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Northchase Nursing and Rehabilitation Center

3015 Enterprise Drive, Wilmington, NC 28405 · For profit - Limited Liability company · 140 certified beds · (910) 791-3451 Medicare & Medicaid certified

Call the home — (910) 791-3451 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jun 20251 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$7,901 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2025
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,901 in federal fines (most recent 2024-01-03)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4320 Henson Dr · (910) 350-1787 · Call to confirm hours
Pharmacy
2033 Corporate Dr # B2 · (910) 859-8211 · Call to confirm hours
Grocery
Food Lion0.2 mi
3211 Enterprise Dr · (910) 790-9938 · Call to confirm hours
Park
Upi Parks0.6 mi
2021 Corporate Dr · (910) 799-8080 · Typically dawn to dusk
Place of worship
4569 Technology Dr

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 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased10.6%15.6%15.4%better
Long-stay residents who lose too much weight10.0%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.7%0.9%better
Long-stay residents with a urinary tract infection1.7%2.3%2.0%better
Long-stay residents with depressive symptoms2.1%5.9%6.5%better
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 injury2.7%3.5%3.3%better
Long-stay residents whose ability to walk worsened11.3%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.1%21.3%18.9%typical
Long-stay residents given the seasonal flu vaccine93.6%94.1%95.3%typical
Long-stay residents with pressure ulcers5.3%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control7.4%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table26.8%14.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.1%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine87.8%78.1%79.4%better
Short-stay residents rehospitalized after admission23.1%22.9%22.6%typical
Short-stay residents with an outpatient ER visit14.1%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.931.781.67worse
Long-stay outpatient ER visits per 1,000 resident days1.951.801.80typical

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.

57.2% 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 196 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.2%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
75.9%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 75.9% 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 112 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNF57.2%CMS range 50.7–62.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.6–14.410.7%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 discharge75.9%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 discharge73.2%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 discharge67.9%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 identified99.4%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 setting94.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%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 worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 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

0.76
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.49
Total nurse hours/ resident / day
0.60
RN hoursweekends
39.8%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 128.4 residents a day — about 92% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 3.61 on weekdays — 12% thinner on weekends. RN hours go from 0.82 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-06-23)
14
at the previous standard inspection (2024-05-17)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-01-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and resident interviews, the facility failed to provide a safe transfer when a resident (Resident #1) fell from a mechanical lift while being transferred by Nurse Aide #1 and Nurse Aide #2 and sustained a 10-centimeter laceration to the right ankle requiring 9 sutures, a contusion to the left wrist and left shoulder, and pain as a result of the fall for 1 of 3 residents observed for falls. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 had a diagnoses of congestive heart failure and hypoxia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and demonstrated no behaviors. Resident #1 required total dependence with two person physical assistance with transfers and did not receive anticoagulant (blood thinner) medication. Resident #1's weight was recorded as 199 pounds. A review of Resident #1's care plan dated 09/21/23 revealed Resident #1 had a plan of care for activities 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 · Past Non-Compliance
  • Potential for harm · Ecited before2025-06-23 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to discard expired medications on 2 of 4 medication (med) carts observed (200 hall and 100 hall med carts) and date medications when they were opened to allow for the determination of their shortened expiration date for medications stored on 3 of 4 med carts (100 hall, 200 hall, and 400 hall) med carts reviewed for medication storage. Findings included: 1 a. An observation was conducted on 6/11/25 at 9:46 AM of the 200 hall med cart in the presence of Nurse #8. The observation revealed the following medications were stored on the cart. - An opened box of ipratropium bromide 0.5 milligrams (mg) and albuterol sulfate 3 mg (inhaled medications used to treat chronic obstructive pulmonary disease (COPD) nebulizer treatments containing 3 vials dispensed for Resident #23 with an opened date 2/6/25. The manufacturer's instructions included discarding medication 2 weeks after it was opened. - An open bottle of floor stock zinc sulfate (a supplement) 50 mg tablets with a manufacturer's expiration date of 1/25. - An opened box 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and staff interviews, the facility failed to remove expired food items stored for use in 1 of 1 walk-in refrigerator and 1 of 2 nourishment rooms and failed to label and date leftover food in 1 of 2 nourishment rooms observed (Rehabilitation Hall nourishment room). This deficient practice had the potential to affect the food served to the residents. The findings included: 1. An observation in the kitchen on 6/9/25 at 11:00 AM revealed the following items in the walk-in refrigerator: - an opened bag of Swiss cheese with no opened date. - a metal container with pureed mixed fruit with no label and no opened date. - a metal container with stewed tomatoes with an opened date of 5/28/25 and a use by date of 5/29/25. - a metal container with pimentos with a label with an open date of 6/4/25. - an opened plastic bag of deli turkey with no opened date. - an opened plastic bag of deli ham with no opened date. - an opened half full box of muffins with no opened date. - an opened carton of honey thick tea with no opened date. - an opened carton of honey…

