Yanceyville Rehabilitation and Healthcare Center
1086 Main Street North, Yanceyville, NC 27379 · For profit - Limited Liability company · 157 certified beds · (336) 694-5916 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2025
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.9% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.4% | 7.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.1% | 5.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.2% | 18.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 21.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 5.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.3% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.5% | 14.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.4% | 78.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 9.2% | 22.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 19.4% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.33 | 1.78 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.90 | 1.80 | 1.80 | typical |
‡ 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.
33.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 33.2%CMS range 22.9–42.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.0–13.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 65.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 62.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 3.9–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 157 beds and averages 148.5 residents a day — about 95% occupied, or roughly 8 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.75 hrs/resident/day on weekends vs 3.24 on weekdays — 15% thinner on weekends. RN hours go from 0.28 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · E2026-05-29 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 Psychiatric Nurse Practitioner (NP) interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new serious mental illness disorder was identified for residents previously determined to have a Level I PASRR status for 4 of 8 residents reviewed for PASRR (Residents #10, #79, #120, #145). 3. Resident #120's Level I PASRR Determination Notification document dated 6/12/25 revealed the document was valid for his stay at the facility. The document further indicated no further PASSR screening was required unless a significant change occurred. Resident #120 was admitted on [DATE] with a diagnosis of major depressive disorder. Review of physician orders revealed an order dated 10/13/25 for Risperidone (an antipsychotic medication used to treat bipolar disorder) 0.5 milligram (mg) at bedtime for mood. Review of a Psychiatric note dated 11/19/25 revealed Resident #120 was assessed by the Psychiatric Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observation and staff interviews, the facility failed to store dry food away from moisture, keep dry goods covered, failed to label and date leftover food stored for use, and discard expired food. This was for 1 of 1 dry goods storage room, 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and 1 of 1 reach-in refrigerator. The facility also failed to maintain the walk in refrigerator floor in a clean and sanitary condition, keep 1 of 4 ice machines clean, and failed to maintain the ceiling above the steam table to prevent peeling paint. These failures had the potential to affect food served to residents.Findings include:1a. On 5/26/26 at 9:20 AM during an observation of the dry storage area with Dietary Manager #1, eight 8 ounce white disposable cups half filled with rice crisp cereal sat on a tray with white powder on the surface. The cups were covered. A second tray was stacked on top of the white disposable cups. The tray also had twelve 8 ounce disposable cups of dry cereal that were covered. The tray also had some white powder on it. None of the cups were labeled or dated.…
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.
- Potential for harm · D2026-05-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for activities (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses that included legal blindness and adjustment disorder with mixed anxiety and depressed mood.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9's assessment of daily activity preferences revealed it was somewhat important for him to listen to music and to go outside.Review of the care plan last revised on 3/11/26 revealed no goals or interventions related to activities.Review of Resident #9's activity participation documentation for the month of May 2026 revealed self-directed activities included watching tv and relaxing in room, and 1:1 activity noted staff provided hydration and snacks.The Activity Director was interviewed on 5/29/26 at10:30 AM. The Activity…
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.
- Potential for harm · Dcited before2026-05-29 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 3 of 4 cognitively impaired residents reviewed for activities (Residents #32, Resident #44 and Resident #9). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic behavior and Alzheimer's disease. Review of the Modified Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and dependent on staff for all Activities of Daily Living (ADL). The assessment indicated Resident #32 preferred listening to music, keeping up with news, participating in group activities, and spending time outdoors when the weather was good. Review of the care plan dated 2/13/26 revealed the resident was care planned for activities and was dependent on staff to meet emotional, intellectual, physical, and social needs. Interventions included ensuring…
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.
