Rockwell Park Rehabilitation and Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Met the expected recovery: 37.9% 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 29 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 82.9 residents a day — about 69% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.49 hrs/resident/day is at or above 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 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.64 on weekdays — 15% thinner on weekends. RN hours go from 0.69 to 0.34 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%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

34 citations, most serious first. The 18 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-05 · 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 observations, record review, and staff, resident, and Medical Director interviews, the facility failed to ensure the necessary supervision was provided to prevent a cognitively impaired resident who was care planned as having a history of attempting to leave the facility, who wandered aimlessly and had impaired safety awareness from exiting the building at night without staff knowledge. On 07/17/25, the resident was last seen at 9:00 PM. At approximately 9:30 PM Nurse Aide (NA) #1 was unable to locate Resident #1. Staff members searched the building before checking the back doorway employee entrance, which required a keycode for exit. Resident #1 was found outside lying on his left side with his wheelchair on top of his lower back area. Resident #1 had traveled approximately 30 feet out of a back employee entrance down a sidewalk that led to a dark dumpster area which was approximately 5 feet from where Resident #1 was found and that staff sometimes used as a parking area. The area of sidewalk where…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-25 · 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 #1 and Medical Director interviews, the facility failed to recognize the current treatment plan was not effective and the seriousness of a resident with a diagnosis of hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone) not responding to high doses of levothyroxine (medication used to treat hypothyroidism). As of [DATE] Resident #1 had an active order for an endocrinology consultation for hypothyroidism. On [DATE] lab work was obtained and resulted in a critically high TSH (Thyroid Stimulating Hormone) level of 50.3 (normal range 0.5 to 5.0). The endocrinology consultation order was not faxed by the facility to the consultation office until [DATE] and a referral to an endocrinologist for an evaluation was not scheduled. Resident #1's thyroid medication remained at the same dosage for the month of [DATE] and [DATE] at 225 mcg (microgram) by mouth daily. On [DATE] Resident #1 had a thyroid stimulating hormone (TSH) level of 50.3 (normal range…

  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 · Jcited before2024-11-27 · 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 observations, record review, and resident, facility staff, Nurse Practitioner (NP), Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to protect a resident's right to be from physical abuse (Resident #49). On 09/14/24 at approximately 9:00 AM Nurse #3 heard a loud hit or thud coming from across the unit and then observed Resident #49 rolling out of his room in his wheelchair and witnessed Resident #79 swinging his arm with a fist and hit Resident #49 on the back of the head. Resident #49 was noted to slump over in his wheelchair and have a loss of consciousness for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of a traumatic brain injury and immediately after being hit in the head by Resident #79 he was noted to have a change of condition as evidenced by a change in level of assistance needed for transfer and bed mobility changed, confusion and inability to self-propel in his wheelchair. Later in the day…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-11-27 · 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 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact, had lower extremity impairment on one side, utilized a manual wheelchair for mobility, required supervision to moderate assistance with transfers, and received dialysis treatments. The MDS further revealed Resident #55 was not coded for receiving an anticoagulant. A review of the Care Plan dated 11/13/24 indicated Resident #55 required minimal to extensive assistance with activities of daily living, was a right lower extremity amputee with a prosthesis, utilized a wheelchair to assist with mobility and received dialysis treatment 3 times a week. A review of Driver #1's statement dated 11/15/24 indicated he picked up Resident #55 from the dialysis center, loaded him in the transportation van and secured his…

  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 · Jcited before2024-11-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, Medical Director and staff interviews, the facility failed to provide safe van transportation when Driver #1 failed to secure Resident #55's wheelchair in the facility van per the manufacturer's instructions. On 11/15/24, during transport from the dialysis center, Driver #1 did not secure Resident #55's wheelchair in the facility van per the manufacturer's instructions, and when he drove out of the parking lot and turned right onto the main road, Resident #55 fell backwards in his wheelchair and hit his head on the van floor. Resident #55 was assessed by Nurse #1 when he returned to the facility, was noted to have an abrasion and swelling to the back of his head and was complaining of severe head pain. He was transported to the Emergency Department (ED) for further evaluation and diagnosed with a closed head injury, scalp abrasion, and strained neck muscles. There was a high likelihood of a serious adverse outcome or injury when Resident #55's wheelchair 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-04-29 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 observations, record review, resident, physician, and staff interview the facility failed to protect a severely cognitively impaired resident from the right to be free from physical abuse (Resident #5). Resident #5 experienced physical abuse twice on 12/27/23 when before bingo Resident #4 placed her arm around the Resident #5's neck, and pulled her forward, and then on the same day, placed Resident #5 in a chokehold with her arm while she was seated in her wheelchair. Resident #5 was held in the chokehold position which caused the resident to gasp and her face to become red. In addition, the facility failed to protect a severely cognitively impaired resident from the right to be free from sexual abuse (Resident #3). Resident #3 experienced sexual abuse on 2/26/24 when Resident #2 touched and rubbed her pubic area. Based on the reasonable person concept, being placed in a chokehold and non-consensual sexual contact would cause a reasonable person to experience psychosocial harm, trauma and fear from…