    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 · D2025-06-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and family interviews, the facility failed to honor a resident's choice to receive a shower for 1 of 1 resident reviewed for choices (Resident #172). Findings included: Resident #172 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, anxiety, depression, and insomnia. The Minimum Data Set admission assessment dated [DATE] revealed Resident #172 was moderately cognitively impaired and demonstrated no behaviors or refusals of care. She required substantial / maximal assistance with one staff physical assistance with bed mobility and transfers, and substantial / maximal assistance with one staff physical assistance with personal hygiene. She had no functional impairments with range of motion, used a walker and a wheelchair and required one staff physical assistance with bathing/showering. Resident #172 was frequently incontinent of bowel and bladder. A review of Resident #172's care plan dated 06/04/25 revealed a plan of care for Activities of Daily…

    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 · D2025-06-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Nurse Practitioner (NP), Medical Director interviews, and Consultant Pharmacist interviews, the facility failed to protect a resident's right to be free from neglect, when a nurse (Nurse #1) disregarded a severe drug-to drug interaction alert sent from the pharmacy to the resident's electronic medical record (EMR), regarding a newly prescribed antibiotic and a heart medication the resident (Resident #30) was currently prescribed. Nurse #1 neglected to read a severe drug-to-drug interaction alert received from the pharmacy regarding a newly prescribed antibiotic and did not notify the physician of the alert. The resident was administered the antibiotic by the nurse and there was no significant harm to the resident. This deficient practice occurred for 1 of 1 resident reviewed for neglect. The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), obstructive pulmonary disease (COPD), lymphedema, kidney…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-23 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Consultant Pharmacist, and Pharmacy Manager, the facility failed to prevent misappropriation of a resident's controlled medication (30 hydrocodone/acetaminophen 5-325 milligrams (mg) pills and 30 oxycodone hydrochloride 10 mg pills) prescribed by the physician for pain for 1 of 1 resident reviewed for misappropriation of property (Resident #267). Findings included: Resident #267 was admitted to the facility on [DATE] with diagnoses to include dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and mood disturbance, history of falls, atrial fibrillation. She was receiving hospice care at the time of the misappropriation. The physician's orders for Resident #267 included: - Hydrocodone/Acetaminophen 5-325 mg oral tablet every 8 hours for pain ordered on [DATE]. - Oxycodone hydrochloride oral tablet 10 mg. Give 10 mg by mouth every 6 hours as needed (PRN) for pain ordered on [DATE]. The pharmacy packing slips for Resident #267's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-23 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Preadmission Screening and Resident Review (PASRR) for 2 of 26 residents reviewed for MDS assessments (Resident #14 and #16). Findings included: 1. Resident #14 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, and bipolar disorder. Review of Resident #14's electronic health record revealed Resident's PASARR was completed on 02/12/21 and indicated Resident #14 was screened as Level II (a person centered evaluation that is completed for residents identified as having a mental illness diagnoses. It helps to determine appropriate placement and the need of specialized services). A review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was not coded as a Level II PASRR. A review of Resident #14's care plan dated 05/29/25 revealed a plan of care for a Level II Preadmission Screening and Resident Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Nurse Practitioner (NP), and Consultant Pharmacist interviews, the facility failed to prevent the administration of unnecessary medication when a resident (Resident #30) a) received a dose of ceftriaxone (an antibiotic used to treat bacterial infections) as a one-time dose by intramuscular injection. Resident #30 had a documented allergy to ceftriaxone documented on the allergy list in the electronic medical record (EMR) and b) administered azithromycin ( an antibiotic used to treat bacterial infections) that had a drug to drug interaction alert not to be administered with amiodarone without a baseline electrocardiogram (EKG is a test that measures the electrical impulses in the heart for abnormal rhythms because of risk of long QT syndrome (prolonged QT interval on the EKG (which increases the risk of a dangerous heart rhythm). This deficient practice occurred for 1 of 6 residents reviewed for medication errors. The findings included: a).The hospital discharge summary sent…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-06-23 · tag F0806 — failed to honor food preferences — isolated
    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 a resident's food preferences. This deficient practice was for 1 of 3 residents reviewed for food preferences (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE]. A physician order dated 02/12/21 revealed Resident #14 had an order to receive a regular diet, with regular texture, and thin consistency. A diet communication slip dated 05/15/25 revealed resident requests grits in the morning and no orange juice. This slip was signed by Nurse #11. Review of a nursing note written on 05/17/25 by Nurse #11, revealed Resident approached nurse and stated that she needed nurse to go to the kitchen and reiterate that she wants grits for breakfast every morning and no orange juice. This nurse let resident know that she wrote a dietary slip the other day, as resident requested, and handed it to the kitchen staff herself. Nurse will again let kitchen know the residents' request. The Minimum Data…

