the following information: - A meeting conducted on 9/29/22 indicated the food was cold and residents wanted different kinds of snacks. - A meeting conducted on 10/31/2022 indicated the new Dietary Manager met with residents to talk about the trays not getting passed out when meal carts are delivered to the halls. - A meeting dated 11/16/2022 indicated the food was still cold. An observation and interview of Nurse Assistant (NA) #9 passing trays on the 200 long hall occurred on 12/6/2022 at 12:30 PM. NA #9 was the only staff member observed passing trays on long hall from an insulated meal cart and it took her 23 minutes to deliver trays to 19 residents.…

    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 · E2022-12-09 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 honor food preferences for 3 of 5 residents (Resident #34, #59, #215 ) reviewed for food preferences. Findings included. 1). Resident #34 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, and diabetes. A physician order dated 12/07/20 revealed Resident #34 was to receive a low concentrated sweets (LCS) diet, with Regular texture, Thin consistency. A care plan dated 04/1/21 revealed Resident #34 was at risk for nutritional decline, dehydration, and weight fluctuations related to history of stroke, congestive heart failure, diabetes, the need for a therapeutic diet, and edema status. The goal of care included in part to be free of significant weight changes. Interventions included in part; to encourage adequate…

    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 · D2022-12-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to update the comprehensive care plan to include the use of antipsychotic medications for 1 of 21 residents reviewed for care plans (Resident # 24). The findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses to include Moyamoya disease (a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain) and vascular dementia with behavioral disturbance and bipolar disorder. Review of the electronic medical record (EMR) for Resident #24 revealed a physician's order dated 8/23/2022 for Zyprexa (an antipsychotic medication) 5mg tablet, give 1 tablet by mouth at bedtime for dementia with behaviors, bipolar. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and was coded as having delusions, verbal and other behaviors 4-6 days per week. Resident #24 was assessed to be receiving antipsychotic medication 7 days a week.…

    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 before2022-12-09 · 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 Physician Assistant (PA) interviews, the facility failed to complete a neurological assessment to include a) current vital signs with each neurological assessment recorded and b) assessment of hand grasps and observation of changes in behavior for 1 of 1 resident reviewed for falls (Resident #50) . Findings: Resident #50 was admitted to the facility on [DATE] with medical diagnoses which included in part advanced dementia with behaviors. Resident's 10/19/22 quarterly Minimum Data Set (MDS) assessment revealed that resident had severe cognitive impairment, exhibited no behaviors and had history of falls. A review of an incident report documented by Nurse #1 on 11/2/22 at 6:00 PM revealed that the Nursing Assistant (NA) observed Resident #50 lying on the floor beside her bed with bleeding from the right side of the head above the temple region. As a result of the incident Resident #50 sustained skin tears to the left lower arm, the right knee, and the top of her scalp. Review of…

    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 before2022-12-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews the facility failed to: 1) remove expired insulins from 1 of 2 medication storage rooms (200/300 hall) and 2) keep unattended medications stored in a locked compartment for 1 of 1 resident observed with medications at the bedside (Resident #49). Findings included. 1). An observation was conducted with Unit Manger #1 on 12/08/22 at 1:00 PM of the 200/300 hall medication storage room. The observation revealed two opened Novolin 70/30 (70 % intermediate acting/30 % short acting) insulin flex pens found in the medication storage refrigerator with handwritten opened dates of 10/14/22 on insulin pen #1 and 10/03/22 on insulin pen #2. A review of the manufacturer's storage instructions for Novolin 70/30 flex pen insulin revealed to discard 28 days after opening. An interview was conducted on 12/08/22 at 1:00 PM with Unit Manager #1. She acknowledged the insulin pens had expired and stated she thought she had discarded all of the expired medications in the medication room…

    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 before2022-12-09 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation surveys of 9/23/21. This was for 1 deficiency cited in the area of label and store drugs and biologicals (F761) cited on the current recertification and complaint investigation survey of 12/9/22. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F761 Based on observations, and staff interviews the facility failed to: 1) remove expired insulins from 1 of 2 medication storage rooms (200/300 hall) and 2) keep unattended medications stored in a locked compartment for 1 of 1 resident observed with medications at the bedside (Resident #49). During the recertification and complaint survey completed on 9/23/21 the facility failed…

    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
  • No harm found · C2024-04-02 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews the facility failed to post accurate nurse staffing information for 15 of 84 days for daily nursing posted staffing data reviewed. This included nursing and unlicensed nursing staff. Findings included: Review of the daily posted staffing from January 2024 through March 24, 2024, revealed the daily posted staffing sheets were blank. Staffing sheets for 2/23/24, 2/24/24, 2/25/24, 2/26/24,2/27/24, 2/28/24, 2/29/24, 3/7/24, 3/8/24,3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, and 3/16/24 were completed with the date. There was no indication of the number of licensed and unlicensed staff members working for each shift, the hours worked, and resident census in the facility for any of the dates. An interview was conducted with Unit Manager #1 who stated he was responsible for completing the daily posted staffing. He reported on the dates the staffing information was not completed he was not in the facility. Unit Manager #1 stated he was unsure who was responsible for completing the daily posted staffing when he was not in the facility. An interview…

    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 plan of correction
  • No harm found · B2024-04-02 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete discharge Minimum Data Set (MDS) assessments for 3 of 3 residents reviewed for discharge. (Resident #63, Resident #13, and Resident #52). The findings included: 1. Resident #63 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of Resident #63's MDS records did not include a discharge assessment for 10/2/23. An interview was conducted with the MDS Nurse on 3/26/24 at 1:50 PM who stated she was unsure the reason a discharge assessment was not completed. During an interview with the MDS Coordinator on 3/26/24 at 1:57 PM she stated she was unsure the reason the discharge assessment was overlooked. An interview was conducted with the Administrator on 3/28/24 at 10:56 AM who stated the discharge assessment should have been completed within the required timeframes. 2. Resident #13 was admitted to the facility on [DATE] and discharged to the community on 10/23/23. Review of Resident #13's MDS records did not…

    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 · B2024-04-02 · tag F0641 — pattern
    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 staff interviews and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 24 residents reviewed for MDS accuracy (Resident #38 and Resident #323). Findings included: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included dementia and depression. Resident #38's significant change in status MDS assessment dated [DATE] revealed she was not assessed for cognition. The cognition section of the assessment had been dashed, indicating the assessment had not been completed. During an interview with the MDS nurse on 3/27/24 at 1:55 PM she stated the cognition section of the MDS assessment should have been completed by the facility social worker. An interview was conducted with the social worker on 3/27/24 at 3:09 PM who stated an assessment for cognition should have been completed for Resident #38. She reported she had been out of the facility, and the assessments were missed. During an interview with the Administrator on 3/28/24 at 10:56…

    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

$24,470 in federal fines across 2 penalties.

  • $16,452 — penalty dated 2024-07-19
  • $8,018 — penalty dated 2024-04-02

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 →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA 2 of 5Crawford Manor Healthcare CenterCleveland, OH

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
WRIGHTSVILLE OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/15/2012
SABER HEALTHCARE HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/01/2020
WWBV HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 09/30/2019
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/05/2026
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICERsince 03/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
JOINER, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/29/2020
WIW DYNASTY LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 01/01/2023
SABER GOVERNANCE LLCOrganizationADP OF THE SNFsince 09/01/2019
SABER HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 02/13/2013

CMS files one row per role, so the 15 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$9.5M
Net patient revenuemost recent cost report
+9.0%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 11%Other / private 35%

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$335per resident / day
operating cost
$10,189per month
≈ monthly operating cost
$368per 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 345557. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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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