  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 · Jcited before2024-04-29 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 a resident interview, staff interviews and record review, the facility failed to report an incidence of physical abuse to facility administration to protect a resident from further physical abuse. Resident #5 experienced physical abuse twice on 12/27/23. Both incidents occurred on 12/27/23 before 2:30 PM. Resident #4 first physically assaulted Resident #5 in the dining room. This occurrence of physical abuse was not reported to the facility administration. As a result, Resident #4 physically assaulted Resident #5 again in the hallway. The deficient practice occurred for 1 of 4 sampled residents reviewed for abuse (Resident #5). The findings included: The facility's policy, Abuse Prevention, Intervention, Reporting and Investigation, effective November 2016, recorded in part, The facility will ensure the protection, prompt reporting, and interventions in response to alleged, suspected, or witnessed abuse of any resident. It is the responsibility of employees to promptly report to facility management any…

  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 · Gcited before2026-01-07 · 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 observations, record review, and staff and Medical Director interviews, the facility failed to provide safe transport for a resident in a wheelchair when Nurse #1 transported Resident #1 in a wheelchair to the medication cart while Resident #1 held her legs up because she was unable to bend them and place them on the wheelchair footrests. Resident #1's left leg dropped down between the wheelchair footrests and got caught underneath the wheelchair. Resident #1 was complaining of severe pain to her left leg with swelling noted to her left shin and was transferred to the emergency department (ED) for further evaluation. X-rays obtained in the ED revealed Resident #1 sustained a left proximal (upper) tibia (shinbone) fracture and her left leg was placed in a splint and she returned to the facility with orders for hydrocodone/acetaminophen 5-325 milligrams two tablets administered every 6 hours as needed to manage her pain. This deficient practice occurred for 1 of 3 residents reviewed for accidents…

  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 · Past Non-Compliance
• Potential for harm · D2026-03-27 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 #1, Family Member #2, Hospital Case Manager, and Regional Ombudsman interviews, the facility failed to readmit Resident #93 after being transferred to the hospital for an evaluation for agitation, wandering and unsteady gait for 1 of 3 residents reviewed for inappropriate discharges (Resident #93).Findings included: Resident #93 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, dysphagia, and chronic kidney disease. Resident #93 was discharged on 2/28/26. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was severely cognitively impaired and required assistance from staff with all activities of daily living (ADL). Resident #93 was not coded for any behaviors. The MDS indicated he was not coded for any discharge planning and wished to remain in the facility long-term.A review of Resident #93's care plans created on 2/3/26 revealed a focus area for the need 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 · Dcited before2026-03-27 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan to include immobilizer care for 1 of 1 resident reviewed for positioning and mobility (Resident #14).The findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses that included fracture of upper end of right tibia (shin bone). A physician's order dated 2/17/2026 for a right lower extremity knee immobilizer to be worn at all times and removed for skin checks and hygiene, with the right lower extremity maintained in extension. The order further instructed staff to document skin integrity every morning and at bedtime, related to a fracture of the upper end of the right tibia and to notify the provider if the skin was not intact.Resident #14's comprehensive care plan dated 2/17/2026 revealed no goals or interventions related to the right knee immobilizer. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was cognitively intact. An interview…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident and staff interviews, the facility failed to provide a safe transfer using the mechanical lift for 1 of 4 residents reviewed for accidents (Resident #8).The findings included: A review of the manufacturer's instruction manual dated 2015 for the mechanical lift provided by the facility read in part: When using the lift for a bed transfer, position the legs under the bed and open the legs to a widened position for stability. Do not position the lift by pushing or pulling on the lift arm or the patient. Resident #8 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact, had lower extremity range of motion impairment on both sides, and required substantial to maximal assistance with transfers. The care plan dated 10/30/25 indicated Resident #8…

