Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Biltmore Haven Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Obtain Immediate Assessment After Van Fall: A driver failed to have a resident medically assessed after the resident’s wheelchair tipped backward in a transport van and his head struck the floor. The driver moved the resident back upright and returned him to the facility without calling EMS or immediately notifying the DON or a nurse. The injury was later discovered when a bump and abrasion were noted on the back of the resident’s head, and the resident reported the van fall. The resident was later found to have a hematoma and abrasion, with CT showing no intracranial injury.
A resident was transported in a facility van when the driver failed to properly secure the wheelchair and lap belt per manufacturer instructions. The driver later stated he was in a hurry and attached the front tie-downs incorrectly and routed the lap belt through the wheelchair side panels instead of next to the resident. As the van pulled away from a stop light, the wheelchair tipped backward and the resident hit his head on the van floor, resulting in a hematoma and abrasion; a head CT showed no acute intracranial abnormality.
The facility did not accurately submit RN and licensed nurse staffing data to CMS through the PBJ system, as hours worked by salaried staff and nurses from sister facilities were not consistently recorded or manually adjusted, resulting in reported gaps in RN and 24-hour licensed nursing coverage.
Multiple residents were affected when controlled medications, including clonazepam and oxycodone, went missing after being removed from medication carts by the former DON. Documentation and interviews revealed that required procedures for tracking and returning controlled substances were not consistently followed, resulting in significant quantities of medication and their count sheets being unaccounted for. The facility's process failures allowed for the misappropriation of resident medications.
Staff failed to label and date opened multi-dose oral inhalers and eye drops on several medication carts, with multiple opened medications found undated and some lacking resident identification. Interviews with medication aides, a nurse, and the DON confirmed that all opened medications should be labeled with the date opened and the resident's name, but this was not consistently done.
The facility did not follow the posted menu when a cook ran out of regular consistency carrots during lunch meal service, resulting in 7-9 residents receiving a substitute vegetable instead. The cook did not notify the DM of the shortage until meal service had begun, preventing timely correction.
Surveyors found that bread and buns were stored past their use by dates in the dry goods area, and a walk-in refrigerator had a water leak dripping onto food containers and a circulatory fan cover with a thick buildup of debris. The Dietary Manager was responsible for ensuring timely removal or freezing of bread, and the fan cover was not on a regular cleaning schedule.
A resident with Parkinson's disease and impaired mobility did not receive scheduled bathing or shaving assistance as required by their care plan. The resident was observed with significant facial hair growth and reported not being bathed or shaved as expected. Documentation of ADL care was inconsistent, and the assigned NA declined to shave the resident due to personal limitations, failing to ensure the task was completed by another staff member.
Nurse aides did not have documented competency checks and failed to follow proper hand hygiene and infection control practices during incontinence and catheter care for a resident. One aide was observed not removing soiled gloves or performing hand hygiene before applying a clean brief and touching items in the environment, and also did not wear a gown during catheter care for a resident requiring enhanced barrier precautions.
The facility did not ensure that nurses documented essential information in the medical records for three residents, including details of admission, discharge, and death. In each case, required progress notes were missing, and staff interviews confirmed that these omissions were not in line with facility expectations.
A resident with intact cognition was not invited to participate in a care plan meeting after returning from a hospital stay, as the meeting was cancelled during hospitalization and not rescheduled. The responsible social worker acknowledged the oversight, and the administrator confirmed that no follow-up or care plan meeting occurred after the resident's return.
A resident with diabetes and GERD, who was cognitively intact, was found to have multiple medications at bedside and reported self-administering them as needed. There was no documented assessment or care plan for self-administration, and nursing staff were unaware the medications were present. The DON confirmed that required assessments and physician orders for self-administration were not completed, and that medications should not have been stored in the resident's room.
A resident with multiple complex diagnoses who wished to transfer to a SNF closer to family did not have a documented or effective discharge planning process. Despite repeated requests from the resident and family, referrals were inconsistently documented, lacked follow-up, and did not include responses from potential receiving SNFs, resulting in the resident's preferences not being met.
