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Lake Way Rehabilitation and Healthcare Center

2607 Main Street, Benton, KY 42025 · For profit - Limited Liability company · 96 certified beds · (270) 527-3296 Medicare & Medicaid certified

Call the home — (270) 527-3296 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Oct 20201 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Oct 2020
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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
  • about 22% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
543 Powell Ln · (270) 415-7070 · Call to confirm hours
Pharmacy
2606 Main St · (270) 527-1409 · Call to confirm hours
Grocery
2602 Main St · (270) 527-4326 · Call to confirm hours
Park
Benton City Park, 201 E 17th St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 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 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.9%13.8%15.4%worse
Long-stay residents who lose too much weight8.4%6.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection2.0%1.6%2.0%typical
Long-stay residents with depressive symptoms9.5%17.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.6%3.9%3.3%better
Long-stay residents whose ability to walk worsened19.2%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication24.7%29.8%18.9%worse
Long-stay residents given the seasonal flu vaccine94.0%96.2%95.3%typical
Long-stay residents with pressure ulcers4.8%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control17.9%19.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.8%16.1%17.1%better
Short-stay residents who newly got an antipsychotic medication4.3%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine77.2%83.5%79.4%typical
Short-stay residents rehospitalized after admission27.4%24.2%22.6%worse
Short-stay residents with an outpatient ER visit4.7%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.991.941.67worse
Long-stay outpatient ER visits per 1,000 resident days1.742.141.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.4%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
55.8%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 55.8% 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 52 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.4%CMS range 43.0–58.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.9–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.88
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.50
Total nurse hours/ resident / day
0.65
RN hoursweekends
51.2%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 86.4 residents a day — about 90% occupied, or roughly 10 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.69 on weekdays — 19% thinner on weekends. RN hours go from 0.97 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

1
deficiencies at the latest standard inspection (2025-07-09)
3
at the previous standard inspection (2020-10-08)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2019-01-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy, it was determined the facility failed to ensure that each resident was free from mistreatment, abuse or neglect for one (1) sampled resident out of a selected sample of twenty-four (24) residents (Resident #17). Resident #17 alleged State Registered Nurse Aide (SRNA) #1 made rude or demeaning comments to him/her and he/she felt bullied. On [DATE], State Registered Nurse Aide (SRNA) #1 made the statement towards Resident #17 Gahh, Attitude much during lunch time tray pass. Resident #17's family member #1 reported the incident to Licensed Practical Nurse (LPN) #1 who then reported the incident to Registered Nurse (RN) #3 the on duty weekend supervisor. However, RN #3 did not report the incident to the Administrator. Resident #17 stated SRNA #1's behavior causes him/her a significant amount of anxiety and made him/her feel helpless. Resident #17 was tearful when explaining the effects these interactions had on him/her. The findings include: Review 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-09 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 interviews and review of facility policies, the facility failed to have a designated Infection Preventionist (IP) who was responsible for the facility's Infection Control Program which had the potential to affect 84 of 84 residents. The findings include:During the entrance conference on [DATE] at 9:21 AM, the Administrator stated the facility had an Infection Preventionist (IP).Review of the facility policy titled, Infection Prevention and Control Program dated 04/2023, revealed, the Infection Prevention and Control Program (IPCP) of the facility was designated to establish and maintain an effective program that provided a safe, sanitary and comfortable environment. Further review revealed the facility's IPCP attempted to prevent the development and the transmission of diseases and infections. Review of the facility policy titled, Infection Control Preventionist dated 04/2023, revealed the facility would designate an Infection Control Preventionist (ICP) in compliance with federal, state, or local laws.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-10-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, review of the facility investigation, and facility policy review, it was determined the facility failed to ensure medications were not misappropriated for two (2) of three (3) sampled residents (Resident #47 and Resident #57). On 05/20/2020, Licensed Practical Nurse (LPN) #1 notified the Director of Nursing that they were unable to reorder narcotic's for Resident #47 and Resident #57, because the pharmacy stated they had already sent them out on 04/13/2020 and 05/08/2020. The findings include: Review of the facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, last revised 03/10/2017, revealed the facility believes residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. 