Holly Springs Rehabilitation And Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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.

54.1% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 90.3 residents a day — about 75% occupied, or roughly 30 beds typically open. It usually has some room. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.24 hrs/resident/day on weekends vs 3.79 on weekdays — 14% thinner on weekends. RN hours go from 0.52 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

Inspection deficiencies

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

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

35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · Gcited before2025-11-24 · 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 observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents (Resident #1), when the facility did not increase monitoring despite repeated episodes of the resident entering other residents' rooms and consuming food while on NPO (nothing by mouth) status, resulting in multiple transfers to the emergency department for possible aspiration. Findings include:Review of a reported complaint related to Resident #1 revealed the resident has a Percutaneous Endoscopic Gastrostomy (PEG) tube and the facility is not monitoring him closely enough and he is getting food from various places throughout the facility.Review of a statement provided by the facility administration revealed the facility did not have any policies or procedures related to accidents, monitoring or supervision.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses of personal history 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-27 · 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 staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan to provide for two-person assistance with a lift during a transfer in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy Care Plans, Comprehensive Person-Centered with reviewed date of November 2024 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #1's Care Plan that was initiated on 07/27/23, revealed that she had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and had interventions in place that included, Transfer: The resident requires Total by two (2) staff to move between surfaces as necessary. Full Body Lift Extra Large Sling 2 Person Transfers . During an interview…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-27 · 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 observation, staff and resident interviews, record review and facility policy review, the facility failed to provide two-person assistance during a transfer for a dependent resident in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy titled, Safe Patient Handling and Moving Protocol with reviewed date of 06/10/2024, revealed The Quality Assurance (QA) Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. Under the Transfer and Bed Mobility/Positioning Technique Training topic, , .It is important to remember that each resident is different; transfer techniques and bed mobility/positioning may need to be modified for the particular resident to meet their individual needs. Please verify level of assistance required prior to initiating…

  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 · F2026-05-14 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interview, and facility policy review, the facility failed to have the required staff present and in attendance for each quarterly Quality Assurance and Performance Improvement (QAPI) meetings for four (4) of 4 quarterly meetings dated 09/30/25, 12/29/25, 03/31/26 and 05/01/26. Findings include:Review of facility document titled QAPI Program undated revealed, .Leadership of the QAPI committee will include the Medical Director and or Nurse Practitioner (NP), Administrator, and Director of Nurses.QAPI meetings will be held monthly. The following individuals serve on the committee: Administrator, or a designee who is in a leadership role; Director of Nursing services; Medical Director; Infection Preventionist; and Representatives of the following departments, as requested by the administrator: Pharmacy; Social Services; Activity Services; Environmental Services; Human Resources; and Medical Records.Review of facility documents titled Stand Up Sign-in Sheet/QA Meeting dated 9/30/2025, 12/29/2025, 3/31/2026, and 5/1/2026, failed to evidence participation 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-14 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve resident grievances related to food service concerns identified during Resident Council meetings for five (5) of thirteen residents. (Resident #7, Resident #11, Resident #36, Resident #62, and Resident #74) Findings Include:Review of the facility policy titled Filing Grievances/Complaints with a revision date of 6/2024 revealed .3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing (if requested), including a rationale for the response .A record review of the Resident Council Minutes dated 12/16/25, under New Business, revealed residents voiced concerns stating, The food is inedible and not worth eating, and The food is awful, it's the same every time and never a different variety. The minutes documented the Dietary Manager (DM) was present during the meeting.A record review of the Resident Council Minutes dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-14 · tag F0656 — failed to write and follow a full care plan — pattern
  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 observations, interviews, record review and facility policy review, the facility failed to implement care plan interventions as written for three (3) of 19 sampled residents. (Resident #2, Resident #27, and Resident #39) The scope and severity for this deficiency were cited at an E due to previous citations of F656 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, reviewed 6/2/25, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #2 Review of Care Plan Report revealed under Focus: The resident has an ADL (activity of daily living) deficit r/t (related to CVA (cerebrovascular accident).Interventions .Staff to ask resident on shower days if they would like to be…

  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 · Ecited before2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 observations, interviews, record review, and facility policy review, the facility failed to provide facial hair grooming, fingernail care, and oral hygiene for three (3) of nineteen (19) samples residents reviewed for activities of daily living (ADL) care. Residents #2, Resident #27, and Resident #39. The scope and severity for this deficiency was cited at an E due to previous citations of F677 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), with a revision date of March 2018, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . Resident #2 On 5/11/2026 at 11:05 AM, and again on 5/12/2026 at 9:00 AM, observations of Resident #2 revealed facial hair that was approximately one (1) inch in length. During an observation and interview on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-14 · tag F0550 — failed to protect resident dignity and rights — isolated
  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