- Potential for harm · D2026-05-29 · tag F0685 — isolatedAssist 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 observation, record review, resident and staff interview, and Resident Representative (RR) interview, the facility failed to identify hearing aides were missing and determine whether an appointment was needed to maintain hearing abilities for a resident with reported hearing difficulties for 1 of 1 resident reviewed for communication (Resident #81). The findings included:Resident #81 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had severe cognitive impairment and was coded for moderate hearing difficulty with the use of hearing aids.The care plan initiated on 7/25/25 and reviewed on 2/26/26 indicated Resident #81 had a care plan in place for having a communication/hearing impairment and wore bilateral hearing aids. The written interventions included staff to assist Resident #81 daily with putting the hearing aids in every morning and removing them every night and to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-29 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 provide pureed food items with a pudding like consistency as required. This failure had the potential to affect 11 of 11 residents who had orders for a pureed texture diet.Findings included:1a. A continuous lunch meal observation in the 500 hallway dining room on 5/26/26 from 12:10 PM to 12:20 PM revealed that residents on the 500 hallway received their trays first. Two residents were present in the 500-hallway dining room, each receiving assistance from staff. Both residents had meal tickets indicating a regular diet with pureed consistency.Observation of the residents' trays revealed a lunch meal consisting of pureed tuna salad, pureed broccoli salad, pureed potato salad, and pureed bread. The food was served on a divided plate. Pureed peaches and pears was dessert and served in an individual cup. The pureed food in the divided plated appeared thin and runny, with liquid separating from the solids. When staff tilted the spoon, the food ran off the spoon and did not hold its shape.During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents. The findings included: During a kitchen tour on 2/24/25 at 10:32 AM, the following observations were made with the kitchen Regional Dietary Director: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. b. The 2-plate warmers had 2 rows of clean plates stored inside the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. c. The 6-compartment steam table had floating food particles in standing water, the lids of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-27 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and staff interviews, the facility failed to ensure the garbage and refuse was contained in 3 of 3 dumpsters and 1 of 1 grease interceptor container and failed to ensure the surrounding area clean and free from debris. This practice had the potential to attract pests and rodents. The findings included: During an initial tour observation on 2/24/25 at 10:45AM, revealed there were 3 dumpsters and 1 grease interceptor container located near a wooded area at the back of the facility that had large amounts trash bags of garbage and refuse overflowing from the tops and loose paper products, boxes, mattresses, furniture old pallets, clothing, blankets and loose food products outside of dumpsters on the ground and surrounding areas. The grease interceptor container was leaking grease on the ground along with the trash onto the parking lot. A follow-up observation was conducted on 2/25/25 at 7:30 AM revealed the trash bags filled with garbage left on the ground overflowing and the surrounding area had not been thoroughly cleaned evidence by the remaining paper and food…
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.
- Potential for harm · Ecited before2025-02-27 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 4 of 5 cognitively impaired residents reviewed for activities (Residents #29, Resident #52, Resident #137 and Resident #68). The findings included: 1a. Resident #29 was admitted to the facility on [DATE]. The diagnoses included cognitive impairment and dementia. Resident #29 resided on the memory care unit. Resident #29 was coded on the annual Minimum Data Set (MDS) assessment dated [DATE] as having cognition impairment and he needed assistance with activities. The MDS also coded Resident #29's activity interest as very important to participate in favorite activities to include pets, music and news and current events. The annual activity assessment dated [DATE] revealed Resident #29's preferences included listening to music, news, and current events. A focus area on the care plan dated 2/18/25 revealed Resident #29 was dependent on staff 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.
- Potential for harm · D2025-02-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 3 of 3 residents who were assisted with meals. Staff were observed standing beside the side of the residents' beds while feeding assistance was provided (Resident #62, Resident #14 and Resident # 68). Findings included: 1. Resident #62 was admitted on [DATE]. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was assessed as moderately cognitively impaired. The assessment indicated Resident #62 was dependent on staff for eating and was on a therapeutic diet. The assessment indicated the resident had a significant weight loss and was under hospice care. During a continuous lunch meal observation on 2/24/25 from 1:15 PM to 1:20 PM, Resident #62 was observed in bed and Nurse Aide (NA) #2 was observed standing beside Resident #62's bed, leaning over and assisting the resident with eating. There was one chair on the other side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-02-27 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 and staff interviews, the facility failed to facilitate a resident's participation in the development of their plan of care for 1 of 29 residents reviewed for comprehensive care plans (Resident #110). The findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis that included Diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. Record review of copies of the care plan invitation letters sent to the resident revealed Resident #110 was scheduled for care plan meetings on 1/28/24, 5/7/24, 8/29/24, and 1/28/25 but there was no documentation that Resident #110 participated. During an interview on 2/24/25 at 1:53 p.m. Resident #110 revealed he had not attended his care plan meetings since admission to the facility. Resident #110 revealed he had always received invitation letters from the Social Worker Assistant, but the dates came and went without anyone coming to get him to the meeting.…
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.
- Potential for harm · D2025-02-27 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 staff, Adult Protective Services Social Worker (APS-SW), family and the Arresting Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of property leading to a suspected monetary loss of $11,670.68. The deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #400). Findings included: Resident #400 was admitted to the facility on [DATE] and discharged on 2/10/25. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #400 was cognitively intact. The initial allegation report dated 2/18/25 stated that it was brought to the facility's attention by the Police Department that Nurse Aide #7 was allegedly using a resident's credit card without permission. The report stated that the family of Resident #400 noted charges on a credit card when the monthly bill was received on 2/18/25 and the family notified the local Police department on 2/18/25 and the police initiated 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.
