Mary Gran Nursing 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.

55.5% 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 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 44 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 212 beds and averages 101.3 residents a day — about 48% occupied, or roughly 111 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 2.97 hrs/resident/day on weekends vs 3.41 on weekdays — 13% thinner on weekends. RN hours go from 0.41 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

27 citations, most serious first. The 15 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-14 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Medical Director #1, Cardiologist, LifeVest Resident Representative and LifeVest Technician interviews, the facility failed to consult with Medical Director #1 when Resident #119's LifeVest (an external defibrillator designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) delivered treatment shocks to her multiple times in the early morning hours on [DATE]. The LifeVest Resident Representative contacted Resident #119's Cardiologist on [DATE] about Resident #119's severe episodes of ventricular tachycardia, a life-threatening rapid heart rate. The Cardiologist called the facility and requested to talk to the Medical Director. The Cardiologist recommended that the resident be sent to the hospital for evaluation. The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital…

  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 · J2025-08-14 · 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 record review and staff, LifeVest Technician, LifeVest Resident Representative, Medical Director #1 and Cardiologist interviews, the facility failed to protect Resident #119's right to be free from neglect. Resident #119 was admitted on [DATE] with a LifeVest (a wearable device designed to detect life-threatening rapid heart rhythm and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). The nurses and nurse aides had no training on how to care for and manage a resident who required a LifeVest and staff neglected to provide necessary care and services after the LifeVest delivered several treatment shocks. Nurse #1 observed the device deliver treatment shocks to the resident in the early morning hours of [DATE] and took no action with the exception of notifying the oncoming first shift nurse that the Life Vest was shocking the resident all through the night. The Physician was not contacted to evaluate Resident #119 after the treatment shocks were delivered as specified in…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-08-14 · 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, Medical Director #1, Cardiologist, LifeVest technician and LifeVest patient representative interviews, the facility failed to obtain physician directives for staff about what to do when the LifeVest delivered a shock, identify the seriousness of Resident #119's cardiac status and the need for a comprehensive medical evaluation when a LifeVest (an external defibrillator device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) shocked the resident multiple times in the early morning hours (beginning shortly after midnight) of 2/11/25. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. From 2/11/25 through 2/13/25 the facility failed to consult with the physician regarding the LifeVest having delivered treatment shocks to 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
• Immediate jeopardy · J2025-08-14 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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, Medical Director #1, Cardiologist, Resident Representative, LifeVest technician, and LifeVest patient representative interviews, the facility failed to ensure staff were trained and competent to care for a resident who wore a LifeVest (a device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). Resident #119 received a treatment shock multiple times by the LifeVest she was wearing in the early morning hours (beginning shortly after midnight) on [DATE]. Nurse #1, an agency nurse assigned to Resident #119, observed the device deliver the treatment shocks to Resident #119 and took no action with the exception of notifying the oncoming first shift nurse (Nurse #5) that the LifeVest was shocking the resident all through the night. The 7 of 7 staff members that cared for Resident #119 from [DATE] through [DATE] that included Nurse #1, Nurse #5, Nurse #6, Nurse #8, Nurse Aide (NA) #2,…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to lock the left brake on Resident #3's wheelchair during a one person stand-pivot transfer on 3/14/25. The left wheelchair brake mechanism was worn and did not engage with the rubber on the tire. The resident could not stand independently or stop the wheelchair when it started to roll. Nurse Aide (NA) #1 lowered Resident #3 to the floor. Both Resident #3 and NA#1 heard a pop. Nurse #3 assessed Resident #3 who denied pain and wanted to go to a scheduled dialysis appointment. During the dialysis appointment, Resident #3 experienced left knee pain. A portable x-ray taken at the facility was negative. Resident #3 continued to have pain and was sent to an orthopedic clinic where he had another x-ray with a negative result. He was treated with a left knee steroid injection for pain. Pain continued after the injection. On 3/28/25 Resident #3 was sent to the hospital for further evaluation.…

  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 before2025-08-14 · 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

