Bear Mountain Health and Rehabilitation

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.

Therapy staffing: this home’s payroll records show 0.55 therapist hours per resident per day in 2026Q1 — more than 85% 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 therapy on weekdays, with essentially none at the weekend. 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 77 beds and averages 65.3 residents a day — about 85% occupied, or roughly 12 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.47 on weekdays — 18% thinner on weekends. RN hours go from 0.55 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%.

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

Inspection trend

Deficiencies are 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.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Actual harm · G2023-08-10 · 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 observation, record review, resident and staff interviews, Psychiatric Physician's Assistant interview, and the Medical Director interview the facility failed to protect the rights of a resident to be free from abuse. Resident #1 was found bleeding with a laceration to her upper lip, and a bruise to her right index finger and hand. Resident #2 had struck Resident #1 with the bed adjustment remote control causing the laceration to Resident #1's lip and pulled a ring from Resident #1's right index finger. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstruction Pulmonary Disorder (COPD), panic disorder, depression, and anxiety. The quarterly Minimum Data set (MDS) assessment dated [DATE] coded Resident #2 as cognitively intact. She was assessed to need extensive assistance with bed mobility, dressing, toileting, and eating. Resident #2's care plan, dated 2/28/23 revealed…

  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
• Actual harm · G2022-12-16 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician a resident's pain was not controlled after the administration of pain medication. The resident called emergency medical services and was evaluated for abdominal pain and diagnosed with acute cholecystitis (inflammation of the gallbladder) that required admission to the hospital for the surgical removal of the gallbladder for 1 of 2 residents reviewed for hospitalizations (Resident #270). The findings included: Resident #270 was admitted to the facility on [DATE] with diagnoses including a history of cervical spine trauma and quadriplegia. Resident #270 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE] revealed Resident #270 was assessed as being cognitively intact. Routine and as needed pain medications were received during the lookback period and the resident reported his pain was moderate, frequent, and interfered with…

  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
• Actual harm · G2022-12-16 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Medical Director and staff the facility failed to complete a thorough assessment of a resident requesting to go to the emergency room due to increased pain. The resident called emergency medical services and was transported to the hospital and diagnosed with acute cholecystitis (inflammation of the gallbladder) that required surgical removal of the gallbladder for 1 of 2 residents reviewed for hospitalization (Resident #270). The findings included: Resident #270 was admitted to the facility on [DATE] with diagnoses including a history of cervical spine trauma and quadriplegia. Resident #270 was discharged to the hospital on [DATE]. The quarterly Minimum Data Set, dated [DATE] revealed Resident #270 was assessed as being cognitively intact. Routine and as needed pain medications were received during the lookback period and the resident reported his pain was moderate, frequent, and interfered with sleep and activities. Opioids (narcotic pain medications) were given…

  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 before2025-12-30 · 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 record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. The hospital discharge summary ordered sitagliptin/metformin (Janumet extended release). The facility instead entered and administered metformin, omitting the sitagliptin component and the extended-release formulation. This deficient practice occurred for 1 of 3 residents reviewed for providing care according to professional standards (Resident #1).Findings included:A hospital Discharge summary dated [DATE] included the following medication order: metformin-sitagliptin (Janumet extended release (XR) 100 milligram (mg)-1000 mg oral tablet, 1 tablet by mouth daily for diabetes. According to manufacturer's information, metformin-sitagliptin is a combination of two medications and is marketed under the brand name of Janumet extended release XR.Resident #1 was admitted to the facility on [DATE]. Her…

  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 · D2025-12-30 · tag F0773 — isolated
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Clinical Practice Manager, and Physician Assistant (PA) interviews, the facility failed to notify the medical provider of abnormal laboratory results for 1 of 1 resident reviewed for notification of laboratory results (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included Type-2 diabetes mellitus, hypertension (high blood pressure), long-term use of anticoagulants (blood thinning medication), metabolic encephalopathy (confusion caused by chemical imbalances in the body), malignant neoplasm of the pancreas (pancreatic cancer), hypo-osmolality (excess water relative to solutes such as electrolytes) and hyponatremia (low sodium level), anemia (low red blood cells), hypothyroidism (thyroid disorder), and a disorder of urea cycle metabolism (body cannot properly remove ammonia from the body).An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment.A physician order 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-09 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 1 of 2 residents who were assisted with meals (Resident #2). Staff were observed standing beside the resident's bed while feeding assistance was provided. The finding included: Resident #2 was admitted to the facility on [DATE] with diagnoses including dysphagia and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #2 with intact cognition. The assessment indicated Resident #2 was dependent on staff for eating and receiving a mechanically altered diet. During a continuous breakfast observation on 05/07/25 from 9:01 AM to 9:10 AM, Resident #2 was observed seated at approximately 45-degree angle in her bed. Her breakfast tray was brought into the room by Nurse Aide (NA) #1 and placed on top of the overbed table in front of Resident #2. NA #1 stood on the left side of the bed. She set up the tray and started feeding Resident #2 while she was standing and…