1. Record review revealed the facility admitted Resident #47 on 08/22/2013 with diagnoses which included Major…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2020-10-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, it was determined the facility failed to ensure expired medications were not stored and accessible in one (1) of three (3) medication storage carts. The findings include: Review of the facility policy titled, Provider of Pharmaceutical Services, dated September 2020, revealed the facility and [NAME] Medical Group shall provide appropriate methods and procedures for the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals to meet the needs of each resident. Pharmaceutical services are provided in accordance with accepted professional standards and appropriate federal, state and local laws. Consulting and clinical services shall be provided by [NAME] Medical Group. Review of facility policy titled, Return of Unused Medications dated September 2020, revealed medications may be returned to [NAME] Medical Group for reasons that a medication reached its expiration date. The policy outlined appropriate procedure for returning…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-10-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, it was determined the facility failed to ensure medical records, were complete and accurately documented for one (1) of three (3) sampled residents (Resident #30). The findings include: Review of facility policy titled, Medication Administration Person-Centered Care, last revised September 2020, revealed the facility guidelines was medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of facility policy revealed the individual who administers the medication dose records the administration on the resident's Medication Administration Report (MAR) at the time of administration. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Record review revealed the facility admitted…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-01-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on 01/08/19, revealed expired foods were being kept in the walk-in refrigerator, [NAME] #1 used her bare hand to place hard boiled eggs on a resident's lunch tray, and the side oven was visibly dirty with build up. In addition, observations of staff during dining room observation, revealed staff were handling residents' rolls, bread and straws with their bare hands. Review of the Census and Condition, dated 01/08/19, revealed seventy-five (75) of seventy-seven (77) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Use and Storage of Leftovers, last revised 01/23/18, revealed each day staff will check leftovers and throw out any foods that have been kept up to the maximum length of time allowed. Observation of the kitchen on 01/08/19 at 09:27 AM, revealed in the walk-in refrigerator a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-01-10 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 observation, interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents (Resident #17) and five (5) unsampled residents (Resident #35, Resident #34, Resident #39, Resident #70 and Resident #37) residents were treated with dignity and respect . On 12/22/18, a staff member asked Resident #17 if he/she wanted a lunch tray and the resident responded yes, then no, then yes and the staff member responded inappropriately by saying to the resident gahh, Attitude much. In addition, observations on 01/09/19 revealed a staff member entered Resident #35's, Resident #34's, Resident #39's, Resident #70's and Resident #37's rooms without knocking and/or identifying herself to residents before entering. The findings include: Review of the facility policy, Dignity, dated July 2013, revealed residents are given care and treatment in a manner that helps preserve their dignity, self-esteem, and self-respect. Each resident is valued…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-01-10 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of facility policy, it was determined the facility failed to have evidence allegations of abuse, or mistreatment, were thoroughly investigated by the facility or prevent further potential abuse while investigation in progress for one (1) of twenty-four (24) sampled residents (Resident #17) and three (3) unsampled residents (Residents #14, #58 and #46). Resident #17's Family Member #1 reported to Licensed Practical Nurse (LPN) #1 that State Registered Nurse Aide (SRNA) #1 made a rude and belittling comment to Resident #17. LPN #1 reported the alleged abuse/mistreatment to Registered Nurse (RN) #3, the weekend supervisor, on 12/22/18; however, RN #3 did not report the incident to the Administrator. The facility failed to remove SRNA from resident care and investigate the incident. SRNA was not removed from resident care until 01/08/19 at approximately 6:00 PM (approximately seventeen {17} days later). In addition, Resident #14 expressed concerns with aides shoving residents to hurry them up during resident council on 9/21/18. However, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents has the opportunity to exercise his or her autonomy regarding those things that are important in his or her life. Staff failed to provide Resident #49 the opportunity to choose which clothes he/she wanted to wear on a daily basis. The findings Include: Review of the facility policy, Residents Rights, not dated, revealed the discussion of Residents Rights will be included in the orientation of the new employees. The Administrator assumes the responsibility for the implementation of the Residents Rights. The facility also will ensure that their employees are