    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 · Ecited before2024-05-17 · 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 record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the area of nutrition for 4 of 11 residents whose MDS assessments were reviewed for nutrition (Residents #107, #12, #19, # 69). Findings included: 1. Resident #107 was admitted on [DATE] with diagnosis which included adult failure to thrive and diabetes. Review of Resident #107's electronic health record revealed the following weights were recorded: 10/2/2023- 207.3 pounds (Lbs.) 11/10/2023- 205.1 Lbs. 12/5/2023- 194.2 Lbs. 1/19/2024- 181.8 Lbs. 1/30/2024- 177.1 Lbs. 2/9/2024- 172.5 Lbs. 3/26/2024- 147.6 Lbs. 4/2/2024 1:14 PM- 152.3 Lbs. 4/10/2024 2:35 PM- 158.1 Lbs. Review of Resident #107's weights recorded revealed resident had a 47.1-pound weight loss in180 days (22.92 percent). Review of Resident #107's 4/12/24 quarterly Minimum Data Set (MDS) indicated resident had a mild cognitive impairment. Resident #107's weight was 158 pounds and resident was coded as had no weight loss 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and resident interviews, the facility failed to update the comprehensive care plan to reflect changes in care interventions in the areas of mobility and nutrition. This was for 3 of 11 residents whose care plans were reviewed (Resident #107, Resident #12, and Resident #19). Findings included: 1.Resident #107 was admitted on [DATE] with diagnosis which included: stroke with hemiparesis, adult failure to thrive and diabetes. a. Review of Resident #107's nutrition care plan last revised on 1/31/2024 revealed a problem of state of nourishment more than body requirement characterized by weight gain, obesity, excessive appetite related to: increased caloric and fat intake, and sedentary lifestyle. The goal indicated the resident would adhere to a prescribed diet, would eat food only from their own plate, and would eliminate snacking between meals. The care plan did not include a goal of a desired weight to be achieved. Interventions included avoiding using food as a reward, using…

    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
Show the remaining 16 citations
  • Potential for harm · E2024-05-17 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 observations, record review, staff, and the Nurse Practitioner interviews the facility failed to 1.) obtain blood pressure readings or heart rate prior to administering the antihypertensive medication Metoprolol which had parameters to hold the medication if the systolic blood pressure was less than 110 mmHg (millimeters of mercury) or heart rate less than 60 beats per minute. (Resident #17) and 2.) obtain physician ordered weekly weights for a resident with congestive heart failure. (Resident #44). This occurred for 2 of 2 residents (Resident #17, Resident #44) reviewed for quality of care. Findings included. 1.) Resident #17 was admitted to the facility on [DATE] with diagnoses including hypertension, and end stage renal disease. A care plan dated 02/10/23 with a target date of 06/18/24 revealed Resident #17 had end stage renal disease, received hemodialysis and was at risk for complications. Interventions included to monitor vital signs. A physician's order dated 04/02/24 for Resident #17 revealed…

