Longleaf Neuro-Medical Treatment Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

Staffing

How full it usually is: this home is certified for 248 beds and averages 81.4 residents a day — about 33% occupied, or roughly 167 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 12.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.28 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 8.73 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

This home’s total nursing-staff turnover of 26% is below 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

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

Inspection deficiencies

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

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

21 citations, most serious first. The 16 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · K2024-03-14 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 protect residents from the accused staff during an investigation of staff to resident abuse. On 2/15/24 staff observed Nurse Aide (NA) #1 strike Resident #21 with a closed fist twice in the face and push him down on the floor. An abuse investigation was initiated on 2/15/24. On 2/16/24, during the abuse investigation, NA #1 arrived at the facility, clocked in at 6:56 AM and was given a resident care assignment. NA #1 clocked out at 10:56 AM. This deficient practice was for 1 of 3 residents (Resident #21) reviewed for abuse and had the high likelihood of serious injury/harm for other residents. Immediate Jeopardy began on 2/16/24 when Nurse Aide #1 provided direct care to residents following witnessed physical abuse of Resident #21 on 2/15/24. Immediate Jeopardy was removed on 3/15/24 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower level and severity of E (no harm with the potential for more than minimal harm…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-03-14 · 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, observation, and interviews with police, psychologist, physician, resident, and staff, the facility failed to protect Resident #21 from physical abuse perpetrated by Nurse Aide (NA) #1. On [DATE] Resident #21 was attempting to leave a common area of the facility by lifting his walker up over his head to get past two residents who were seated. NA #1 prevented his exit by placing her hands on the walker to position it back on the floor. Resident #21 hit NA #1 and told her to shut up followed by the use of profanity. NA #1 then struck Resident #21 with a closed fist twice in the face and pushed him down to the floor. The resident sustained a small scratch on his face. He indicated the incident made him mad. A reasonable person would have been traumatized by being physically abused by their caregiver in their home environment. This deficient practice affected 1 of 3 residents reviewed for abuse. Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Kcited before2022-09-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, staff and Physician interviews the facility failed to safeguard a resident from entrapment when Resident #21's half side rail was in the up position, he fell out of bed, his right arm became caught between the side rail and the mattress, and he was unable to free himself. Resident #21 sustained 2 abrasions to his knee and was at high likelihood of suffering serious injury or death as a result of the entrapment. The facility also failed to follow the manufacturer's instructions for a mechanical lift when transferring Resident #8 out of bed resulting in the resident falling out of the lift face first to the floor. Resident #8 experienced pain and sustained soft tissue swelling, a scalp hematoma, and a laceration to the forehead. This deficient practice affected 2 of 6 residents reviewed for accidents. Immediate Jeopardy for example #1 began on 8-16-22 when Resident #21's right arm became entrapped in the side rail of his bed when he fell out of bed and example #2…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2022-09-09 · tag F0835 — failed to run the facility competently — pattern
  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 observations, record review resident staff, and Physicain interviews the facility failed to provide oversight to ensure effective systems were in place for ongoing monitoring after concerns were identified with side rails and mechanical lift transfers placing other residents at risk for entrapment with side rails and accidents involving mechanical lifts. In addition, Administration failed to act or revise measures implemented for the use of side rails when auditing revealed the system implemented was ineffective. Immediate Jeopardy for example #1 began on 8-16-22 when the facility failed to act and revise the ongoing monitoring of side rails and a resident was found entrapped in his half side rail. Example #2 began on 1-20-22 when the facility failed to have ongoing monitoring of staff after a resident's fall from a mechanical lift. Immediate Jeopardy was removed on 9-10-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide care in a safe manner. During incontinence care a resident fell while standing and sustained a fracture of the left distal femoral shaft (break in the lower portion of the thighbone just above the knee) with malalignment. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] with diagnoses that included major neurocognitive disorder due to vascular disease with behavioral disturbance and disorganized schizophrenia. Resident #1 was not available for interview because she was hospitalized at the time of the investigation.The care plan dated 7/9/2025 and revised 3/26/2026 documented Resident #1 was at risk for falls/injury related to dementia, poor safety awareness, aggression, and medication use. Interventions included implementing fall prevention measures, assisting the resident with personal hygiene, queueing and reorientation as needed,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, staff and physician interviews, the facility did not provide care in a safe manner when 1.) Resident #3 fell to the floor from a mechanical lift (a device that uses electric or hydraulic power to safely transfer patients who have limited mobility) during a transfer from the bed to a chair sustaining a 4-centimeter posterior (at the back or rear of something) scalp laceration (cut or tear in the skin of the scalp) requiring evaluation in the emergency room and wound closure with 7 staples and 2.) Resident #4 fell out of a shower bed requiring evaluation in the emergency room sustaining an occipital hematoma (a collection of blood in or around the back part of the brain), a 2 x 2 centimeter (cm) reddened area to the left elbow, and an abrasion (superficial skin injury) to the left buttocks. This deficient practice affected 2 of 3 residents reviewed for accidents (Resident #3 and Resident #4).The findings included: 1.Resident #3 was admitted to the facility 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-17 · 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, resident interview and staff interviews, the facility failed to ensure safe wheelchair transport for one resident reviewed for accident prevention. Staff transported the resident in a wheelchair without leg rests attached, resulting in the resident's left leg dragging on the floor and becoming caught underneath the wheelchair, causing minor injury to the resident's knee. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). The findings included:Resident #2 was admitted on [DATE] with diagnoses including functional quadriplegia, cerebral palsy, right arm pain and localized edema.Review of the care plan dated 7/25/2025 revealed Resident #2 required extensive assistance with activities of daily living related to cerebral palsy. The care plan indicated the resident participated in activities of daily living (ADL's) by alerting staff to needs and performing limited hygiene tasks with setup and supervision. The annual Minimum Data Set (MDS)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · 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 interviews, and Medical Director interview, the facility failed to provide care and services in accordance professional standards of practice when staff moved and repositioned the resident after a fall prior to nursing assessment for 1 of 3 resident reviewed for accidents (Resident #1). Findings included:A review of the records showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included major neurocognitive disorder due to vascular disease with behavioral disturbance, and disorganized schizophrenia. Resident #1 was not available for interview because she was hospitalized at the time of the investigation. A review of the care plan dated 7/9/2025 showed problems, goals, and interventions that included providing socialization through staff review, cueing and reorientation as needed, assessing for mood changes, administering medications as ordered, assisting with personal hygiene, monitoring for continence patterns, implementing fall prevention measures…