Two residents had inaccurate Minimum Data Set (MDS) assessments, with one resident's schizophrenia diagnosis omitted from a quarterly MDS despite ongoing antipsychotic therapy, and another resident incorrectly coded as having PTSD despite no supporting history. Staff interviews confirmed these were coding errors and not in line with facility expectations.
Several residents, including those with diabetes, respiratory failure, muscle weakness, colostomy, and dementia, did not have baseline care plans completed or accurately documented within 48 hours of admission. The DON and Administrator confirmed these omissions and oversights, with some baseline care plans missing entirely and others lacking critical information about residents' conditions.
A resident with chronic respiratory failure and COPD received supplemental oxygen without the physician's order specifying the flow rate or delivery method, and no cautionary signage was posted to indicate oxygen use in the room. The DON and administrator confirmed these omissions, noting the lack of signage was due to an after-hours admission and the incomplete order was an oversight.
A resident with hemiplegia and chronic pain was provided with quarter bed rails to assist with bed mobility, but the facility did not complete a required assessment for entrapment risk before installing or using the bed rails. Staff interviews revealed that the assessment was overlooked because the bed rails were ordered by Hospice, contrary to facility policy.
A nurse aide did not wear a gown while providing urinary catheter care to a resident on enhanced barrier precautions and failed to remove gloves and perform hand hygiene after cleaning stool and before touching other items in the environment. Facility leadership confirmed that these actions did not follow established infection control policies.
Surveyors found that personal care items in two shared bathrooms were not labeled or properly stored, and PTAC units in six resident rooms had multiple broken slats and other disrepair. The DON confirmed staff responsibility for labeling and covering items, while the Maintenance Director and Administrator acknowledged the PTAC issues had not been addressed or reported as expected.
Failure to Obtain Immediate Medical Assessment After Van Fall
Penalty
Summary
Driver #1 failed to have Resident #1 assessed for injury by a qualified medical professional before moving him after a fall in the facility transport van. Resident #1 was seated in his wheelchair when it tipped backward in the van, and his head hit the van floor. Driver #1 then lifted Resident #1 and the wheelchair back upright and returned him to the facility without calling EMS or obtaining an immediate medical assessment. Driver #1 later stated he was not qualified to assess the resident for injury after the fall and acknowledged he should have called 911. Resident #1 was admitted with diagnoses including type 2 diabetes mellitus, acute respiratory failure with hypoxia, cognitive communication deficit, and bilateral upper extremity and left above-knee amputations. The quarterly MDS indicated he was cognitively intact, required maximum assistance with transfers and wheelchair locomotion, and had no pain or blood thinner use during the look-back period. After the van incident, staff later noted a raised area on the back of his head when MA #1 cut his hair, and Resident #1 reported that he had fallen backward in the wheelchair in the van and hit his head on the floor. The ADON assessed Resident #1 and found a hematoma and abrasion to the back of the head. Neurological checks were started, and the NP and Medical Director later documented that Resident #1 had a posterior occipital hematoma but remained alert and oriented, with no intracranial injury on CT. The report also states that Driver #1 did not immediately notify the Administrator, DON, or a nurse when he returned to the facility, and staff learned of the incident only after the head injury was noticed during the haircut and Resident #1 described what had happened.
Improper wheelchair securement during transport caused resident fall
Penalty
Summary
Driver #1 failed to safely secure a resident in the facility transport van on 03/02/2026 when the resident was being taken to a medical appointment in his wheelchair. The resident had diagnoses including type 2 diabetes mellitus, acute respiratory failure with hypoxia, cognitive communication deficit, acquired absence of the left leg above the knee, and absence of both hands. The quarterly MDS indicated he was cognitively intact, had functional limitations in range of motion of both upper and lower extremities, required substantial to maximum assistance with transfers and locomotion by manual wheelchair, had no pain during the look-back period, and was not receiving blood thinners. Manufacturer instructions for the van’s wheelchair securement system required the rear retractors to be attached to a structural member of the wheelchair, the front or rear retractors to be tensioned as needed, and the lap belt to be worn low across the pelvis and positioned directly next to the resident, not over wheelchair arm rests or side panels. Driver #1 later stated he was in a hurry when loading the resident and did not realize one wheelchair retractor tie-down was loose. He also stated he placed the lap belt through the opening in the side panels of the wheelchair rather than directly next to the resident. During a later demonstration, he showed that he had attached the front retractors to the outer structure of the wheelchair rather than a secure structure underneath it. While the van was moving away from a stop light, the resident’s wheelchair tipped backward and the resident hit his head on the van floor. Driver #1 stated he heard a loud bump, stopped the vehicle, found the resident with his head on the floor, and then raised him back upright in the wheelchair. The resident stated the wheelchair fell backward when the van pulled away from the stop light and that he hit his head on the floor. Facility staff later noted a hematoma and abrasion to the back of the resident’s head, and the resident’s head CT showed no acute intracranial abnormality.