trained on a regular basis regarding Resident Rights. Record review, revealed the facility admitted Resident #49 on 02/19/17 with diagnoses which included Major Depressive Disorder, Panic Disorder, and Anxiety Disorder. Review of Annual Minimum Data Set (MDS) assessment, dated 12/07/18, revealed the facility assessed Resident #49's cognition as intact with a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) of twenty-four (24) sampled residents, (Residents #15, #18, and #75). Staff failed to ensure Resident #15 was wearing bunny boot to left heel to prevent pressure ulcers and Resident #75 was wearing Multi Podus AFO boots to prevent foot drop; on 01/08/19 and 01/09/19, per care plan. In addition, the facility failed to develop a person-centered plan of care for infections although, Resident #18 had been hospitalized twice for a UTI, treated once for fever of unknown origin, and twice for an abscess to his/her right cheek. The findings include: Review of the facility's policy,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of twenty-four (24) sampled residents (Residents #38). Review of Resident #38's Comprehensive Care Plan revealed the facility failed to review and revise the care plan to address the resident's decline in bowel and bladder continence and put interventions in place to restore Resident #38's bowel and bladder continence to the extent possible. The findings include: Review of the facility's policy, Resident Care Plan, last revised 11/13/17, revealed it is the policy of the facility to provide a written resident-centered care plan based upon physician's orders, the assessment of the resident needs, and preferences, and pre-admission screening and resident review (PASRR). Any new problem or need of the resident, which is identified between his/her scheduled care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2019-01-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review and facility policy review, it was determined the facility failed to ensure services provided or arranged by the facility were provided according to accepted standards of clinical practice for one (1) of twenty-four (24) sampled residents (Resident #65). Observation of a medication pass on 01/09/19 revealed staff crushed Do Not Crush medication and administered it to Resident #65. The findings include: Review of facility policy titled, Crushing of Tablets and Emptying of Capsules, last revised 01/01/14, revealed the solid dosage forms of many medications should not be crushed or chewed for a variety of reasons and if crushing is contraindicated the nurse should consult the pharmacist for assistance in obtaining the medication in and alternate formulation, if possible. Record review revealed the facility admitted Resident #65 to the facility on [DATE] with diagnoses which included Coronary Artery Disease, Hypertension, Diabetes Mellitus and Hyperlipidemia. Review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, interview, record review, and facility policy review it was determined the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (3) of twenty-four (24) sampled residents (Residents #45, #8 and #5). The facility failed to ensure Resident #45 received adequate oral hygiene to prevent dry mouth and lips, and severe foul mouth odor, failed to provide nail care to Resident #5 due to dirty, long nails; and poor body hygiene to Resident #8 related to a dead skin build up on left foot. The findings include: Review of the facility policy titled, Oral Hygiene, dated April 2013, revealed the objective was to cleanse the mouth for personal hygiene, to lessen the occurrence of mouth infections, and to stimulate the gums. Further review revealed staff should explain procedure to the resident, place resident on his/her side if not able to be in a sitting…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents, received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan that will meet each resident's physical, mental, and psychosocial well-being (Resident #18). The facility failed to recognize and assess risk factors related to Resident #18's physical well-being resulting in a decline of the resident's health. The resident was hospitalized twice related to multiple infections, on 09/21/18 with Respiratory Failure, Right Lower Lobe (RLL) Pneumonia, Sepsis, and Lactic Acidosis; and on 10/04/18 with Right -Sided Pneumonia, and Mucous Plug of Tracheostomy. However, there was no care plan to address the resident's risk for respiratory infections or the resident's asking for and obtaining food and liquid when the resident was assessed as not being able to eat or drink by mouth (NPO). The findings include: Review of the facility's policy, Standard…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services to promote healing, and prevent new ulcers from developing unless clinically unavoidable for one (1) of twenty-four (24) sampled residents (Resident #15). Resident #15 was assessed by the facility to have an unstageable Pressure Ulcer to the left heel on 10/25/18 with an intervention to place specialty pressure relieving (bunny) boot to left heel as tolerated; however, observations on 01/08/19 and 01/09/19 revealed the boot was not on the resident's left heel. The findings include: Review of the facility's policy, Wound/Ulcer Treatment, dated 05/22/18, revealed the rationale is to provide guidelines for care and treatment of wound/ulcers understanding that treatment regimens may vary depending upon the needs of the wound, the patient, and the environment. Record review revealed the facility admitted Resident #15 on 06/14/18 with diagnoses which included Peripheral Vascular…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with limited range of motion (ROM) received appropriate services, care, and equipment to assure that ROM and mobility maintains is maintained for one (1) of twenty-four (24) sampled residents (Resident #75). Resident #75 was assessed and care planned to wear multi podus boots on both feet to minimize foot drop; however, observations on 01/08/19 and 01/09/19 revealed the resident did not have the podus boots on. The findings include: Interview with the Director of Therapy Services on 01/10/19 at 12:40 PM, revealed the facility does not have a policy related to Therapy Services. She stated she spoke with her Regional Boss and was informed there is not a policy regarding therapy services however, therapy services are communicated with the Interdisciplinary Team (IDT). She revealed therapy services are requested by physician order, and residents are evaluated to determine if treatment is needed. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of twenty-four (24) sampled residents (Resident #65). Resident #65 was assessed to require two (2) staff for toileting as the resident was unsteady moving on/off the toilet and only able to stabilize with staff assistance. However, on 12/09/18, two (2) staff transferred the resident to the toilet and left the resident unattended which resulted in a fall. The resident sustained an abrasion to left knee and scratch to right side of nose. The findings include: Review of the facility policy titled, Fall Risk Protocol, dated 11/20/12, revealed the objective of this protocol is to implement guidelines to identify a resident's risk for falls. The protocol will seek to prevent the resident's fall and/or minimize injury from a fall, plan the resident's safety within the facility, and to periodically review and evaluate 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible or ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain, for two (2) of twenty-four (24) sampled residents (Residents #18 and #38). Resident #38 had a decline in bladder and bowel continence; however, the facility failed to assess the type of incontinence and to develop interventions to try to improve or maintain his/her bowel and bladder continence. In addition, observation of Resident #18's perineal care on 01/09/19 revealed the staff member failed to educate the resident (who was going to do his/her own perineal care) on the proper technique related to ensuring to clean from front to back, and did not provide the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-01-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 interview, record review, and facility policy review, it was determined the facility failed to ensure that medical records on each resident are complete and accurately documented in accordance with accepted professional standards and practices for one (1) of twenty-four (24) sampled residents (Resident #34). Review of the Falls Risk Assessments dated 10/16/18 and 01/04/19 revealed staff inaccurately documented Resident #34 had no falls in the last one-hundred twenty (120) days, no devices in use, and was not a risk for falls. Observation and record review revealed the resident had devices in use, had a fall on 10/26/18, and if documented accurately would have been assessed as a high risk for falls. The findings include: Interview on 01/10/19 at 3:30 PM with the Administrator revealed there was no documentation policy. Record review revealed the facility admitted Resident #34 on 06/02/17 with diagnoses which included Cognitive Communication Deficit, Left Hip Pain, Lack of Coordination, Need 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure proper incontinent/perineal care was performed for two (2) of twenty-four (24) sampled residents (Residents #45 and #74). Staff failed to remove gloves after providing incontinent care to Resident #45 and #74 and before touching non-contaminated items and environmental services per facility policy. The findings include: Review of facility policy titled, Standard Precautions, dated September 2014, revealed for staff to wear gloves when touching blood, bodily fluids, secretions, excretions, and contaminated items. Put on gloves just before touching mucous membranes or non-intact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly, before touching non-contaminated items and environmental surfaces and before going to another resident, and wash hands to avoid transfer of microorganism to other residents or environments. 1. Record review…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-01-10 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and review of the Skilled Nursing Facility Beneficiary Protections Notifications it was determined the facility failed to ensure they issued the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents/beneficiaries when Medicare covered services were ending for three (3) of three (3) Medicare Discharges reviewed which included one (1) of twenty-four (24) sampled residents (Resident #75) and two (2) unsampled residents (Resident #56 and #30). Review of Residents' #75, #56 and #30's Medicare Discharges, revealed the facility did not issue a SNFABN CMS Form 10055. The findings include: Interview with the Administrator on 01/09/19 10:35 AM, revealed the facility did not have a specific policy related to beneficiary protection notices and they follow federal guidelines. 1. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #75 from Medicare Part 'A' services with the last covered day being 12/24/18; however, the resident still…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-01-10 · tag F0623 — pattern