  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 · Ecited before2024-03-14 · 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

  Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the complaint investigation survey of 6/29/23. This was for one deficiency in the area of investigate/prevent/correct alleged violation (F610) that was recited on the current recertification and complaint investigation survey of 3/14/24. 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: F610: Based on record review and staff interviews the facility failed to protect residents from the accused staff during an investigation of staff to resident abuse. On 2/15/24 staff observed Nurse Aide (NA) #1 strike Resident #21 with a closed fist twice in the face and push him down on the floor. An abuse investigation was initiated on 2/15/24. On 2/16/24, during the abuse investigation, NA #1 arrived at 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 · D2024-03-14 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observation, staff interviews, and resident interviews the facility failed to implement their abuse policy in the area of reporting related to notifying Adult Protective Services (APS) and law enforcement of an allegation of staff physical abuse towards a resident for 1 of 3 residents investigated for abuse (Resident #21). Findings included: Review of the facility policy entitled Protecting Patients/Residents from Rights Infringements, dated 7/26/23 revealed an immediate report will be made to local Adult Protective Services when there is reason to believe a resident has been abuse, or exploited. Review of the facility policy entitled Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility, dated 4/6/23 revealed a suspected crime must be reported to the facility's Police Chief within two hours. Review of a facility reported incident initial report completed by the Risk Manager dated 2/15/24 revealed on 2/15/24 at 12:19 PM Resident #21 allegedly hit Nurse Aide (NA) #1 on the left side of her face twice while NA #1 was trying to redirect…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · E2022-09-09 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff, facility Pharmacist, and Physicians' interviews, the Pharmacist failed to identify drug irregularities and provide recommendations for the use of as needed (PRN) psychotropic (drug that affect the mental state) for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69 and #5). Findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included schizophrenia. A Physician's order dated 3/21/22 read in part for Lorazepam (antianxiety medication) 2 milligrams (mg) by mouth every 6 hours PRN for agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 7/22/22 read in part for Lorazepam 2 mg by mouth or tube every 6 hours PRN for agitation and may give IM if refuse by mouth or tube. Reviews of the monthly drug regimen reviews for April through August completed by Pharmacist #1 for Resident #7 revealed no recommendations for a stop date for the Lorazepam. An interview on 9/08/22 at 11:22 AM 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-09-09 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff, facility Pharmacist, and Physician interviews, the facility failed to ensure Physician's orders for as needed (PRN) psychotropic (drug that affect the mental state) were time limited in duration for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69, and #5). Findings included: 1. Resident #7 was admitted to the facility on [DATE] with a diagnosis which included schizophrenia. The quarterly Minimum Data Set, dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7's care plan last revised on 9/07/22 revealed a focus for psychoactive medication to manage symptoms associated with mood disorder and residual schizophrenia. The interventions included monitoring for adverse side effects and documentation of behaviors to establish medication effectiveness. A Physician's order dated 3/21/22 read in part for Lorazepam (antianxiety medication) 2 milligrams (mg) by mouth every 6 hours PRN for agitation and may give intramuscularly (IM) if…