    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 · E2024-05-17 · 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, observations and staff, resident and Nurse Practitioner interviews, the facility failed to provide physician ordered nutritional supplements on meal trays and failed to obtain physician ordered weights for 2 of 10 residents reviewed for nutrition (Resident #107 and Resident #19). 1.Resident #107 was admitted on [DATE]. Resident's medical diagnosis included stroke, failure to thrive, protein calorie malnutrition and diabetes. Review of Resident #107's electronic health record revealed the following weights were recorded: 10/2/2023- 207.3 pounds (Lbs.) 11/10/2023- 205.1 Lbs. 12/5/2023- 194.2 Lbs. 1/19/2024- 181.8 Lbs. 1/30/2024- 177.1 Lbs. 2/9/2024- 172.5 Lbs. 3/26/2024- 147.6 Lbs. 4/2/2024- 152.3 Lbs. 4/10/2024- 158.1 Lbs. 4/16/2024- 158.0 Lbs. 4/23/2024 No weight recorded. 4/30/2024 No weight recorded. 5/7/2024- 161.3 Lbs. 5/14/2024- 157.8 Lbs. Review of Resident #107's electronic health record revealed a 1/26/2024 physician order for Mighty Shake nutritional supplement three times per…

    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 · E2024-05-17 · tag F0745 — failed to provide medically-related social services — pattern
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 resident, staff and Nurse Practitioner interviews, the facility failed to ensure a resident had an appointment scheduled for a physician ordered mammogram (Resident #22) for 1 of 1 resident sampled for medically related social services. Findings included: Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included diabetes and history of left breast keloid (thick scar tisssue resulting from excessive growth of fibrous tissue). Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. Review of the facility grievance log revealed a grievance form dated 12/4/23 completed by the resident received by the Director of Nursing/ Assistant Administrator. The grievance was regarding Resident #22's request for a referral for a mammogram. Resident #22 stated she had requested an appointment for a mammogram, and it had not been scheduled. The outcome of the grievance indicated an appointment for a mammogram was to be made…

    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 · E2024-05-17 · 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 staff, Pharmacy Consultant, and Nurse Practitioner interviews the facility failed to 1a.) administer the antihypertensive medication Metoprolol prescribed to lower blood pressure, the oral diabetic medication Tradjenta prescribed to lower blood sugar , a phosphate binder Sevelamer (a medication prescribed to lower the amount of phosphorus in the blood when receiving dialysis), and Cymbalta prescribed for neuropathy to a hemodialysis resident after returning from dialysis treatments. This resulted in the resident (Resident #17) not receiving a total of 15 doses of Metoprolol, 15 doses of Tradjenta, 15 doses of Sevelamer, and 8 doses of Cymbalta. 1b.) administer the full course of the oral antifungal Diflucan prescribed for treatment of vaginitis according to the physicians order (Resident #17). This resulted in 2 of the 3 doses of Diflucan not administered. This occurred for 1 of 5 resident reviewed for medication administration (Resident #17). Findings included. 1a.) Resident #17 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-17 · 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 observation, record review, resident and staff interview, the facility failed to ensure food was palatable and served at an appetizing temperature for 4 of 8 residents reviewed for food palatability and temperature (Residents #22, #116, and #107) and 5 of 5 Resident Council members in attendance at a Resident Council meeting (Residents #23, #119, #14, #75 and #41). Findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnosis which included diabetes. Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #22 on 5/13/24 at 12:00 PM. Resident #22 revealed the food was cold and not appetizing or cooked well. Resident #22 stated she wished she could make a choice about what she received to eat. Meal observation of Resident #22's lunch tray on 5/13/24 at 12:30 PM revealed resident received 2 chicken tenders, a scoop of potato salad and a scoop of macaroni and cheese. Resident refused 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-17 · 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 c. Resident #22 was admitted to the facility on [DATE]. Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. An interview was conducted with Resident #22 on 5/13/24 at 12:00 PM. Resident #22 stated she wished she could make a choice about what she received to eat. An interview was conducted on 5/14/24 at 9:12 AM with Resident #22. The resident indicated the only thing she was offered as an alternate was a grilled cheese sandwich. A meal observation conducted on 5/16/24 at 12:26 PM revealed Resident #22 was in bed with the head of the bed elevated feeding herself a pasta take out meal. Resident stated she ordered take out as she did not like the lunch and did not want a grilled cheese sandwich again. Resident #22 stated the staff used to take the orders for the meals and offer the meal or an alternate prior to the meal but they had not been doing that for a long time. An interview was conducted on 5/17/24 at 9:50 AM with the Dietary Manager. The Dietary…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and Nurse Practitioner (NP) interview the facility failed to notify the provider of significant weight gain greater than 3-pounds (lbs.) in 24-hours (hrs.), or 5-lbs. in a week, for a resident that required weight gain monitoring for possible cardiac fluid overload due to resident's history of Congestive Heart Failure (CHF). This deficient practice occurred for 1 of 11 sampled residents reviewed for notification of change. (Resident #20) Findings included: Resident #20 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF). A physician order written to start on 05/01/24 revealed daily weights times 2-weeks and notify provider of 3-lb. weight gain in 24-hours or 5-lbs. in a week, then weekly during day shift for CHF for 14-days, with start day 05/01/24. Review of Resident #20's Medical Administration Record (MAR) dated 05/01/24 through 05/14/24 revealed to obtain daily weights and report weight gain greater than 3-lbs. in 24-hours or 5-lbs.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0582 — isolated
    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) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification who required the provision of the SNF-ABN form (Resident #126 and #129). Findings included: a. Resident #126 was admitted to the facility on [DATE]. Review of Beneficiary Notices - Residents discharged Within the Last Six Months form revealed Resident #126 Medicare Part A skilled services ended on 01/29/24. She remained in the facility with benefit days remaining, per Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123). Record review revealed that Resident #126 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN). b. Resident #129 was admitted to the facility on [DATE]. Review of Beneficiary Notices - Residents discharged Within the Last Six Months form…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 provide tray set-up and assistance with eating to maintain resident's ability to feed themselves for 3 of 3 residents (Resident #112, #126, and #131) reviewed for activities of daily living (ADL). The findings included: 1. Resident #112 was admitted [DATE] with diagnoses that included: dysphagia, dementia, and mild protein calorie malnutrition. Resident #112 was receiving palliative care through hospice services. The resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate to severe cognitive impairments and required supervision and set up only for meals during the assessment period. Resident #112's care plan dated 03/26/24 revealed a potential for fluid volume deficit related to anemia, with nourishment less than body requirement, inadequate intake, and decreased appetite. A nursing note dated 05/10/24 at 10:41 AM for Resident #112 revealed the resident had triggered a 110% weight loss…