Inaccurate PBJ Staffing Data Submission Due to Incomplete Manual Adjustments
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one of the three quarters reviewed. Specifically, the PBJ report for Quarter 1 of Fiscal Year 2025 showed missing Registered Nurse (RN) hours on several dates and indicated a lack of licensed nursing coverage for 24 hours on multiple days. However, a review of daily staff schedules and nursing staff time detail reports revealed inconsistencies, with some records showing RN presence for at least 8 hours and licensed nursing coverage, while others did not. The discrepancies were particularly noted for specific dates where either RN hours or 24-hour licensed nursing coverage were not properly documented. Interviews with facility leadership revealed that the Administrator and Director of Nursing, both RNs and salaried employees, often worked nursing shifts but did not clock in or out, resulting in their hours not appearing in the time detail reports. Additionally, when nurses from sister facilities worked at this location, their hours were not automatically recorded due to system limitations, requiring manual adjustments by the corporate office. The corporate office was not always consistent in manually inputting these hours, leading to inaccurate PBJ submissions and triggering findings of insufficient RN and licensed nursing coverage.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of their controlled medications, resulting in missing narcotics for four residents. The facility's policy required that all residents be free from misappropriation of property, including medications. However, for each of the four residents reviewed, there were significant discrepancies between the number of controlled substance tablets received from the pharmacy, the number documented as administered, and the number that should have remained in the facility. In each case, the controlled substances and their declining count sheets were removed from the medication cart by the former DON, with documentation indicating the medications were to be returned to the pharmacy, but there was no record of return and the medications could not be accounted for. For one resident with anxiety and bipolar disorder, 60 tablets of clonazepam were received, but only 5 were documented as administered, leaving 55 unaccounted for after the former DON removed the medication from the cart. For three other residents with chronic pain or recent fractures, similar patterns occurred with oxycodone: the number of tablets received, administered, and remaining did not match, and significant quantities of the medication were missing after being removed from the cart by the former DON. In all cases, the declining count sheets were also missing, and there was no evidence that the medications were returned to the pharmacy as required. Interviews and documentation revealed that the process for removing and returning controlled substances was not consistently followed, particularly the requirement for two signatures when removing narcotics from the medication cart. The facility's investigation, supported by pharmacy audits and interviews with staff and law enforcement, identified a breakdown in the process that allowed the medications to go missing. Law enforcement was unable to determine the exact circumstances of the diversion due to gaps in documentation and access, but confirmed that the facility's process failures contributed to the loss of resident medications.
Failure to Label and Date Opened Multi-Dose Medications on Medication Carts
Penalty
Summary
Surveyors observed that staff failed to properly label and date multi-dose oral inhalers and eye drops on three of four medication carts reviewed. Specifically, multiple opened bottles of eye drops and inhalers were found without opened dates or resident names, despite manufacturer recommendations to date these medications upon opening and discard them within specified timeframes. Some medications were also found unlabeled, lacking the resident's name. These observations were made in the presence of medication aides, nurses, and the Assistant Director of Nursing, who confirmed that all opened medications should be labeled with the date opened and the resident's name. Interviews with staff, including medication aides, a nurse, the DON, and the Administrator, revealed a lack of awareness or oversight regarding the requirement to label and date opened medications. The DON stated that third shift staff were responsible for checking medication carts nightly to ensure compliance, and the Administrator confirmed the expectation that all medications be labeled and dated at the time of opening. Despite these expectations, the deficiency was observed across multiple medication carts.
