Pine Crest Health & 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 100 beds and averages 72.1 residents a day — about 72% occupied, or roughly 28 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.71 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 2.86 hrs/resident/day on weekends vs 3.12 on weekdays — 8% thinner on weekends. RN hours go from 0.60 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% 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 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.

28 citations, most serious first. The 17 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · K2024-05-07 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 reviews, staff, responsible person (RP) and Medical Director (MD) interviews, the facility failed to notify the MD when multiple doses of significant morning medications (seizure medication, insulin, depression medication, and chronic kidney and heart failure medication) were not administered due to Resident #20 being out of facility for dialysis treatment and not administered her morning medications. There was a high likelihood of failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Additionally, the facility failed to notify the Responsible Person (RP) for Resident #66 when Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with handle. This…

  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 · K2024-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with a handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. The maintenance room was observed on 4/17/24 to be unlocked. This practice has a high likelihood that residents could access materials that could cause serious harm or injury. Immediate Jeopardy began on 2/21/24 when Resident #66 accessed a long rigid knife with a handle and 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-05-07 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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, resident, staff, and Medical Doctor (MD) interview the facility failed to prevent a significant medication error by failing to administer morning medications for a dialysis resident (Resident #20) for 1 of 3 residents reviewed for assuring the facility was free of medication errors. Resident #20 attended dialysis treatments on Tuesday, Thursday, and Saturday from 5:30 AM to 10:30 AM and was not administered her significant morning medications. Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Immediate jeopardy began on 04/02/24 when the facility failed to administer Resident #20's morning medications. Immediate jeopardy was removed on 04/27/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal.…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-05-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays by 1 of 2 cooks (Cook #1). Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. Food items were left open to air in 1 of 1 walk-in freezer and a food item was not discarded by the use by date in the reach in refrigerator. Immediate Jeopardy began on 04/16/24 when residents were served undercooked fried chicken for 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, picture, manufacturer's instructions, resident, family member #5, staff, consultant pharmacist, and Medical Director interviews the facility failed to ensure that single resident insulin pens were not shared between residents. On 07/10/23 Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Regurgitation (emission) of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed. This has the high likelihood to spread bloodborne pathogens such as human immunodeficiency virus (HIV), Hepatitis B and Hepatitis C. This affected 1 of 3 residents reviewed for infection control. The facility also failed to initiate Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds such as indwelling…

  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
• Actual harm · G2022-12-30 · 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 observation, record review, resident, and staff interviews the facility failed to provide care in a manner that maintained the resident's dignity by not providing incontinence care when needed. This is evidenced by Resident #266 feeling violated. This occurred for 1 of 4 residents reviewed for dignity. (Resident #266) The findings included: Resident #266 was readmitted to the facility on [DATE] with diagnoses that included stroke, muscle weakness, lack of coordination and major depressive disorder. Resident #266's most recent Minimum Data Set, dated [DATE] revealed he was cognitively intact with no refusals of care. He required extensive assistance with bed mobility, toileting, and personal hygiene. He had functional limitations on one side for the upper and lower extremities. Resident #266 was frequently incontinent of bladder and always incontinent of bowel. While touring the 200 hall on 12/12/22 at 10:15 AM there was a noticeable odor of feces when passing Resident #266's room. An observation 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-12-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, and staff interviews, the facility failed to provide incontinence care, which resulted in resident #266 feeling violated for 1 of 6 dependent residents reviewed for activities of daily living (ADL). (Resident #266) The findings included: Resident #266 was readmitted to the facility on [DATE] with diagnoses that included stroke, diabetes, muscle weakness, lack of coordination and major depressive disorder. Resident #266's most recent Minimum Data Set, dated [DATE] revealed he was cognitively intact with no refusals of care. He required extensive assistance with bed mobility, toileting, and personal hygiene. He had functional limitations on one side for the upper and lower extremities. Resident #266 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #266's was care plan revised on 12/12/22 revealed the following: -Resident #266 had an ADL self-care deficit related to hemiplegia. The interventions included resident needs extensive…

