Highfield Nursing and Rehabilitation

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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.

41.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.8% 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 76 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 38% 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 104.6 residents a day — about 87% occupied, or roughly 15 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.

Weekend coverage: total nurse staffing is 2.73 hrs/resident/day on weekends vs 3.29 on weekdays — 17% thinner on weekends. RN hours go from 0.37 to 0.23 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 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.

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.

20 citations, most serious first. The 14 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · J2025-02-28 · 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, and interviews with staff, Psychiatric Nurse Practitioner, Responsible Party (RP), and the Police Detective, the facility failed to protect the right of two cognitively impaired residents (Residents # 1 and # 7) to be free from abuse. On the evening of 2/6/25 Resident # 2 returned from an outing and was observed by staff to show signs of being inebriated. That evening he was also observed at the bedside of Resident # 1, who was cognitively impaired and who did not have the ability to invite him into her room. After his removal from Resident # 1's room by staff, Resident # 2 was observed in Resident # 1's room a second time with the curtain pulled so that he and Resident # 1 were out of view. During this second incident, Nurse Aide # 1 and Nurse # 1 entered the room and walked around the curtain and witnessed Resident # 2 with his hand under Resident # 1's right leg lifting it up while Resident # 1's brief was open on the right side exposing part of her private area. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-11-22 · 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 staff, family member, Physician Assistant, and Medical Director interviews the facility failed to notify the physician of a significant change in condition when staff were unable to obtain a urine sample on 3 instances (10/31/24 at approximately 5:00 AM and 9:00 PM and 11/1/24 at approximately 5:30 AM) for a resident identified with complaints of burning urination and decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. On 10/30/24 the resident complained of burning urination (dysuria) and was ordered a urinalysis (used to detect abnormalities such as blood, protein, glucose, and indirect indicators of bacterial infection) and urine culture and sensitivity (used to diagnose a urinary tract infection and determine the best treatment). Resident #294 exhibited signs and symptoms of dehydration on 10/31/24 at…

  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
• Immediate jeopardy · J2024-11-22 · 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 staff, family member, Physician Assistant, and Medical Director interviews, the facility staff failed to recognize the seriousness of a significant change in condition, the importance of and identify the need for urgent medical attention to address an emergent situation. On 10/29/24 a sudden decrease in food and fluid intake was observed by staff. Resident #294 reported burning with urination to the night shift nurse (10/29/24 at 11:00 PM through 10/30/24 at 7:00 AM) and an order for a urinalysis (UA) and urine culture and sensitivity (C & S) was obtained from Physician Assistant #2 on 10/30/24. No attempts were made to collect the urine specimen for the UA until 10/31/24 at around 5:00 AM and the nurse was not successful. Another nurse attempted to obtain the urine specimen the evening of 10/31/24 and the morning of 11/1/24 but was not successful. Resident #294 was administered his diuretic daily 10/29/24 through 11/1/24 despite decreased intake. The poor intake continued and by…

