University Place Nursing and Rehabilitation 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.

37.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 35.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 207 beds and averages 154.4 residents a day — about 75% occupied, or roughly 53 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.26 hrs/resident/day on weekends vs 3.74 on weekdays — 13% thinner on weekends. RN hours go from 0.48 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

35 citations, most serious first. The 12 most serious are shown; the remaining 23 are one tap away and print in full.

• Actual harm · Gcited before2024-10-15 · tag F0760 — failed to prevent significant medication errors — isolated
  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 observations, record review, and staff, Resident Representative, Physician Assistant and Pharmacist interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer a daily dose of Cenobamate (seizure medication) from 9/05/24 through 9/18/24. Resident #1 was observed having a mild seizure (eyes rolled back and upper body twitching that lasted approximately 2 minutes) on 9/18/24. This deficient practice occurred for 1 of 3 residents reviewed for medication errors. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to continue Divalproex Sodium (seizure medication) 750 milligrams (mg) in the morning and 1000 mg at bedtime, Zonisamide (seizure medication) 400 mg at bedtime, decrease Lacosamide (seizure medication) to 200 mg twice…

  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 · Past Non-Compliance
• Actual harm · H2024-03-13 · 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 4 of 5 residents reviewed for activities (Resident #17, 31, 35, and 110). The residents expressed not being able to leave the facility for over a year made them feel more dependent, less social, sad, and they missed getting out with the group to shop and socialize. The findings included: A review of the February 2024 activity calendar 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 minutes from February 2023 through February 2024 revealed grievances for scheduled group activities outside of facility were discussed each month during meetings and the response given from 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-24 · 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 observations and staff interviews, the facility failed to remove a dented can located on shelf ready for use and failed to reseal and label and date leftover food items stored for use. These practices occurred in 1 of 1 walk-in freezer and 1 of 1 dry storage room and had the potential to affect food served to residents. The findings included: An initial tour of the kitchen occurred on 7/21/25 at 10:09 AM. The following concerns were identified:a. Items in the walk-in freezer that were open to air and not resealed but labeled included: -one 15.33 pound (lb.) box of Texas Toast bread, dated 7/11/25-one 7.93lb box of churros, dated 10/24/25 Items in the walk-in freezer that were open to air, not resealed, and not labeled included:-one18.9lb box of [NAME] cheese omelets -one 20lb box of cookie dough ballsb. Items in the dry storage area that were opened and resealed but not dated included:-one bag of brown sugar-one 22.6-ounce (oz) bag of brown gravy mix -one 31oz bag of white sugar -one 160oz bag of elbow…

  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 · D2025-07-24 · 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, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #23 hit Resident #96 in the face with a closed fist resulting in a slightly swollen area to the outer aspect of Resident #96's left eye. This affected 1 of 8 residents (Resident #96) reviewed for resident-to-resident abuse. The findings included:Resident #23 was admitted to the facility on [DATE] with diagnoses which included mild vascular dementia without behavioral disturbance, psychotic disturbance or mood disturbance due to a previous cerebral infarction (a condition where brain tissue dies due to a lack of blood supply) and hypertensive heart disease with heart failure.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 was able to ambulate 10 feet with a rolling walker unassisted but generally self-propelled in a wheelchair.A review of the care plan…

  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 · Dcited before2025-07-24 · 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, staff interviews, and record reviews the facility failed to remove expired medications stored in 1 of 4 medication carts (Garden City).The findings included:An observation of the Garden City medication cart was conducted on 7/22/25 at 1:30 PM in the presence of Nurse #1. The following expired medications were found in the Garden City medication cart, a pack of Catapres 0.1 micrograms (medication to lower blood pressure) with an expiration date of 7/18/25 in the second drawer from the top; and a pack of Atarax 25 milligrams (treat anxiety and itching) with an expiration date 2/27/25 were in the second drawer from the top. An interview with Nurse #1 was completed on 7/23/25 at 1:50 PM. The Nurse stated that all staff who administer medication were responsible for checking medication expiration dates. The night shift had more down time and was expected to check the medication carts to restock and get rid of expired medications.An interview with the Unit Manager was completed on 7/23/2025 at 1:54 PM. The Unit Manager reported that expired medications were placed…

  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 before2025-07-24 · 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 implement their policy for hand hygiene when Nurse #3 failed to perform hand hygiene during medication administration after handling medication bottles and dispensed pills into her bare hand before placing the pills in a medicine cup. In addition, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse Aide (NA) #3 failed to wear personal protective equipment (PPE) during a high contact care activity that included transferring Resident #122 who had a chronic wound and an indwelling urinary catheter and when NA #3 and NA #4 transferred Resident #117 who had an indwelling urinary catheter. This was for 3 of 5 staff members observed for infection control practices (Nurse #3, NA #3 and NA #4). The findings included:1. A review of the facility's policy titled Medication Administration - Person Centered Care dated last revised on 6/2021 revealed in part the following: If breaking tablets was necessary to administer the proper dose, hands are washed with soap and water…

