Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Asheboro Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment experienced four falls—two with no injuries and two with minor injuries—between assessments, but only one fall with no injury was documented on the MDS. The MDS Coordinator confirmed the oversight after reviewing the records, and facility leadership acknowledged the assessment should have been coded accurately.
Two residents with newly diagnosed serious mental illnesses were not referred for required Level II PASRR evaluations. One resident developed schizoaffective disorder after admission, and another was diagnosed with unspecified psychosis and prescribed an antipsychotic, but in both cases, staff did not initiate the necessary PASRR referral. The social worker, administrator, and DON were unaware of the need for new referrals following these diagnoses.
A resident with a history of bladder dysfunction and an indwelling urinary catheter did not have a urology provider's order for monthly catheter changes transcribed or implemented. The order was documented in a specialist's progress note but was not added to the resident's active orders or scheduled for administration, due to an oversight by the assigned nurse and lack of managerial review.
Feeding tubes were utilized for a resident without documented medical necessity or resident agreement, and appropriate care for a resident with a feeding tube was not provided.
Two residents did not receive safe respiratory care: one was given oxygen at a lower rate than prescribed, and two unsecured oxygen cylinders were found stored in another resident's room. Staff confirmed the oxygen was not set at the ordered rate and that oxygen tanks should not be left unsecured in resident rooms.
A nurse failed to follow infection control protocols by not performing hand hygiene before preparing or administering medications to two residents and by not performing hand hygiene before donning gloves and after removing gloves during eye drop administration. This was confirmed through observation and staff interviews, revealing noncompliance with facility policies.
Nurse staffing data was not posted daily as required, with the posted information found to be outdated on one survey day. The absence of the scheduler due to vacation and lack of clarity among nursing staff regarding posting responsibilities led to the deficiency, as confirmed by interviews with staff, the DON, and the Administrator.
A resident's room and bathroom were found to have persistent urine odor, yellow staining on the toilet seat, and wetness on the floor over several days. Staff interviews revealed delays in cleaning and a lack of communication regarding the need to replace the stained toilet seat, resulting in an environment that was not clean, safe, or comfortable.
The Pharmacy Consultant at an LTC facility failed to monitor target behaviors and side effects of psychotropic medications for three residents. One resident with bipolar disorder and depression was not monitored for behaviors like crying and suicidal thoughts. Another resident with dementia and depression lacked documentation for behavior and side effect monitoring. A third resident with anxiety and Alzheimer's showed increased behaviors, but no monitoring was recommended. Interviews revealed an expectation for such monitoring, which was not met.
The facility failed to monitor targeted behaviors and side effects for residents prescribed psychotropic medications. A resident with depression and dementia was not monitored for specific behaviors or side effects after being prescribed Seroquel and Sertraline. Another resident with vascular dementia did not receive a baseline AIMS assessment when prescribed Seroquel. Additionally, residents with bipolar disorder and Alzheimer's disease were not monitored for behaviors or side effects related to their antipsychotic medications. Staff interviews confirmed these oversights.
A facility failed to update a smoking care plan for a resident with cognitive impairment and extensive ADL assistance needs. The resident was assessed as a safe smoker not requiring supervision, but the care plan inaccurately stated supervision was needed. Interviews with staff revealed the care plan should have been updated to reflect the resident's independent smoking status.
A resident with a gastric feeding tube was incorrectly prescribed Guaifenesin Liquid to be administered orally, despite being NPO. The error was due to a default setting in the electronic medical system, which was not corrected by the verifying nurse. The ADON confirmed the mistake and noted the expectation for accurate entry of medication routes.
Two residents experienced inaccurate MDS coding in a facility. One resident with right foot drop and diabetes had contractures in both lower extremities, but the MDS assessment only noted limited range of motion on one side. Another resident with major depressive disorder and schizophrenia was not correctly coded for antipsychotic medication usage and PASRR Level II status. These oversights were acknowledged by the MDS Nurse and Social Worker.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of falls. The resident, who had a diagnosis of dementia and was severely cognitively impaired, experienced four falls between the last quarterly assessment and the significant change assessment. Two of these falls resulted in no injuries, while the other two resulted in minor injuries. However, the MDS assessment only documented one fall with no injury during this period. The MDS Coordinator confirmed, upon review of the resident's medical record and the assessment, that the correct number and type of falls were not coded, attributing the error to an oversight. The DON and Administrator acknowledged that the MDS should accurately reflect the resident's condition.