  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 · D2025-05-09 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASARR) and high-risk drug classes usage that involved anticoagulant, antipsychotic, and opioid medications for 3 of the 7 sampled residents (Residents #11, #24, and #52). Findings included: a. Resident #11 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and peripheral vascular disease. A review of the Medication Administration Records (MAR) for January 2025 revealed Resident #11 did not receive any anticoagulant throughout the month. Instead, the MAR indicated that he received 1 tablet of enteric-coated aspirin 81 milligrams (mg) by mouth once daily since 01/20/25. The quarterly MDS assessment dated [DATE] coded Resident #11 with intact cognition. The Medication section of the MDS indicated Resident #11 had received anticoagulant during the 7-day assessment periods. b. Resident #24 was 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 · Dcited before2025-05-09 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to refer a resident with newly diagnosed serious mental illnesses for Pre-admission Screening and Annual Resident Review (PASARR) Level II screening for 1 of 2 residents reviewed for PASARR (Resident #36). The findings included: A review of Resident #36's medical records revealed he had a PASRR Level I evaluation completed in 2023. Resident #36 was admitted to the facility on [DATE] with diagnoses including bipolar disorder. A review of Resident #36's list of cumulative diagnoses revealed a new diagnosis of bipolar disorder with an onset date of 03/13/24 was documented in his medical record. A review of physician's order dated 03/14/24 revealed Resident #36 had an order to receive 1 tablet of Depakote 500 milligrams (mg) delayed release by mouth 2 times daily for mood symptoms related to bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The Section A1500 indicated he was not…

  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 · Dcited before2025-05-09 · 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 observations, record review, and Medical Director (MD), resident and staff interviews, the facility failed to readjust medication orders after those orders had been updated which resulted in the resident missing one dose of five medications for 1 of 1 resident reviewed for pharmacy services (Resident #36). The finding included: Resident #36 was admitted to the facility on [DATE] with diagnoses including stroke, insomnia, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The assessment indicated Resident #36 had adequate hearing and vision with clear speech. During the initial interview conducted with Resident #36 on 05/05/25 at 1:13 PM, he stated he disliked nursing staff waking him up around midnight at times to administer his medications. A review of medication administration records (MAR) on 05/05/25 revealed Resident #36 had the following 5 active physician's orders to receive medications once daily at either 8:00 PM or 10:00…

  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 · D2025-05-09 · 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 record review, observation, and staff interviews, the facility failed to intervene effectively when two residents became agitated and were yelling at each other in a common area. Resident #44 was cognitively impaired and had a history of violent behaviors caused Resident #229 to sustain a skin tear by hitting her on the hand with a cellphone. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #229). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, schizophrenia (psychiatric disorder), vascular dementia with mood disturbance, aphasia (brain disorder that affects the ability to communicate) following cerebral infarction, bipolar disorder (mood disorder), anxiety disorder, violent behaviors. Resident #44 was a current resident at the facility. 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 · D2025-05-09 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter bag and drainage spout from touching the floor to reduce the risk of infection for 1 of 1 resident (Resident #62). This deficient practice occurred for 1 of 1 resident reviewed with a urinary catheter. Findings included: Resident #62 was admitted to the facility on [DATE] and had been re-admitted to the facility on [DATE]. His diagnoses included chronic obstructive uropathy. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was never/rarely understood and his cognitive skills for daily decisions making were severely impaired. He was documented on the MDS as having an indwelling catheter. Resident #62 had a care plan dated 6/14/24 for long term indwelling catheter. The care plan interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door. An order dated 4/3/25 read, indwelling urinary catheter…

  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 · D2024-03-07 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interview the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for medications at bedside (Resident #67). The findings included: Resident # 67 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus with hyperglycemia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #67 was cognitively intact. Review of Resident #67's medical record revealed no documentation that Resident #67 had been assessed to self-administer medications at bedside. An in-room observation and interview with Resident #67 on 3/4/24 at 11:17 AM revealed a medication cup sitting on Resident #67's overbed table containing 11 pills. Resident #67 stated the nurse had brought her medication to her about 30 minutes prior for her to take. Resident #67 said she told the nurse she would take the pills after she used the bathroom,…

  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 before2024-03-07 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with new mental health diagnoses for 1 of 2 residents reviewed for PASRR (Resident #23). The findings included: Review of Resident #23's medical record revealed the resident had a PASRR level I completed prior to his admission dated 8/3/17. He was admitted to the facility on [DATE] with diagnoses of bipolar disorder and anxiety disorder. A diagnosis of major depressive disorder was added on 8/29/23. Review of Resident #23's medical records revealed no PASRR level II had been completed. Review of Resident #23's annual Minimum Data Set (MDS) dated [DATE] revealed he had not been evaluated by Level II PASRR. During an interview on 3/6/24 at 2:25 pm, the Interim Administrator and the Social Worker (SW) explained the facility's PASRR process. The SW stated all residents had PASRR when they got to the facility. Their diagnoses determined what kind 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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASCENT HEALTHCARE MANAGEMENT — 6 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 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 27% 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

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

What families pay in NC