  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 · Ecited before2024-10-15 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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, and staff interviews, the facility failed to accurately document the administration of 14 doses of a seizure medication in the medical record for 1 of 1 resident reviewed for accurate medical records (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to start Cenobamate once a day at bedtime with a gradual dose increase to 100 mg. A review of Resident #1's physician orders revealed the following orders: Cenobamate 50 mg to be administered once a day at bedtime 9/05/24 through 9/18/24. Cenobamate 100 mg to be administered once a day at bedtime 9/19/24 and continue. A review of Resident #1's Medication Administration Record (MAR) from August 2024 through September 2024 revealed Cenobamate 50 mg was documented as given daily at bedtime from 9/05/24 through 9/18/24. A review…

  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 before2024-08-27 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, and Physician Assistant interviews the facility failed to dispose of a plastic bag that had been used to crush medications for Resident #24 and the plastic bag ended up on Resident #23's breakfast tray. Resident #23 believed the crushed white substance was powdered sugar and sprinkled it on his breakfast. This affected 1 of 5 residents reviewed for medication errors. The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic pain. A physician order dated 05/06/24 read, Acetaminophen 500 milligram (mg) by mouth give 2 tablets 3 times a day for chronic pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #23 was cognitively intact and had no behaviors. The MDS further revealed that Resident #23 frequently reported pain of a 9 on a pain scale. Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. A physician order dated 10/18/23…

  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 · Past Non-Compliance
• Potential for harm · D2024-08-27 · 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, a resident interview, interviews with staff and record review, the facility failed to provide food in a form to meet the individual needs of a resident with a physician order for a regular diet with mechanical soft texture (Resident #19). This failure occurred for 1 of 3 sampled residents reviewed for mechanically altered diets. The findings included: A review of menus, recipes and the Diets policy, revised 9/2010 revealed residents with a physician order for a regular diet, mechanical soft texture should receive regular mechanical soft textured foods and meats from the regular menu would be ground, easy to chew and easy to swallow. Resident #19 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, dementia (mild) with mood disturbance, cognitive communication deficit, and psychosis. A review of the August 2024 Physician Order Summary revealed Resident #19 had a physician order for a regular diet with mechanical soft texture. A 8/7/24 quarterly Minimum…

  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 before2024-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews, the facility failed to safely assist a resident without causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 was documented to be transferred by a lift and was assisted by Nurse Aide #1 alone. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included dementia and hypertension. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severally cognitively impaired and required extensive assistance with transfers. Review of Resident #1's care plan revised on 04/19/24 revealed the resident was care planned for Activities of Daily Living (ADL). The goal was for Resident #1's care to be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Interventions included chair to bed and to chair transfer required a mechanical life for Resident #1. Review of Resident #1's care…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-30 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #3 re-admitted to the facility on [DATE]. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact with no psychosis, behaviors, or rejection of care. Review of Resident #3's medical record revealed no documentation that Resident #87 had been assessed to self-administer medications. Further review of Resident #3's medical record revealed no care plan for self-administration of medications. An observation of Resident #3 completed on 05/29/24 at 10:17 AM revealed her to be in her room, sitting in her wheelchair watching television. On Resident #3's overbed tray was a bottle of antacid chewable tablets. Additional observations made on 05/29/24 at 12:50 PM, 2:44 PM, and 3:00 PM all revealed the antacid chewable tablets remained on Resident #3's overbed table. An interview with Nurse #2 on 05/29/24 at 3:58 PM revealed she did not believe that the facility allowed residents to self-administer medications. She reported she knew that none of 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 · Dcited before2024-05-30 · 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 record review, observations, and Resident Representative (RR) and staff interviews the facility failed to provide nail care for 2 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #4 and Resident #5). The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, and muscle weakness. Resident #4 did not have a diagnosis of diabetes. A review of the shower schedule for Resident #4 revealed he was scheduled to receive showers on Mondays and Fridays. The last documented nail care was on 3/8/2024 and was documented in a nursing progress note. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired with impairment on both sides of the upper and lower extremities. Resident #4 was documented as maximum assist for personal hygiene. A review of the care plan dated 4/4/2024 revealed Resident #4 required staff support to achieve the highest practical level of function for activities…

  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

$276,401 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $9,318 — penalty dated 2024-10-15
• $267,083 — penalty dated 2024-03-13
• Medicare payment denial — starting 2024-04-04 for 148 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.

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 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 10 rows in the source record cover these 7 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.

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

Follow the money — this home’s finances

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

About 81% 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 $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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