    Provide 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 interview and record review, it was determined the facility failed to give notification of transfer/discharge to the Ombudsman per regulatory guidelines for three of twenty-four (24) sampled residents (Residents #15, #19, and #74). The findings include: Interview with the facility Administrator on 01/10/19 at 4:40 PM revealed the facility has no policy on Ombudsman notification. 1. Record review revealed the facility admitted Resident #15 on 06/14/18 with diagnoses which included Diabetes, Peripheral Vascular Disease, and Dependence on Dialysis. Review of Nursing Notes revealed the resident was admitted to the hospital on [DATE] for worsening of foot wound and readmitted to the facility on [DATE]. Further review of the record revealed there was no documented evidence the Ombudsman was made aware of the transfer/discharge. 2. Record review revealed the facility admitted Resident #19 on 09/21/18 with diagnoses which included Dependence on Renal Dialysis, Diabetes, and Osteoarthritis. Review of Nursing…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-01-10 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 interview, record review, and facility policy review it was determined the facility failed to ensure that residents and or residents representatives are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility for three (3) of twenty-four (24) sampled residents (Residents #15, #19, and #74). The facility failed to provide bed hold notices for Residents #15, #19, and #74 at the time of transfer/discharge to the hospital. The findings include: Review of the facility policy titled, Bed hold and admission Rights, dated July 2013, revealed when hospitalized or on therapeutic leave (over night stay in a non-health cafe setting), a resident can retain his/her bed in the facility by paying for the bed to be held. Payment can be made by private funds, by insurance coverage, or by the Medicaid program. An information sheet is sent with the resident to the hospital which includes a description 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 3 of 53.3-0.3 vs chain
The other 39 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Ayden Court Nursing and Rehabilitation CenterAyden, NC 1 of 5Greendale Forest Nursing and Rehabilitation CenterSnow Hill, NC 1 of 5River Trace Nursing and Rehabilitation CenterWashington, NC 1 of 5Somerwoods Rehabilitation and Healthcare CenterSomerset, KY 1 of 5University Place Nursing and Rehabilitation CenterCharlotte, NC 2 of 5Cherry Point Bay Nursing and Rehabilitation CenterHavelock, NC 2 of 5Clear Creek Nursing & Rehabilitation CenterMint Hill, NC 2 of 5Graham Healthcare and Rehabilitation CenterRobbinsville, NC 2 of 5Greenwood Rehabilitation and Healthcare CenterBowling Green, KY 2 of 5Macon Valley Nursing and Rehabilitation CenterFranklin, NC 2 of 5Magnolia Lane Nursing and Rehabilitation CenterMorganton, NC 2 of 5Northchase Nursing and Rehabilitation CenterWilmington, NC 2 of 5Tower Nursing and Rehabilitation CenterRaleigh, NC 2 of 5Westwood Hills Nursing and Rehabilitation CenterWilkesboro, NC 2 of 5Willow Creek Nursing and Rehabilitation CenterGoldsboro, NC 3 of 5Bethany Woods Nursing and Rehabilitation CenterAlbemarle, NC 3 of 5Franklin Oaks Nursing and Rehabilitation CenterLouisburg, NC 3 of 5Greenhaven Health and Rehabilitation CenterGreensboro, NC 3 of 5Harmony Hall Nursing and Rehabilitation CenterKinston, NC 3 of 5Pine Ridge Health and Rehabilitation CenterThomasville, NC 3 of 5Piney Grove Nursing and Rehabilitation CenterKernersville, NC 3 of 5Premier Nursing and Rehabilitation CenterJacksonville, NC 3 of 5Richmond Pines Healthcare and Rehabilitation CenteHamlet, NC 3 of 5Riverpoint Crest Nursing and Rehabilitation CenterNew Bern, NC 3 of 5Smoky Mountain Health and Rehabilitation CenterWaynesville, NC 3 of 5Springbrook Nursing and Rehabilitation CenterClayton, NC 4 of 5Barbour Court Nursing and Rehabilitation CenterSmithfield, NC 4 of 5Carolina Rivers Nursing and Rehabilitation CenterJacksonville, NC 4 of 5Chowan River Nursing and Rehabilitation CenterEdenton, NC 4 of 5Croatan Ridge Nursing and Rehabilitation CenterNewport, NC 4 of 5Kerr Lake Nursing and Rehabilitation CenterHenderson, NC 4 of 5Lake Park Nursing and Rehabilitation CenterIndian Trail, NC 4 of 5Northampton Nursing and Rehabilitation CenterJackson, NC 4 of 5Wayland Nursing And Rehabilitation CenterKeysville, VA 4 of 5Wilson Pines Nursing and Rehabilitation CenterWilson, NC 5 of 5Grantsbrook Nursing and Rehabilitation CenterGrantsboro, NC 5 of 5Harnett Woods Nursing and Rehabilitation CenterDunn, NC 5 of 5Jacob's Creek Nursing and Rehabilitation CenterMadison, NC 5 of 5Maple Grove Health and Rehabilitation CenterGreensboro, NC

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
BOICE, GALEIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/05/2018
JOHNSON, DIANNEIndividualCORPORATE OFFICERsince 01/01/2011
PRINCIPLE LONG TERM CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2011
HOOD, LYNNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/08/2017
HILL, RAYMONDIndividualADP OF THE SNFsince 01/01/2011
HILL, ROBERTIndividualADP OF THE SNFsince 01/01/2011
HILL, STEPHENIndividualADP OF THE SNFsince 01/01/2011
MCCLELLAN, RANDALLIndividualADP OF THE SNFsince 07/01/2025
ZETTER, DAVIDIndividualADP OF THE SNFsince 02/01/2023

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.0M
Net patient revenuemost recent cost report
-14.9%
Operating marginrevenue minus expenses
$1.8M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 13%Other / private 20%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$334per resident / day
operating cost
$10,155per month
≈ monthly operating cost
$291per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kentucky Medicaid page.

Typical monthly cost in Kentucky
$9,718/mo
Nursing home (semi-private)
$11,254/mo
Nursing home (private)
$5,528/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 185258. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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