Failure to Follow Posted Menu Due to Insufficient Food Item
Penalty
Summary
The facility failed to follow the posted menu and meal spreadsheet when they ran out of regular consistency carrots while plating meals for lunch. The menu for the day specified Swedish meatballs with gravy, buttered noodles, and sliced carrots. During the lunch meal service, it was observed that the last serving of regular consistency carrots was plated before all residents on the 300 hall had been served, resulting in 7-9 residents not receiving the menu-specified carrots. Instead, capri vegetables (mixed vegetables) were prepared and served as a substitute. The cook reported that she normally needed six bags of carrots but only had five available for the meal. She did not notify the Dietary Manager about the shortage until the tray line had already started. The Dietary Manager confirmed that, had she been notified earlier, additional carrots could have been purchased to meet the menu requirements. The Administrator stated that the posted menu should be followed and that the cook should have communicated the shortage as soon as it was identified.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen, as observed during a survey. In the dry goods storage area, multiple loaves of sliced bread and packages of hamburger buns were found stored past their use by dates. The fill-in Dietary Manager stated that the procedure was to remove bread from the rack and freeze it before the use by date, and that the regular Dietary Manager was responsible for this task. The expired bread remained on the rack, indicating a lapse in following established procedures for food storage. Additionally, in the walk-in refrigerator, a steady drip of water was observed coming from a pipe connected to the refrigeration unit, with water dripping onto a container of pickles and pooling on the floor. The circulatory fan cover in the refrigerator was also found to have a thick buildup of a crumbly black and gray substance. The fill-in Dietary Manager was unaware of how long the water leak had been present and stated he would notify maintenance. The regular Dietary Manager confirmed that the fan cover should be included in a regular cleaning schedule and that he was responsible for ensuring bread was frozen by the use by date. The Maintenance Supervisor was not aware of the water leak prior to being notified and stated the fan cover was not on a routine cleaning schedule.
Failure to Provide ADL Care and Personal Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease and generalized muscle weakness, who required assistance with activities of daily living (ADLs), did not receive appropriate personal hygiene care. The resident's care plan specified the need for set-up or clean-up assistance with personal hygiene, including shaving and bathing on scheduled days. Despite these interventions, observations revealed the resident had not been shaved and had not received a bath for a week, as evidenced by the presence of long whiskers and beard hair. The resident reported a preference for being shaved and stated he was unable to shave himself, believing he had only been shaved once during the month. Review of facility records showed inconsistencies in documentation, with no record of showers or bathing for the resident throughout the month, despite shower sheets indicating otherwise. During an interview, the nurse aide assigned to the resident admitted to not feeling comfortable shaving him due to her own arm tremors and could not recall who, if anyone, was asked to complete the shaving. The aide also acknowledged sometimes forgetting to complete shower documentation. The Director of Nursing confirmed that shower sheets should be completed after each bath or shower and that the resident should have been shaved if requested.
Failure to Ensure Nurse Aide Competency and Adherence to Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated the necessary competencies and skills to provide individualized care, particularly regarding hand hygiene during incontinence care. Record reviews revealed that three nurse aides did not have documented evidence of skills or competency checks upon hire or at any time thereafter. Specifically, one nurse aide was observed not removing soiled gloves and not performing hand hygiene before applying a clean brief and touching other items in a resident's environment after providing incontinence care to a dependent resident. Additionally, the same nurse aide did not don a gown while providing urinary catheter care to a resident who required enhanced barrier precautions due to the presence of a urinary catheter. During an interview, the nurse aide stated she had not received any training from the facility regarding proper glove removal, hand hygiene, or the application of clean gloves after incontinence care. These findings were based on both employee file reviews and direct observation of care practices.
Failure to Document Key Resident Events in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting key events such as admission, discharge, or death. For one resident, there was no progress note documenting her admission, including the time of arrival, condition, or care needs, despite her profile page indicating the admission date. The Director of Nursing (DON) confirmed that a progress note should have been written at the time of admission, and attributed the omission to the admission occurring after normal business hours. Another resident's medical record lacked documentation regarding the circumstances of his death, including how he was found, the time of death, and notifications made, even though the Minimum Data Set (MDS) indicated a death in the facility. Similarly, a third resident's record did not include a nurse's note about his discharge home, such as the time of departure, who accompanied him, or his condition at discharge, although all required discharge notices were issued. Staff interviews confirmed that nurses were responsible for these entries and were unable to explain the omissions.