  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 · D2025-08-07 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 1 of 3 residents (Resident #32) reviewed for beneficiary notification. The findings included: Resident #32 was admitted to the facility on [DATE] and Medicare Part A services began on 12/20/24. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was issued on 3/02/25 to Resident #32 which explained Medicare Part A coverage for skilled services would end on 3/04/25. Resident #32 remained in the facility. A review of the medical record revealed a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided to Resident #32. An interview conducted with the Business Office Manager (BOM) on 8/05/25 at 1:10 PM revealed she was responsible for issuing the CMS-10055 ABN and CMS-10123 NOMNC when a resident's Medicare Part A benefit was ending. She…

  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 before2025-08-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to revise a resident's care plan with current cardiopulmonary resuscitation code status for 1 of 21 residents (Resident #64) reviewed for care plans. The findings included:Resident #64 was admitted to the facility on [DATE]. Her diagnoses included myasthenia gravis, diabetes mellitus, and essential primary hypertension. A review of Resident #64's care plan last revised on [DATE] indicated cardiopulmonary resuscitation (CPR)/Full Code status with a goal initiation date of [DATE], a goal revision date of [DATE] and a goal target date of [DATE]. Resident #64's most recent quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and revealed she was cognitively intact. A review of Resident #64's electronic medical record (EMR) social work progress note dated [DATE] revealed the Social Worker (SW) reviewed Resident #64's advanced directives with her and her code status was changed from a CPR/Full Code to Do Not Resuscitate (DNR) on the same date.A…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities resulting in a medication error rate of 8% for 1 of 5 residents observed during medication administration observation (Resident #6). Findings included: On 08/06/2025 at 9:07 AM, Nurse #3 was observed and interviewed as he prepared to administer medication to Resident #8. He stated Resident #8 had a gastrostomy tube (g-tube) as indicated on his medication sheet located on the top of the medication cart. Nurse #3 obtained the medication aspirin 81 milligrams (mg) and losartan 50mg from the medication cart and proceeded to crush the medication and place it into a cup. Upon entrance into the resident room, Resident #8 was observed lying in bed as well as her roommate Resident #6. Resident #8 did not have a g-tube, and Resident #6 did have a g-tube. Nurse #3 was observed administering the medication prescribed to Resident #8 to Resident #6 during the medication pass observation. A review of Resident #8's…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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, interviews with Registered Dietitian, Speech Therapist, and staff, the facility failed to modify a resident's diet order to meet her individual needs for 1 of 5 residents reviewed for nutrition (Resident #47).Findings included:Resident #47 was admitted to the facility 02/20/25 with a diagnosis including malnutrition. Hospital records revealed Resident #47 had a hospital stay on 03/30/25 due to shortness of breath. She was discharged back to the facility on [DATE].Review of Resident #47's physician orders revealed an order dated 04/07/25 for a regular diet. A Nurse Practitioner note dated 06/11/25 revealed Resident #47 was evaluated for a nursing request for medication and lab review. It was the Nurse Practitioner's initial encounter with Resident #47. Resident #47 expressed during the evaluation that she was concerned her dentures were missing. The Nurse Practitioner had a discussion with the Director of Nursing regarding the resident's lost dentures, and the DON was aware…

  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 · Dcited before2025-08-07 · 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 observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #2 did not doff her gloves, perform hand hygiene and don clean gloves prior to cleaning wound and applying new wound dressing to Resident #31's sacrum. Additionally, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 did not don a gown during a high contact care activity which included dressing Resident #31 who had a chronic wound and feeding tube. The deficient practice occurred for 2 of 5 staff members observed for infection control practices (Nurse #1 and Nurse #2).The findings included: A. The Hand Hygiene policy without revision date, revealed hand hygiene means to clean one’s hands with either a sanitizer product or with soap and water and glove use was not a substitute for hand hygiene. The policy also revealed staff were to perform hand hygiene for the following: - During all care activities and while working in all locations within the facility. - Before and after wearing gloves. - After…