    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 · D2024-05-17 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident, staff and Nurse Practitioner interviews, the facility failed to obtain an appointment with an ophthalmologist for evaluation of vision for 1 of 1 resident (Resident # 22) reviewed for vision. Findings included: Resident # 22 was admitted to the facility on [DATE]. Resident #22's medical diagnoses included cataracts and diabetes. Review of the facility grievance log revealed a grievance form dated 12/4/23 completed by Resident #22 was received by the Director of Nursing (DON) and the Assistant Administrator. The grievance was regarding Resident #22's request for a referral to an eye doctor for cataracts. Resident #22 stated the request had previously been made to the hall nurse. The outcome was that referrals and appointments were to be made. Findings of the grievance indicated that the DON stated Resident #22 sees the in-house eye care provider for her eye care and was last seen on 12/6/22. The grievance indicated an annual visit was tentatively scheduled 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 · Dcited before2024-05-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, and staff interviews the facility failed to secure a medication cart that was left unattended and unlocked with the keys in the lock while the cart was in the hallway near resident rooms. This was observed for 1 of 4 medication carts reviewed for medication storage. (400 Hall medication cart) Findings included. During an observation on 05/13/24 at 03:10 PM the medication cart on the 400 hallway was observed unattended and unlocked with the cart keys left in the lock. The nurse was not in site of the cart. A visitor was standing 3 feet away from the medication cart. The nurse was observed coming out of a resident's room from down the hallway approximately 2-3 minutes later. During an interview on 05/13/24 at 3:15 PM Nurse #3 stated she got distracted when she was called away by a resident. She acknowledged she walked away from the medication cart and left the keys in the lock and the cart unlocked. She stated it was done in error. During an interview on 05/17/24 at 11:43 AM the Director of Nursing stated Nurse #3 reported to her after the error. She stated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff, resident, and the Nurse Practitioner interviews the facility failed to implement the Enhanced Barrier Precautions (EBP) policy regarding donning Personal Protective Equipment (PPE) to include donning gloves and gown during high contact resident care activities. Two Nurse Aides were observed providing care to a resident with an indwelling central venous catheter used for dialysis and who received wound care to the right lower extremity and were not wearing a gown during care. This occurred for 1 of 5 resident (Resident #82) observed for Infection Control. Findings included. The facility's Enhanced Barrier Precautions policy updated on 04/01/24 read: Enhanced Barrier Precautions were used in conjunction with Standard Precautions to reduce the risk of multidrug resistant organism (MDRO) transmission during high contact resident care activities. This included the use of both gloves and gown. Enhanced Barrier Precautions are to be in place for the duration of the residents stay or until resolution of a wound or discontinuation of an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-01-26 · 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, record review, and staff interviews the facility failed to maintain the final rinse cycle temperature of the high temperature sanitizing dish machine at or above 180 degrees Fahrenheit per manufacturers recommendations and failed to routinely monitor and record the dish machine wash and rinse cycle temperatures for 1 of 1 dish machines observed. 2) failed to obtain food temperatures prior to serving and failed to maintain consistent food temperature logs during 1 of 2 observations. 3). failed to label and date leftover food and ensure the nourishment room refrigerator was free from debris for 1 of 2 nourishment rooms (200 Hall nourishment room). This practice had the potential to affect the food served to the residents. Findings included. 1.) An observation was made on 01/23/23 at 1:27 PM of the wash and rinse sanitizing cycles of dishware placed in the high temperature sanitizing dish machine by Dietary Aide #1. The loaded dish rack placed in the dish machine was observed to have a wash cycle temp of 160 degrees Fahrenheit and a final rinse cycle temperature…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · 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: 1a) repair drywall wall damage in 6 of 7 resident rooms (302, 309, 506, 508, 514, and 612), 1b) failed to remove the black greenish substance from the commode base caulking in 4 of 13 resident rooms (506, 508, 510, and 615), 1c) failed to ensure the ceiling light cover was free from damage in 1 of 4 shower rooms (300 hall), 1d) failed to ensure the florescent ceiling light cover was free from damage in 1 of 3 nursing stations (over exit door by [NAME] nursing station). Findings included: 1a. An observation on 01/23/23 at 11:40 AM revealed drywall wall damage in 6 of 7 resident rooms (302, 309, 506, 508, 514, and 612). 1b. An observation on 01/23/23 at 11:40 AM revealed black greenish substance from the commode base caulking in 4 of 13 resident rooms (506, 508, 510, and 615). 1c. An observation on 01/23/23 at 11:40 AM revealed a shower ceiling light cover was damaged and hanging free in 1 of 4 shower rooms (300 hall). 1d. An observation on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-26 · 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 observation, record review, resident and staff interview and test tray evaluation, the facility failed to ensure food was palatable and served at an appetizing temperature for 3 of 24 residents reviewed on the 100, 400 and 700 halls for food palatability and temperature (Resident #332, Resident #18, and Resident #81). Findings: a. Resident # 332 was admitted to the facility on [DATE]. Resident #332s 1/17/23 admission Minimum Data Set (MDS) assessment revealed resident was cognitively intact. Interview on 1/23/23 at 12:18 PM with Resident #332 revealed meals were served cold all the time. Resident #332 indicated the food was the biggest problem since she was admitted to the facility due to receiving cold food and food that did not taste good. Resident #332 stated if she couldn't eat what was served, she ate snacks that her visitors brought her. b. Resident #18 was admitted to the facility on [DATE]. Resident #18's admission Minimum Data Set (MDS) assessment on 12/28/22 indicated resident was cognitively…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-26 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the complaint survey conducted on 8/13/21. This was for two recited deficiencies on the current recertification and complaint survey in the areas of Resident Rights (F584) and Food and Nutrition Services (F804). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included. This tag is cross-referenced to: F584: Based on observations and staff interviews, the facility failed to 1a). repair drywall wall damage in 6 of 7 resident rooms (302, 309, 506, 508, 514 and 612), 1b); failed to remove the black greenish substance from the commode base caulking in 4 of 13 resident rooms (506, 508, 510, and 615), 1c); failed to ensure the ceiling light cover was free from damage in 1 of 4 shower rooms (300…