  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 · D2022-09-09 · 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 complete the Minimum Data Set (MDS) assessment in the areas of anticoagulant medication (Resident #49) and ventilator or respirator (Resident #67) for 2 of 23 residents whose MDS assessments were reviewed. Findings included: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses including dementia and type 2 diabetes. A review of the quarterly Minimum Data Set (MDS) assessment for Resident #49 dated 07/12/2022 revealed he received anticoagulant (blood thinning) medication on 7 of 7 look back period days. A review of his July 2022 Medication Administration Record (MAR) did not reveal any evidence Resident #49 received anticoagulant medication. On 09/08/2022 at 8:48 AM an interview with MDS Nurse #2 indicated she completed the medications section of Resident #49's MDS assessment dated [DATE]. She reviewed his MAR and physician orders for July 2022 and indicated she could not see where he had received anticoagulant…

  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 · D2022-09-09 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to develop and implement an individualized person-centered care plan for 1 of 1 resident (Resident #41) reviewed for care plans. Findings included: Resident #41 was admitted to the facility on [DATE] with multiple diagnoses that included inhalant abuse, dysphagia and aphasia. Physician order dated 5-27-22 revealed an order for Resident #41 to receive 2 liters of oxygen daily. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 was cognitively intact and was coded for the use of oxygen. Review of Resident #41's care plan dated 7-12-22 revealed no goals or interventions for oxygen. During an interview with the MDS supervisor on 9-8-22 at 1:30pm, The MDS supervisor reviewed Resident #41's care plan and stated he was not care planned for his oxygen. She also reviewed Resident #41's MDS dated [DATE] and said Resident #41 should have been care planned for his oxygen. The MDS supervisor stated it was an oversite when the resident's care…

  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 · D2022-09-09 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and facility staff interviews, the facility failed to ensure a physician's order was obtained for the use of a personal alarm for 1 of 5 residents reviewed for falls (Resident #72). The findings included: Resident #72 was admitted to the facility on [DATE]. His diagnoses included Parkinsonism and vitamin D deficiency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was moderately cognitively impaired. He had no behaviors. He required extensive assistance for all activities of daily living except was total dependent for dressing and toileting. He had range of motion impairment on 1 upper extremity and both lower extremities. Resident #72 was coded as having no falls and no alarms. Resident #72's care plan updated 8/9/22 revealed a care plan for falls related to visual impairment, mental illness, abnormal gait, and poor safety awareness. There was not a care plan for a personal alarm. A review of the August 2022 and September 2022 physician's…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-09-09 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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 — the official record, unedited, may be distressing

  Based on observations and staff interviews the facility failed to discard a refrigerated food item prior to the use by date on the label for 1 (walk-in #2) of 2 walk-in refrigerators observed during the initial tour of the kitchen. The findings included: An observation of walk-in refrigerator #2 on 9/6/22 at 10:33 AM revealed a rolling rack containing opened food items. On the rack was a 1/3 size steam table pan which contained strawberries. The label on the plastic wrap covering the pan read preparation date 9/1/22 & use by date 9/4/22. No outward signs of spoilage were observed. During an interview with the Director of Nutritional Services on 9/6/22 at 10:40 AM he stated the strawberries should have been discarded on 9/4/22. He said he was not sure who should have discarded the strawberries on 9/4/22 but he would review the schedule and educate that person. During an interview with the Administrator on 9/9/22 at 2:30 PM she stated foods should be discarded prior to the use by date.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$158,403 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $20,440 — penalty dated 2026-05-14
• $12,948 — penalty dated 2025-12-08
• $125,015 — penalty dated 2024-03-14
• Medicare payment denial — starting 2026-01-03 for 6 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

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

What families pay in NC