Failure to Refer Residents for Level II PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents for a Level II Preadmission Screening and Resident Review (PASRR) after they were newly diagnosed with serious mental illnesses. One resident was admitted with diagnoses including bipolar depression, dementia, anxiety disorder, and frontotemporal neurocognitive disorder, and initially had a Level I PASRR. After being newly diagnosed with schizoaffective disorder, there was no evidence that a Level II PASRR referral was made. The social worker confirmed responsibility for such referrals and acknowledged that the required referral was not completed after the new diagnosis. The administrator and DON were unaware that a new Level II PASRR was needed following a new mental health diagnosis. Another resident was admitted with a Level I PASRR, and a previous Level II PASRR was halted as the resident did not meet criteria for mental illness at that time. Later, the resident was diagnosed with unspecified psychosis and prescribed an antipsychotic medication, but no new Level II PASRR referral was documented. The social worker believed the previous PASRR determination was indefinite and did not require further action, and the administrator and DON were not aware that a new referral was necessary after a secondary mental health diagnosis.
Failure to Transcribe and Implement Monthly Catheter Change Order
Penalty
Summary
The facility failed to follow a urology provider's order to change the indwelling urinary catheter monthly for a resident with obstructive and reflux uropathy and neuromuscular dysfunction of the bladder. The resident had a history of urinary catheter use and was admitted to the facility with several physician orders related to catheter care, including cleansing every shift, monitoring output, changing the catheter when occluded or leaking, and anchoring the tubing. However, after a urology appointment, a new order was documented in the provider's progress note instructing the facility to change the catheter monthly. This order was not transcribed into the resident's active physician orders, nor was it scheduled on the Medication Administration Record or Treatment Administration Record for the appropriate month. Nurse interviews revealed that the nurse responsible for the resident on the day of the urology appointment did not notice or transcribe the monthly catheter change order, describing it as an oversight. The process for transcribing new orders from specialist appointments relied on the assigned nurse, and at the time, there was no unit manager to review and ensure the completeness and accuracy of transcribed orders. The Director of Nursing confirmed that all new orders from specialist appointments should be transcribed correctly and accurately, but this did not occur in this instance.
Failure to Ensure Medically Necessary Use and Proper Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. The report identifies a failure to ensure that feeding tubes are only used when medically necessary and with resident consent, as well as a lack of proper care for residents with feeding tubes.
Failure to Administer Prescribed Oxygen Rate and Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with a history of congestive heart failure and chronic obstructive pulmonary disease, physician orders specified oxygen at 2 liters via nasal cannula as needed for shortness of breath. However, multiple observations over several days revealed that the oxygen concentrator was set at 1.5 liters instead of the prescribed 2 liters. Nursing staff confirmed the discrepancy and were unable to explain why the ordered rate was not being administered, despite checking oxygen rates during medication passes. The Director of Nursing stated that her expectation was for oxygen to be delivered at the ordered rate. For another resident with severe cognitive impairment and a physician order for continuous supplemental oxygen at 2 liters per minute, two unsecured oxygen E cylinders were found stored upright in the resident's room. Facility policy and staff interviews indicated that oxygen cylinders should be stored in designated storage rooms with upright holders or in a transport caddy, not in resident rooms unsecured. The Director of Nursing confirmed that the cylinders should not have been left in the resident's room unsecured.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to follow the facility's infection prevention and control policies during medication administration. Specifically, during observation, the nurse did not perform hand hygiene before preparing or administering medications to two residents, nor did she perform hand hygiene between residents. Additionally, the nurse failed to perform hand hygiene before donning gloves and after removing gloves while administering eye drops to one of the residents. These actions were in direct violation of the facility's policies, which require hand hygiene before and after medication administration and before and after glove use during procedures such as eye drop administration. The nurse acknowledged during an interview that she was aware of the hand hygiene requirements but did not comply due to nervousness and forgetting the procedure. Interviews with the Nurse Practitioner, Director of Nursing, and Infection Preventionist confirmed that the expected practice is to perform hand hygiene between residents and before and after administering eye drops. The observations and staff interviews confirmed that the nurse's failure to perform hand hygiene constituted a breach of infection control protocols.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily as required, with a lapse occurring on one of the four days reviewed during the survey. On the initial day of the survey, the posted staffing information was found to be outdated, displaying a date from two days prior. Staff interviews revealed that the scheduler, who was responsible for posting the daily staffing data, was on vacation, and the responsibility for posting on weekends was delegated to the nursing staff. However, the nursing staff present were either unaware of the requirement or unfamiliar with the process, as one agency nurse stated it was her first day and she could not assist. The Director of Nursing confirmed the division of responsibility for posting, and the Administrator acknowledged the expectation that the schedule be posted accurately even in the scheduler's absence.