- Potential for harm · D2025-02-27 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Resident Representative and staff interviews, the facility failed to provide the resident and Resident Representative with a written notification of transfer or discharge including notification of appeal rights when the resident was discharged for 1 of 2 residents reviewed for hospitalization (Resident #200). The findings included: Resident #200 was originally admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #200 had severe cognitive impairment. The discharge was coded return not anticipated. A review of the medical record revealed Resident #200 was transferred to the hospital on 4/3/24 for psychiatric evaluation and involuntary commitment. Resident #200 was transferred back to the facility on 4/7/24 and then discharged on 4/7/24. There was no documentation a notice of transfer/discharge was provided to Resident #200 or the Resident Representative. A telephone interview was conducted on 2/25/25 11:32 AM with 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.
- Potential for harm · D2025-02-27 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and Resident Representative (RR), hospital Case Manager, Physician, and staff interviews, the facility failed to permit a resident to remain in the facility after the hospital assessed Resident #200 as returning to her baseline and discharged her back to the facility for 1 of 2 residents reviewed for discharge (Resident #200). The findings included: Resident #200 was originally admitted to the facility on [DATE] with multiple diagnoses including anxiety, depression, schizophrenia and bipolar disorder. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #200 had severely impaired cognition. The discharge was coded as planned with return anticipated. Review of the nurses' note dated 4/3/24 revealed that Resident #200 needed to be involuntarily committed due to threat to self, staff and other residents. Exhibiting aggressive behaviors and outbursts and refusing all medications. The provider was notified of the resident's behavior and gave orders to have resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) and failed to complete the Care Area Assessments (CAA) within 14 days of admission for 1 of 3 sampled residents reviewed for comprehensive assessments (Resident #15). The findings included: a. Resident #15 was admitted to the facility on [DATE]. An admission MDS with an Assessment Reference Date of 12/11/24 was completed on 12/24/24. b. The CAA for Resident #15 included fall potential related to medications, neuromuscular issues, incontinence and Parkinson's Disease; nutritional problems related to swallowing issues; hydration issues related swallowing issues; and potential for skin breakdown and pressure ulcer development due to incontinence. The CAA was not completed until 12/24/24 and the care plan decisions were not completed until 12/30/24. The MDS nurses were interviewed on 2/26/25 at 11:02 AM. MDS Nurse #1 reported she was the MDS Director. MDS Nurse #1 reported during December…
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.
- Potential for harm · D2025-02-27 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of the Assessment Reference Date for 1 of 3 sampled residents reviewed for significant change assessments (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE]. Review of Resident #61's MDS assessments revealed a significant change MDS assessment with an Assessment Reference Date of 12/13/24. The MDS assessment was signed off as completed on 12/29/24, 16 days after the assessment reference date. The MDS nurses were interviewed on 2/26/25 at 11:02 AM. MDS Nurse #1 reported she was the MDS director. MDS Nurse #1 reported during December 2024, the MDS staff was low, and the department had difficulty completing assessments on time. MDS Nurse #2 reported the significant change MDS assessment should have been completed 14 days after the Assessment Reference Date for Resident #61. The Administrator was interviewed on 2/27/25 at 1:08…
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.
- Potential for harm · D2025-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 and staff interviews, the facility failed to secure smoking materials, specifically, a lighter for 1 of 4 residents (Resident #16) reviewed for safe smoking. Findings included: Resident was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with exacerbation, diabetes mellitus type 2, and nicotine dependence. Review of the safe smoking screening assessment dated [DATE] revealed the staff reviewed the policy related to smoking times and storage of smoking materials with the resident and resident acknowledged understanding. Resident was assessed as safe smoker and could smoke independently. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was a tobacco user. A review of the most recent quarterly MDS dated [DATE] revealed Resident #16 was assessed as cognitively intact. Review of the assessment indicated the resident exhibited verbal behavior towards others and exhibited rejection 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.
- Potential for harm · Fcited before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to keep food preparation areas, food storage areas and food service equipment clean, free from debris, grease buildup, and/or dried spills on the floor during two kitchen observations. The facility failed to clean the ceiling vents and air condition units located over the food prep and food service area. This practice had the potential to affect food served to all residents. The findings included: 1.During a kitchen tour on 11/14/23 at 10:00AM, the following observations were made with the dietary manager: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being…
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.