    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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$7,901 in federal fines across 1 penalty.

  • $7,901 — penalty dated 2024-01-03

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 PRINCIPLE LONG TERM CARE — 40 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 53.0-1.0 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 39 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Ayden Court Nursing and Rehabilitation CenterAyden, NC 1 of 5Greendale Forest Nursing and Rehabilitation CenterSnow Hill, NC 1 of 5River Trace Nursing and Rehabilitation CenterWashington, NC 1 of 5Somerwoods Rehabilitation and Healthcare CenterSomerset, KY 1 of 5University Place Nursing and Rehabilitation CenterCharlotte, NC 2 of 5Cherry Point Bay Nursing and Rehabilitation CenterHavelock, NC 2 of 5Clear Creek Nursing & Rehabilitation CenterMint Hill, NC 2 of 5Graham Healthcare and Rehabilitation CenterRobbinsville, NC 2 of 5Greenwood Rehabilitation and Healthcare CenterBowling Green, KY 2 of 5Macon Valley Nursing and Rehabilitation CenterFranklin, NC 2 of 5Magnolia Lane Nursing and Rehabilitation CenterMorganton, NC 2 of 5Tower Nursing and Rehabilitation CenterRaleigh, NC 2 of 5Westwood Hills Nursing and Rehabilitation CenterWilkesboro, NC 2 of 5Willow Creek Nursing and Rehabilitation CenterGoldsboro, NC 3 of 5Bethany Woods Nursing and Rehabilitation CenterAlbemarle, NC 3 of 5Franklin Oaks Nursing and Rehabilitation CenterLouisburg, NC 3 of 5Greenhaven Health and Rehabilitation CenterGreensboro, NC 3 of 5Harmony Hall Nursing and Rehabilitation CenterKinston, NC 3 of 5Pine Ridge Health and Rehabilitation CenterThomasville, NC 3 of 5Piney Grove Nursing and Rehabilitation CenterKernersville, NC 3 of 5Premier Nursing and Rehabilitation CenterJacksonville, NC 3 of 5Richmond Pines Healthcare and Rehabilitation CenteHamlet, NC 3 of 5Riverpoint Crest Nursing and Rehabilitation CenterNew Bern, NC 3 of 5Smoky Mountain Health and Rehabilitation CenterWaynesville, NC 3 of 5Springbrook Nursing and Rehabilitation CenterClayton, NC 4 of 5Barbour Court Nursing and Rehabilitation CenterSmithfield, NC 4 of 5Carolina Rivers Nursing and Rehabilitation CenterJacksonville, NC 4 of 5Chowan River Nursing and Rehabilitation CenterEdenton, NC 4 of 5Croatan Ridge Nursing and Rehabilitation CenterNewport, NC 4 of 5Kerr Lake Nursing and Rehabilitation CenterHenderson, NC 4 of 5Lake Park Nursing and Rehabilitation CenterIndian Trail, NC 4 of 5Lake Way Rehabilitation and Healthcare CenterBenton, KY 4 of 5Northampton Nursing and Rehabilitation CenterJackson, NC 4 of 5Wayland Nursing And Rehabilitation CenterKeysville, VA 4 of 5Wilson Pines Nursing and Rehabilitation CenterWilson, NC 5 of 5Grantsbrook Nursing and Rehabilitation CenterGrantsboro, NC 5 of 5Harnett Woods Nursing and Rehabilitation CenterDunn, NC 5 of 5Jacob's Creek Nursing and Rehabilitation CenterMadison, NC 5 of 5Maple Grove Health and Rehabilitation CenterGreensboro, NC

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 / managerTypeRoleSince
JOHNSON, DIANNEIndividualCORPORATE DIRECTORsince 01/01/2011
BOICE, GALEIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/05/2018
PRINCIPLE LONG TERM CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2011
REVIS, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/23/2020
HILL, RAYMONDIndividualADP OF THE SNFsince 01/01/2011
HILL, ROBERTIndividualADP OF THE SNFsince 01/01/2011
HILL, STEPHENIndividualADP OF THE SNFsince 01/01/2011
SEDER, JEFFREYIndividualADP OF THE SNFsince 07/02/2025

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$16.8M
Net patient revenuemost recent cost report
-3.6%
Operating marginrevenue minus expenses
$3.5M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 11%Other / private 20%

This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$365per resident / day
operating cost
$11,100per month
≈ monthly operating cost
$353per 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 345119. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-23, 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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