  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 · E2024-05-07 · tag F0644 — pattern
  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 refer two new residents with serious mental health diagnoses, and one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 3 of 3 residents reviewed for PASRR (Resident #4, #19, and #54). The findings include: 1. Review of Resident #4's medical record revealed the resident had a PASRR level I determination completed prior to his admission and was admitted to the facility on [DATE]. The resident had been diagnosed with post-traumatic stress disorder (PTSD) and mental disorder during his admission. No PASRR level II referral documentation had been observed in Resident #4's medical records. An interview on 04/17/24 at 9:26 AM with the Social Worker (SW) revealed he had been employed as the facility SW since March 2024 and had received training on how to complete PASRR paperwork for residents. He stated he was not aware of Resident #4's mental health diagnosis or that a PASRR level II…

  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 · E2024-05-07 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  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, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 5 of 5 residents reviewed for activities (Residents #203, #102, #114 #216 and #46). The residents expressed not being able to leave the facility made them feel frustrated, awful, forgotten about, hemmed in, angry, and mad. The residents further stated they hated being stuck in the building all the time and once you get here, they won't let you leave. The findings included: A review of the January, February, March, April 2024 activity calendars revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility. Review of Resident Council Meeting minutes from April 2023 through March 2024 residents had voiced the desire to go on outings…

  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 · E2024-05-07 · tag F0698 — failed to provide proper dialysis care — pattern
  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 record review, resident and staff interviews the facility failed to provide breakfast, a bagged meal or snack for 2 of 2 residents (Resident #20 and #21) reviewed for dialysis. The findings included: a. Resident #20 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes and end stage renal disease. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #20 was cognitively intact. An interview with Resident #20 on 4/15/24 at 4:00 PM revealed she did not always receive a meal when she went to dialysis and would have to wait until she returned from her treatments around lunch time before she was able to eat. She stated she attended dialysis three times a week from 5:30 AM to 10:30 AM and the facility was supposed to provide her with a bagged lunch that contained a sandwich, snacks, and drink but for the past several months she had not received her bagged lunch, or it would be missing the sandwich and drink. She stated this past weekend the Administrator had to bring 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 · E2024-05-07 · tag F0802 — failed to prepare enough nourishing food — pattern
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and staff interview the facility failed to verify [NAME] #1's competencies and certifications for food production and meal service prior to first day of employment. The findings included: An interview on 04/16/24 at 02:05 PM with Dietary Manager (DM) #1 revealed new employees should be signed off on competencies before they are left on their own to work. DM #1 explained the kitchen had a checklist of competencies for the cook/chef staff, but DM #1 stated [NAME] #1 was assigned to another staff member for training on his first day (4/15/24). DM #1 revealed that she thought DM #2 from another facility was training [NAME] #1 that day (4/16/24) and she was not aware that DM #2 was not told that she was responsible for training [NAME] #1. DM #1 stated she should have ensured that DM #2 knew she was responsible for training [NAME] #1 on 04/16/24. DM #2 was not given [NAME] #1's checklist on 04/16/24. DM #1 reported that [NAME] #1 had not received food temperature training yet because that training was done on the second day. DM #1 reported she 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 · E2024-05-07 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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, resident and staff interviews the facility failed to provide evening snacks to residents when requested for 4 of 4 residents (Resident #9, #20, #21, and #171) reviewed for frequency of snacks. This practice had the potential to affect other residents who requested evening snacks. The findings included: a. Resident #9 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and heart failure. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #9 was cognitively intact. An interview with Resident #9 on 4/15/24 at 4:31 PM revealed since he had been at the facility he might have received an evening snack maybe once or twice but not on a consistent basis. He stated he did not have the money to be able to purchase his own snacks all of the time and felt the facility should be able to provide him with an evening snack when requested. Resident #9 revealed when he would ask staff about receiving an evening snack, they would tell him there were no snacks…

  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

“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

$144,199 in federal fines across 1 penalty.

• $144,199 — penalty dated 2024-05-07

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.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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 $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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