  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
• Immediate jeopardy · J2024-11-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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, family member, Physician Assistant (PA), and Medical Director interviews the facility failed to ensure staff recognized the seriousness of signs and symptoms of dehydration for a resident receiving a diuretic (Lasix 20 mg daily) and who had decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. Resident #294 exhibited signs and symptoms of dehydration on 10/31/24 at approximately 9:00 PM and 11/1/24 at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. During this time, nursing staff continued to administer the resident's Lasix (diuretic) 20 milligrams once daily at 9:00 AM despite signs and symptoms of dehydration. On 11/1/24 at 10:15 AM the PA ordered 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 observations and resident and staff interviews, the facility failed to maintain intact tiles and grout on a shower room floor and prevent black colored buildup on the shower floor, walls, and ceiling in 1 of 2 shower rooms reviewed for safe, clean, and homelike environment (100/200 shower room).Review of the quarterly MDS dated [DATE] for Resident #29 coded her as cognitively intact.On 3/23/26 at 2:39PM an interview was conducted with Resident #29 that revealed she received showers in the 100/200 shower room [ROOM NUMBER] times per week. Resident #29 went on to state that while receiving showers, she had observed what she described as black colored mold and filth on the walls and the ceiling. She described observations of what she believed was mold, and she felt it had been there since she was admitted (on 7/28/25) but was confident she had observed the mold to be in the shower for at least the past 3 months. Resident #29 indicated she had not reported this or complained about it to anyone in 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
• Potential for harm · D2026-03-26 · 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, record review, and staff interviews, the facility failed to adhere to the required personal protective equipment (PPE) for Resident #29 who had a peg tube (a feeding tube inserted directly into the stomach through the abdominal wall) when nursing staff members were observed providing a bath to the resident without wearing a gown and gloves for 2 of 5 staff members observed for infection control practices (Nurse Aide #1 and NA #2). A facility policy provided by the Director of Nursing (DON) titled 'Enhanced Barrier Precautions' (EBP) revised 11/13/25 indicated the facility would implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. It also stated EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employed targeted gown and gloves during high contact resident care activities. The policy included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting with peg tubes and wound care as…

  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 · Dcited before2025-02-28 · 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, and interviews with resident and staff, the facility failed to provide housekeeping services to ensure a clean bathroom for a bathroom which was jointly shared by multiple residents. This was for one (Resident # 5) of four sampled residents who were interviewed regarding services at the facility. The findings included: Resident # 5 was admitted to the facility on [DATE]. A review of Resident # 5's quarterly Minimum Data Set assessment, dated 12/2/24, revealed Resident # 5 was cognitively intact and continent. During interviews held with Resident # 5 on 2/24/25 at 10:12 AM and again on 2/25/25 at 8:35 AM, Resident # 5 expressed concerns related to his bathroom being cleaned so that he could use it. Resident # 5 reported the following information. He resided in a room which shared a bathroom with two other residents who had an adjoining door to the bathroom from their room. One of the other residents, who used the bathroom, needed adaptive devices (a riser) over the toilet and this 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-28 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 and interviews with resident and staff, the facility failed to ensure a system was in place to avoid placing an item on a resident's tray which she preferred not to have. This was for one (Resident # 4) of three sampled residents reviewed for food choices. The findings included: Resident # 1 was admitted to the facility on [DATE]. Review of Resident # 4's admission Minimum Data Set assessment, dated 1/26/25, revealed the resident was cognitively intact. Review of physician orders revealed Resident # 1 was ordered a regular diet. The Dietary Manager was interviewed on 2/26/25 at 8:55 AM and provided a copy of the way Resident # 4's tray card printed from their system. Observation of the resident's printed dietary card revealed near the top of the card, there was a notation which read, No Potatoes. The Dietary Manager reported the following information. Resident # 4 had a dislike to potatoes. As noted on her printed tray card, it showed as a disklike and she should not be served…

  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 · D2025-02-28 · tag F0807 — failed to offer suitable drinks — isolated
  Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
  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, and staff interviews, the facility failed to ensure a resident received a beverage on her tray per her preference. This was for one (Resident # 8) of three residents reviewed for dietary preferences. The findings included: Record review revealed Resident # 8 was admitted to the facility on [DATE] after sustaining a hip fracture. Review of Resident # 8's 2/21/25 admission Minimum Data Set assessment, dated 2/21/25, revealed the resident was cognitively intact. Review of physician orders revealed the resident was ordered a regular diet. Lunch observations were made on 2/25/25 starting at 12:00 PM. During this lunch time observation Resident # 8 was observed in her room. She had completed eating her lunch meal and stated the food was good, but the dietary department had not served any drinks on her tray. It was observed there were no cups on the meal tray. She further reported that she had some water in a Styrofoam cup at her bedside which she had before the lunch meal tray was…