Failure to Reschedule and Hold Care Plan Meeting After Hospitalization
Penalty
Summary
A resident with intact cognition was admitted to the facility and had previously attended care plan meetings, as documented in the records. A quarterly care plan meeting was scheduled but was cancelled due to the resident's hospitalization. Upon the resident's return to the facility, there was no documentation that the care plan meeting was rescheduled or that the resident was invited to participate in the care planning process. The resident expressed a desire to participate in care plan meetings and reported not having attended one during the current year. The social worker, who was responsible for scheduling care plan meetings and inviting alert and oriented residents, acknowledged that the meeting was not rescheduled after the resident's return from the hospital. The administrator confirmed that the failure to reschedule the care plan meeting was an oversight and that there was no follow-up note or meeting held with the resident after his return.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required. The resident, who was admitted with diagnoses including type 2 diabetes and gastroesophageal reflux disease, had a physician's order for antacid medication. The resident was coded as cognitively intact on her most recent MDS assessment. However, there was no care plan or documented assessment for self-administration of medication in her medical record. During an observation, surveyors found multiple medications, including a partially used bottle of liquid bismuth, chewable antacids, and an unopened topical treatment, at the resident's bedside. The resident stated she took these medications when needed and had them delivered to her. Nursing staff confirmed that the resident was not assessed for self-administration and should not have had medications stored in her room. The assigned nurse was unaware of the presence of these medications and removed them upon discovery. The DON reported that the resident frequently ordered medications to be delivered and refused to allow staff to search her belongings. The DON also acknowledged that a self-administration assessment and a physician's order were required for the resident to self-administer medications, and that medications should be stored on the nurse's medication cart, not in the resident's room.
Failure to Document and Follow Up on Discharge Referrals
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident with complex medical needs, including quadriplegia, pressure ulcer, osteomyelitis, bipolar disorder, and anxiety disorder. The resident had an active care plan indicating a desire to transfer to a skilled nursing facility (SNF) closer to family. Documentation showed that only one referral was made to a nearby SNF at the family’s request, with no follow-up or record of the SNF’s response. There was no evidence of additional referrals or follow-up actions documented in the resident’s record over several months, despite ongoing requests from the resident and family. Interviews with the resident, family member, and social worker (SW) revealed that the family repeatedly requested referrals and follow-up, but the SNF in question had not received any referrals, and the SW did not return calls. The SW stated that she sent several referrals but did not document the names or contact information of the SNFs, only the cities, and did not follow up with the facilities after sending referrals. The administrator confirmed that while referrals were sent, there was no consistent documentation or follow-up process in place. This lack of documentation and follow-up resulted in the resident’s discharge preferences and needs not being adequately addressed.
Inaccurate MDS Coding for Active Diagnoses
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the documentation of active diagnoses. One resident was admitted and re-admitted with a diagnosis of paranoid schizophrenia, which was present on admission and supported by physician orders for antipsychotic therapy. However, the resident's quarterly MDS assessment did not include an active diagnosis of schizophrenia, despite the annual MDS and physician orders indicating its presence. The MDS Nurse reported that she was directed by the corporate office not to code schizophrenia on the MDS after the annual assessment, citing insufficient supporting documentation at the time of admission, and acknowledged that the annual MDS had been incorrectly coded to include the diagnosis. Another resident was admitted with a diagnosis of depression, but the admission MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD). A psychiatry evaluation confirmed that the resident did not have a history of PTSD, and the MDS Coordinator acknowledged this was a coding error. Both the DON and the Administrator confirmed their expectation that MDS assessments should be coded accurately. These inaccuracies in MDS coding were identified through record review and staff interviews.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing residents' immediate needs within 48 hours of admission for four residents. For one resident with diabetes, chronic respiratory failure, and COPD, no baseline care plan was initiated or completed within the required timeframe, despite the resident receiving insulin, antidepressants, and diuretics. The DON acknowledged that either she or the nurse should have completed the baseline care plan but could not explain the omission. Another resident with muscle weakness was admitted and later discharged home without a baseline care plan ever being included in the medical record. The DON confirmed this was overlooked, and the Administrator was unaware of the omission. A third resident admitted with a colostomy had a baseline care plan that did not reflect the presence of the colostomy, despite the admission MDS assessment indicating it. The DON stated this was an oversight. For a fourth resident with lack of coordination and dementia, no baseline care plan was found in the medical record, and the DON confirmed that the interdisciplinary team was responsible for its completion. The Administrator stated her expectation that baseline care plans be completed within 48 hours of admission and be accurate.