Failure to Maintain Clean and Odor-Free Resident Environment
Penalty
Summary
Surveyors observed that a resident's bathroom had yellow staining on the left front of the toilet seat, a trash can containing two soiled adult undergarments, and a strong urine odor present in both the room and bathroom. These conditions persisted over multiple days, with subsequent observations confirming the continued presence of urine odor, yellow staining on the toilet seat, and wetness on the floor around the toilet seeping toward the doorway. The resident was present in the room during all observations and did not have a roommate. Interviews with facility staff revealed that housekeeping had not yet cleaned the room during the initial observation due to their cleaning schedule, and the Housekeeping Director acknowledged that stains on toilet seats typically required maintenance to replace the seat. The Maintenance Director stated he had not received a work order to replace the toilet seat and only became aware of the issue during the interview. The Administrator confirmed that housekeeping was responsible for daily cleaning and ensuring the absence of strong odors in resident rooms.
Pharmacy Consultant Fails to Monitor Psychotropic Medication Effects
Penalty
Summary
The Pharmacy Consultant at the facility failed to identify the need for monitoring target behavioral symptoms and side effects of psychotropic medications for three residents. Resident #73, who was admitted with diagnoses including bipolar disorder and depression, had a history of mental health hospitalizations and was prescribed Fluphenazine. Despite displaying behaviors such as crying and suicidal thoughts, the Pharmacy Consultant's medication review notes did not reflect the need for monitoring these behaviors or side effects. Interviews with the Nurse Practitioner and the Pharmacy Consultant revealed an expectation for such monitoring, which was not met. Resident #82, with diagnoses including depression and dementia with behavioral disturbances, was prescribed Seroquel and Sertraline. The medication administration records lacked documentation of targeted clinical behavior identification and specific side effect monitoring. The Consultant Pharmacist, who started in February 2024, acknowledged the oversight in not identifying the irregularity and the importance of monitoring for adverse side effects. Interviews with the ADON and NP #1 highlighted the absence of documentation from the Consultant Pharmacist regarding the need for monitoring. Resident #68, diagnosed with conditions such as generalized anxiety disorder and Alzheimer's disease, was prescribed Olanzapine and Sertraline. Despite an increase in behaviors like yelling and aggression, the Pharmacy Consultant's medication review notes did not address the need for monitoring these behaviors or side effects. The Pharmacy Consultant admitted to not reviewing the MARs and failing to recommend the necessary monitoring. Interviews with the Nurse Practitioner reiterated the expectation for the Pharmacy Consultant to identify and address these monitoring needs.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to properly identify and monitor targeted clinical behaviors and side effects for residents prescribed psychotropic medications. Resident #82, who was admitted with diagnoses including depression, anxiety, and dementia with behavioral disturbances, was prescribed Seroquel and Sertraline. However, there was no documented evidence of targeted clinical behavior identification or clarification of side effects to be monitored. Interviews with staff revealed that the necessary checks for specific behaviors and side effects were not completed when the medication orders were entered. Resident #145, admitted with vascular dementia and major depressive disorder, was prescribed Seroquel on an as-needed basis for agitation and anxiety. The facility did not complete a baseline abnormal involuntary movement scale (AIMS) assessment at the time of the antipsychotic medication initiation, which is crucial for monitoring potential adverse side effects. The Assistant Director of Nursing mistakenly believed there was a 14-day window to complete the AIMS assessment, leading to a delay in establishing a baseline. Resident #73, with a history of bipolar disorder and depression, was prescribed Fluphenazine. The facility did not monitor specific behaviors or side effects associated with the antipsychotic medication, despite the resident's history of mental health concerns and recent hospitalizations. Similarly, Resident #68, diagnosed with anxiety, depression, and Alzheimer's disease, was prescribed Olanzapine and Sertraline without proper monitoring of targeted behaviors and side effects. The facility's failure to implement these monitoring protocols was confirmed through interviews with staff and a review of medication administration records.