  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 · D2024-11-22 · 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, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of hypnotics medication for 1 of 30 sampled resident reviewed (Resident # 55). Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including dementia. The annual Minimum Data Set (MDS) dated [DATE] had Resident #55 coded as severely cognitively impaired, and hypnotics were taken during the look back period. The August and September 2024 Medication Administration Records (MAR) did not reveal an order for hypnotics. An interview with the Director of Nursing (DON) was conducted on 11/19/2024 at 2:49 PM. The DON stated she look at MARs as far back as April 2024 for Resident #55 and there had not been a hypnotic ordered. The DON also stated the MDS was coded incorrectly and expected the MDS nurse to code the assessment accurately. An interview with the MDS nurse was conducted on 11/19/2024 at 2:58 PM. The MDS Nurse stated she was the one…

  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 · D2024-11-22 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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, and Resident and staff interviews, the facility failed to ensure call bells were plugged into the wall panel for a dependent resident to allow them to call for assistance if needed. The deficient practice was for 1 of 30 residents reviewed for accommodation of needs (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #6 coded as moderately cognitively impaired with clear speech, she makes herself understood and can understand others. Resident #6 was always incontinent with bowel and bladder. An observation and interview were conducted with Resident #6 on 11/18/2024 at 10:43 AM. Resident #6 was in her room, in her bed with head of bed elevated. One end of her call bell wire was placed over the top of the bed and the other end with the red button was tied around the bedrail. The call light panel was not visible from the door. Resident #6 was asked if she could use her call bell 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to protect the resident's right to be free from misappropriation of controlled medication for 1 (Resident #5) of 2 residents reviewed for misappropriation of controlled medication. Findings included: Documentation on the facility abuse, neglect, exploitation and misappropriation policies and procedures, dated as last revised on 11/16/2022, revealed misappropriation of resident property included the diversion of resident's medication, including, but not limited to, controlled substances for staff use or personal gain. The same policy and procedure indicated employees were not at any time to commit misappropriation of property against any resident. Resident #5 had diagnoses of vascular dementia, hemiplegia, and osteoarthritis. Documentation in a quarterly Minimum Data Set assessment dated [DATE] coded Resident #5 as having moderately impaired cognition and received pain medication on an as needed basis. Documentation on physician orders for July 2024…

  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 · E2024-06-27 · 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 record review, staff, and resident interviews, the facility failed to treat residents (Resident #1, and Resident #2) with dignity and respect when staff failed to provide the resident with a bed bath or shower. The residents expressed anger, frustration, and embarrassment. This was for 2 of 8 residents reviewed for dignity. The findings included: 1.Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diabetes, atherosclerotic heart disease, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3 was cognitively intact, dependent on staff for toileting, and required substantial maximum assistance with bathing. Review of Care Plan dated 4/15/24 revealed Resident #1 required assistance with activities of daily living (ADL) care to include bathing. An interview with Resident #1 on 6/26/24 at 11:48 am revealed that the facility frequently ran out of briefs, wash cloths, and towels. She stated yesterday…

  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 · E2024-06-27 · 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 record review, observation, and staff and resident interviews, the facility failed to provide a bed bath or shower for 3 of 7 dependent residents (Resident #1, Resident #2, and Resident #12) reviewed for activities of daily living (ADL) care. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including diabetes, atherosclerotic heart disease, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact, dependent on staff for toileting, and required substantial maximum assistance with bathing. Review of Care Plan dated 4/15/24 revealed Resident #1 required assistance with ADL care to include bathing. An interview with Resident #1 on 6/26/24 at 11:48 am revealed yesterday (6/25/24) she only had one towel, no washcloth and she had to wash herself off with disposable wipes. She further indicated that she did not get a bath today (6/26/24) because the facility ran out of wash cloths and towels. In…

  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

$175,559 in federal fines across 2 penalties.

• $17,345 — penalty dated 2025-02-28
• $158,214 — penalty dated 2024-11-22

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 AVARDIS HEALTH — 38 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 26 rows in the source record cover these 16 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.

10 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 73% 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 $565K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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