Failure to Post Oxygen Safety Signage and Incomplete Oxygen Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order for supplemental oxygen did not specify the required flow rate or the delivery method, such as nasal cannula, for the resident. Despite the resident receiving oxygen via nasal cannula at a flow rate of 3 liters per minute, this information was not documented in the physician's order. The DON acknowledged that the omission of the flow rate in the order was an oversight when entering the information into the electronic medical record. Additionally, the facility did not post cautionary or safety signage indicating that oxygen was in use in the resident's room, on the door, or doorframe during multiple observations. The DON confirmed that signage should have been posted according to facility process, but it was overlooked, particularly because the resident was admitted after normal business hours. The administrator also confirmed that orders should include the amount of oxygen to be administered and that cautionary signage should be posted for residents receiving supplemental oxygen.
Failure to Assess for Entrapment Risk Prior to Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment prior to the installation and use of bed rails. A resident with a history of hemiplegia, hemiparesis, left knee contracture, and chronic pain was observed using quarter bed rails in the upright position on both sides of her bed. The resident reported using the bed rails to reposition herself while in bed. Review of the resident's electronic medical record revealed no documentation of an assessment for entrapment risk before the bed rails were installed or used. Interviews with staff indicated that bed rail assessments were typically completed when therapy recommended bed rails for independent bed mobility, and reassessments were conducted quarterly. However, the DON stated that an assessment was not completed in this case because the bed rails were ordered by Hospice. The Administrator confirmed that bed rail assessments were expected to be completed according to facility policy, but this was not done for the resident in question.
Failure to Implement Infection Control Policies During Catheter and Incontinence Care
Penalty
Summary
Nurse Aide (NA) #3 failed to follow the facility's infection control policies while providing care to a resident who required enhanced barrier precautions (EBP) due to the presence of a urinary catheter. During the observed care, NA #3 did not don a gown as required by the EBP policy when performing urinary catheter care, despite signage and supplies being available at the resident's door. The resident was on EBP, which mandates gown and glove use during high-contact activities such as device care, but NA #3 was unaware of this requirement. Additionally, NA #3 did not adhere to the facility's hand hygiene policy during incontinence care. After cleaning stool from the resident, NA #3 failed to remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment. Interviews with the NA, Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator confirmed that the expected procedures were not followed, as staff are required to remove gloves and perform hand hygiene after contact with stool and before touching other surfaces or items.
Failure to Label Personal Items and Maintain PTAC Units in Good Repair
Penalty
Summary
Surveyors observed that the facility failed to properly label and store personal care items in shared bathrooms and did not maintain packaged terminal air conditioners (PTACs) in good repair in several resident rooms. Specifically, in two shared bathrooms, items such as toothbrushes, bedpans, and denture cups were found unlabeled and, in some cases, uncovered, despite repeated observations over multiple days. The DON confirmed that nursing staff were responsible for ensuring personal items were labeled and covered, and that this should be monitored as staff entered and exited shared bathrooms. Additionally, in six resident rooms, PTAC units were found with multiple broken slats and, in one case, a control cover hanging off the front. These issues were observed repeatedly over several days. The Maintenance Director acknowledged being aware of the need for PTAC repairs but had not yet addressed the units on the affected hall. The Administrator was unaware of the PTAC issues and stated that management should have identified and reported these problems during daily room rounds.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 125 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fletcher Rehabilitation And Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
| Givens Health Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Deerfield Episcopal Retirement | 3 mi | ★★★★★ | 1 | 0 |
| The Lodge At Mills River | 4.5 mi | ★★★★★ | 0 | 0 |
| Fleshers Fairview Health Care | 6.1 mi | ★★★★★ | 23 | 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 July 2026) and official state health department websites.