Failure to Update Smoking Care Plan for Resident
Penalty
Summary
The facility failed to revise a smoking care plan to accurately reflect the level of supervision needed for a resident. Resident #77, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was assessed as a safe smoker not requiring supervision. However, the resident's quarterly Minimum Data Set (MDS) indicated cognitive impairment and a need for extensive assistance with most activities of daily living (ADL). Despite this, the care plan revised on 7/5/24 stated that the resident required supervision when smoking. Interviews with the MDS coordinator and the Administrator revealed that the care plan should have been updated to reflect the resident's status as an independent smoker following the smoking assessment on 5/8/24.
Medication Administration Route Error for Resident with Feeding Tube
Penalty
Summary
The facility failed to transcribe the correct medication administration route for a resident with a gastric feeding tube. The resident, who had severe cognitive impairment and required all nutrition and fluids via a feeding tube, was prescribed Guaifenesin Liquid to be administered by mouth, despite having a physician order indicating nothing by mouth (NPO). The error was identified during a review of the Medication Administration Record (MAR), which inaccurately listed the administration route as oral instead of via the gastric feeding tube. Interviews with nursing staff revealed that the default route in the electronic medical system was set to oral, and the oversight occurred when the nurse failed to change the route to gastrostomy tube during the verification process. The Assistant Director of Nursing confirmed the error and acknowledged that the expectation was for all medication administration routes to be entered correctly upon receipt and verification of the order.
Inaccurate MDS Coding for Range of Motion, Medications, and PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of range of motion, medications, and PASRR (Pre-Admission Screening and Resident Review). Resident #21, who was admitted with diagnoses including right foot drop and diabetes type 2, was found to have contractures in both lower extremities. However, the quarterly MDS assessment inaccurately coded the resident as having limited range of motion on only one side. This oversight was acknowledged by the MDS Nurse during an interview, and an observation confirmed the resident's inability to move her right leg and the presence of a contracture in the left leg. Resident #36, admitted with major depressive disorder and schizophrenia, was also subject to inaccurate MDS coding. Despite physician orders for daily antipsychotic medication, the MDS assessment failed to reflect this medication usage during the 7-day look-back period. Additionally, although the resident had a Level II PASRR determination due to schizophrenia, the MDS assessment did not accurately reflect this status. Both the MDS Nurse and the Social Worker acknowledged these oversights during interviews, and the Administrator confirmed the expectation for accurate MDS assessments.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Asheboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Health And Rehabilitation Of Asheboro | 1.5 mi | ★★★★★ | 0 | 0 |
| Clapp's Convalescent Nursing Home Inc | 2.4 mi | ★★★★★ | 2 | 0 |
| Ramseur Rehabilitation And Healthcare Center | 11 mi | ★★★★★ | 0 | 0 |
| The Graybrier Nursing And Retirement Center | 12.5 mi | ★★★★★ | 6 | 0 |
| Westwood Health And Rehabilitation | 14.9 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.