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a dignified existence by failing to apply a privacy bag to a urinary catheter drainage bag (Resident #82) and failing to provide dignified toileting assistance to a resident (Resident #22) for two (2) of 19 sampled residents. Residents #22 and Resident #82. Findings Include: Record review of facility policy titled Nursing Facility Resident Rights dated 3/6/26 revealed, .Facilities are required to protect and promote these rights for every resident. Dignity, Respect, and Freedom from Abuse: To be treated with dignity, courtesy, and respect .Quality of Care and Participation in Care: To receive care necessary to achieve the highest practicable physical, mental, and psychosocial well-being . Resident #22On 5/11/26 at 11:22 AM, observation and interview with Resident #22 revealed she was sitting in her wheelchair near the doorway of her room with frowning facial expressions and scrunched eyebrows. Resident #22 stated she needed to use the bathroom to have a bowel movement, but…

  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 · D2026-05-14 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident/resident representative (RR) and staff interviews, record review and facility policy review the facility failed to honor a resident's Advance Directive for end-of life decisions for one (1) of 28 residents advance directives reviewed. Resident #25Findings Include:Review of the facility policy titled Advance Directives, with a revision date of [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy.15. In accordance with current regulatory definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: f. Do Not Resuscitate- indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .Record review of the Advance Health Care Directive 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary environment by allowing a resident bathroom toilet to remain soiled for one (1) of 32 rooms on the 200 hall. room [ROOM NUMBER]Findings Include:Review of the facility policy titled 7-Step Daily Washroom Cleaning revealed under, Purpose: To teach Environmental Services employees the proper method to sanitize a washroom or bathroom . Additionally, the policy revealed under, 7-Step Daily Washroom Cleaning Procedure:. 5. Clean and Sanitize Commode - .Use [NAME] mop or toilet brush to disinfect the inside of the bowl .An observation of room [ROOM NUMBER]'s bathroom toilet on 5/11/26 at 2:15 PM revealed dark yellow stagnant urine present inside the toilet bowl and black discoloration adhered along the inner rim/water line of the toilet. The black substance appeared as multiple small circular black spots with a mold-like appearance.An observation and interview on 5/11/26 at 2:21 PM with Licensed…

  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 · D2026-05-14 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and facility policy review, the facility failed to ensure the resident and/or resident representative were provided with written notification of transfer to the hospital for two (2) of 2 residents reviewed for hospitalization. Resident #3 and Resident #95Findings Include:Review of the facility policy titled, Transfer or Discharge Notice with a revised date of 3/3/2026 revealed, .5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which is resident is being transferred or discharged . Record review of Resident #3's Progress Note dated 5/8/26 revealed the Resident was transported to Proper Name of Hospital for tube/drain replacement. Record review of Resident #95's Progress Note dated 3/27/26 revealed Nurse Practitioner (NP) recommended sending to emergency room (ER) for evaluation due to hitting head. Emergency Medical Transport (EMT) transported resident to Proper Name of Hospital.…

  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 · Dcited before2026-05-14 · 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 observations, staff interviews, record review, and facility policy review, the facility failed to provide necessary care and services to prevent worsening contractures and maintain range of motion (ROM) for two (2) of four (4) residents reviewed. (Residents #27 and Resident #39)Findings include:Review of facility policy titled Contracture Management Program revised 3/4/2026, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of Range of Motion.Nursing Responsibilities:.When the resident is discharged from therapy and a Restorative Nursing Program (RNP) has been written, the Director of Nursing (DON) or designee is to ensure the RNP is written correctly and then implemented timely.Resident #27 Review of Resident #27's Order Summary Report, revealed physician orders to Donn (apply) bilateral elbow rolls to patient daily after lunch and doff (remove) at HS (bedtime) and Donn carrots to bilateral hands daily after lunch…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to clarify a clinically questionable dialysis fluid restriction order, failed to accurately transcribe and implement the physician order, and failed to monitor fluid intake for one (1) of five (5) residents reviewed for dialysis services. Resident #22 Findings Include:Review of the facility policy titled Dialysis Management Policy revised 3/12/26 revealed under, Policy: The facility will ensure that residents requiring dialysis receive appropriate clinical oversight, coordination with dialysis providers, and monitoring to maintain health and safety. The facility will coordinate care with the dialysis center and physician to ensure appropriate monitoring of the resident's clinical status, dialysis access, laboratory values, dietary needs, and complications related to dialysis therapy .Record review of Resident #22's Medication Administration Record (MAR) revealed an order dated 4/13/26, Resident to receive dialysis 3 (three) days a week on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$17,898 in federal fines across 3 penalties.

• $9,620 — penalty dated 2025-11-24
• $4,139 — penalty dated 2025-01-27
• $4,139 — penalty dated 2025-01-27

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

Part of a chain

This home belongs to NEXION HEALTH — 51 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 →

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

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $572K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

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 MS