  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 · Past Non-Compliance
• Potential for harm · D2026-03-27 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interviews, the facility failed to remove expired medications stored in 2 of 3 medication rooms reviewed for medication storage (Medication Room for [NAME] Hall and Over the Counter (OTC) Medication Storage Room) and failed to date a vial Tuberculin Purified Protein Derivative (PPD) used for tuberculosis testing when opened in 1 of 2 medication refrigerators (West Hall Medication Room refrigerator).The findings included:An observation of the Over the Counter Medication Storage room was conducted on 3/24/2026 at 2:49 PM in the presence of Unit Manager #1. The following medication was found in the medication room: four boxes of bisacodyl suppositories (a medication used as a stimulant laxative for constipation)10 milligrams (mg) with 12 suppositories per box. The expiration date on the boxes was November 2025. Unit Manager #1 confirmed the expiration date by reading aloud the date printed on the box. An interview with Unit Manager #1 was completed on 3/24/2026 at 2:49 PM. Unit Manager #1 stated the Over-the-Counter Medication Room was checked frequently…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · 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 record review, observations and staff interviews, the facility failed to follow their infection control policy and procedures for Contact Precautions when Nurse Aide (NA) #3 did not wear all necessary Personal Protective Equipment (PPE) while providing incontinence care for Resident #53. The deficiency occurred for 1 of 4 staff members observed for infection control practices (NA #3).The findings included:A review of the facility's policy that was revised in October 2018 titled Contact Precautions, indicated:Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed and hand hygiene performed before leaving the room.…

  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 · E2025-11-20 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and resident interviews, the facility failed to honor a resident's choice to smoke a tobacco cigarette by making residents use vaping devices for 4 of 4 residents reviewed for choices (Resident #42, Resident #23, Resident #18 and Resident #78). This deficient practice had the potential to affect all residents that smoked cigarettes.The findings included: The facility's smoking policy revised on 9/19/25 read in part: This facility is a safe smoking facility, and the use of tobacco products is limited to e-cigarettes and vaping devices and permitted only in designated areas.a. Resident #42 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was moderately cognitively impaired, was able to understand and be understood by others and was coded for current use of tobacco. The care plan dated 9/19/25 indicated Resident #42 had a focus area related to tobacco use and the interventions included supervision when…

  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 · D2025-11-20 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 Responsible Party and staff interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to increasing the frequency for 1 of 5 residents reviewed for unnecessary medications (Resident #62).The findings included:Resident # 62 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was rarely/never understood and had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #62 had physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others which occurred 4 to 6 days during the assessment period. Resident #62 also had verbal behavioral symptoms directed towards others and rejection of evaluation or care behaviors which occurred 1 to 3 days during…

  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 · D2025-11-20 · 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 when her smoking status changed for 1 of 18 residents reviewed for comprehensive care plans (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus.A review of Resident #9's most up-to-date care plan revealed a focus area indicating tobacco use- and Resident #9 was assessed to be an unsafe and supervised smoker with a revision date of 8/19/24. Interventions included conducting smoking safety evaluation on admission and as needed and utilizing a smoking apron.A review of Resident #9's electronic medical record (EMR) revealed a smoking assessment dated [DATE] which indicated Resident #9 as a non-smoker who did not use smokeless tobacco products or electronic cigarettes. The assessment also revealed Resident #9 quit smoking in the previous…

  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 · D2025-11-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of medications to the wrong resident (2 medication errors out of 26 opportunities), resulting in a medication error rate of 7.69% for 1 of 5 residents (Resident #62) observed during medication pass.The findings included:Resident #62 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis (condition where there is breakdown of cartilage in multiple sites throughout the body) and constipation.The Physician's Orders in Resident #62's electronic medical record indicated an active order dated 11/17/23 for Polyethylene Glycol oral powder give 17 grams orally one time a day for constipation - mix with 4 to 8 ounces of fluid and an active order dated 6/26/25 for Acetaminophen liquid 160 milligrams (mg)/5 milliliters - give 650 mg by mouth three times a day for osteoarthritis.A review of Resident #32's Physician's Orders did…

  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 · E2025-05-23 · tag F0641 — pattern
  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 the Minimum Data Set (MDS) assessment in the areas of discharge status (Resident #98), Preadmission Screening and Resident Review (PASRR) (Resident #76), falls (Resident #54), and physical restraints (Resident #73). This deficient practice occurred for 4 of 19 residents reviewed for accuracy of assessments.The findings included:1. Resident #98 was admitted to the facility 6/15/23 and discharged from the facility 4/10/25.The facility Discharge summary dated [DATE] revealed Resident #98 was discharged to an Assisted Living Facility (ALF).The discharge MDS assessment dated [DATE] indicated Resident #98's discharge was unplanned, initiated by the facility and return was not anticipated. Resident #98's discharge location was coded short-term hospital.During an interview with MDS Coordinator #1 on 5/21/25 at 3:46 PM he revealed when a resident was discharged from the facility, he reviewed the electronic medical record and/or…

  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

$338,513 in federal fines across 7 penalties. 1 Medicare payment denial on record.

• $23,397 — penalty dated 2026-03-27
• $12,935 — penalty dated 2025-11-20
• $93,236 — penalty dated 2025-05-23
• $113,051 — penalty dated 2024-11-27
• $78,793 — penalty dated 2024-06-21
• $6,899 — penalty dated 2024-04-29
• $10,202 — penalty dated 2024-04-29
• Medicare payment denial — starting 2024-07-23 for 2 days

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

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 85% 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 $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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.

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