- Potential for harm · E2023-11-17 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews and record review, the facility failed to resolve repeated concerns with scheduled smoking and diet preferences voiced during 2 of 5 months of consecutive Resident Council Meetings reviewed May 2023, thru October 2023. Findings included: The Resident Council Minutes for the period August 2023 through October 2023 were reviewed and revealed the following. The Resident Council minutes dated August 2023: * The staff did not take smokers out on schedule. * The preferences were not changed on the diet slips. The Resident Council minutes dated September 2023: * Smoking issues regarding scheduled times and staff availability were not resolved. * The dietary preferences were not resolved. The Resident Council Minutes for October did not address any concerns or old business. An interview on 11/15/23 at 11:40 AM with the interim Activity Director revealed that the previous Activity Director did not leave Resident Council minutes. She stated the resident council minutes were typed up from notes she found. She did not know if any if the grievances had been…
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.
- Potential for harm · E2023-11-17 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observations, resident and staff interviews and record reviews, the facility to follow the menu for 1 of 1 meal observations for 4 of 4 residents(Resident #7, #58, #109 and #49). During the lunch meal the facility ran out of chicken thighs. The findings included: Review of the facility's lunch meal menu and spreadsheet revealed residents were to receive rancher's chicken thigh, country style tomatoes, black-eyed peas, dinner roll and pumpkin pie and there was no alternate indicated on the menu or on the resident meal ticket on 11/16/23. The entire facility resident meal tickets all read the main meal with no alternate. Observation of the tray line was conducted on 11/16/23 at 11:40 AM- 12:48 PM, the cook, dietary manager and kitchen supervisor were present when the cook ran out of chicken for the residents who received a regular diet. The cook began to serve up an alternate meal of Quiche which was not listed on the facility menu or spreadsheet. The Dietary Manager and Kitchen Supervisor both stated 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.
- Potential for harm · D2023-11-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 record review, observations and staff interviews, the facility failed to remove an expired multi-dose vials of insulin or put the date of opening on multi-dose containers of insulin and inhalers in the medication cart drawer for 2 of 7 medication administration carts (100 hall and 400 hall). Findings Included: 1.On 11/14/23 at 10:00 AM, an observation of the medication administration cart on 100 hall with Nurse #5, revealed one opened and undated Novolog insulin pen injector. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening; one multi-dose vial of Lantus insulin opened on 9/25/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening, which would be on 10/23/23; one Insulin Lispro multidose vial opened on 10/15/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening, which would be on 11/12/23. On 11/14/23 at 10:05 AM, during an interview, Nurse #5 indicated that the nurses, who worked on 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.
- Potential for harm · D2023-11-17 · tag F0806 — failed to honor food preferences — isolatedEnsure 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 resident and staff interviews and record review, the facility failed to obtain and honor food likes/dislikes and to provide an alternative meal of similar nutritive value for 4 of 5 sampled residents, (Resident #88). Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, and Gastroesophageal reflux disease. A review of the most recent Minimum Data Set, dated [DATE] revealed Resident #88 was cognitively intact and fed himself after he was set-up. A review of the Care Plan for Resident #88 dated 8/23/23 goal was to maintain nutrition and weight without significant change. The interventions were to honor food preferences, provide the diet as ordered and report weight loss/gain to the doctor. A review of the orders revealed 11/20/22 Resident #88 was on a diabetic diet. A review of the weight log revealed a 7lb. weight loss was recorded between the months of February 2023 and September 2023. A review of the Food Preferences Form for Resident #88 dated…
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.
- Potential for harm · D2023-11-17 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 staff interview, and record review of the Facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee put into place following the 12/14/21 annual recertification survey. This was for one recited deficiency in the areas of dietary services (F 812). This deficiency was cited again on the annual recertification survey on 11/17/23. This continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F- 812 Based on observation, interviews, and record review the facility failed to label and date food and failed to maintain the nourishment refrigerator clean for 2 of 2 nourishment refrigerators reviewed for food storage (nourishment refrigerator #1 on 200 hallway and nourishment refrigerator #2 on 600 hallway). During the recertification survey, the facility was cited for F812 the facility failed to keep food preparation areas, food storage areas and food…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NC EAST HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2022 |
| ALTER, TZVI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 80% | since 07/01/2022 |
| LEOPARDI, LOIE | Individual | W-2 MANAGING EMPLOYEE | — | since 07/01/2022 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $750K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NC
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.
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 345265. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, 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.