  Based on observations and staff interviews, the facility failed to: a) label and date opened packages of food for 1 of 1 walk in freezers, b) label and date items in the large walk-in refrigerator and a smaller refrigerator for 2 of 2 refrigerators in the kitchen and c) discard expired items in 2 of 2 refrigerators in 2 of 2 nutrition rooms. This deficient practice had the potential to affect the food served to the residents. Findings included:An initial tour of the kitchen was conducted on 8/4/25 at 11:00 AM in the presence of the Dietary Manager.a) Observation of the walk-in freezer revealed the following:An open cardboard box containing an opened plastic bag of hamburger meat with no opened date, an opened plastic bag of tater tots with no opened dated and an opened plastic bag of diced potatoes with no opened date. The following were also observed in the walk-in freezer:An opened bag of chicken tenders with no opened date.An opened bag of frozen cookie dough with no opened date.An opened bag of garlic bread with no opened date. An interview with the Dietary Manager was completed…

  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 · D2025-08-14 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to maintain a residents dignity when Nurse Aide #3 placed a meal tray at the bedside of a cognitively impaired resident (Resident #52) who was dependent on staff for feeding assistance and walked away. Nurse Aide #3 did not return to feed Resident #52 for 40 minutes. Nurse Aide #3 then attempted to feed Resident #52 the cold food on the meal tray. This occurred for 1 of 3 residents reviewed for dignity. A reasonable person may feel helpless, forgotten, and become frustrated at not being able to get assistance to eat their meal. Findings included.Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and dysphagia. A care plan dated 6/13/25 revealed Resident #52 required staff assistance with eating. The goal of care was to receive necessary staff assistance with eating to promote adequate nutrition. Interventions included to provide assistance with meals and promote dignity. The Minimum Data…

  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 · D2025-08-14 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on manufacturer directions, observations, and staff interviews, the facility failed to remove 1 opened multi-dose insulin injector pen that was expired in 1 of 3 medication carts (200-hall medication cart), reviewed for medication storage and labeling.The findings included: The manufacturer's directions for insulin glargine injector pen stated once opened, the product is good for 28-days. Discard after 28 days: Even if there's insulin left in the pen after 28-days, discard it. The insulin may have lost potency after this time.An observation of the 200-hall medication cart and interview with Nurse #5 were conducted on [DATE] at 8:45 AM. An opened insulin glargine injector pen dated [DATE] was found in the cart. The insulin glargine pen had a label on it which stated the insulin pen was to be discarded 28 days after opening. Nurse #5 stated the expired insulin glargine pen dated [DATE] should have been removed after 28-days by the night nurse on the 200-hall medication cart and was not.An interview 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-17 · 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, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.) hold Humulin Regular (short acting) insulin when Resident #7's the blood glucose was less than 150 mg/dl (milligrams per deciliter) at 7:30 AM and less than 120 mg/dl at 11:00 AM and 5:00 PM. 2.) hold Resident #8's Humalog (insulin lispro) short acting insulin 5 units before meals for a blood glucose less than 100 mg/dl. 3.) give Resident #9 Humalog insulin 5 units before meals for premeal blood glucose over 150 mg/dl. 4.) give Resident #10 an additional 4 units of Humalog insulin for premeal blood glucose over 200 mg/dl. 5.) hold Humalog insulin according to the physician's order for Resident #11 and Resident#12 when the blood glucose was less than 120 mg/dl. 6.) administer the antihypertensive medication Clonidine prescribed as needed for increased blood pressure to Resident #3 and Resident#13 when the systolic blood pressure was greater than 160 and 170 millimeters of mercury…

  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 · Fcited before2024-08-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 observation and staff interviews the facility failed to maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and failed to repair peeling paint hanging from the ceiling above 2 of 2 food preparation tables. These practices had the potential to affect 90 of 91 residents' food quality and kitchen sanitation safety. Findings included: 1) The initial tour of the kitchen conducted on 08/05/24 at 11:35 AM the Dietary Manager (DM) said the staff used the solution in the red bucket to wipe down the main food preparation table area after food preparation and prior to manning the tray line. DM said their stainless-steel food preparation tables were wiped down before breakfast and again just before lunch tray line set-up using the sanitizing solution kept in the only red sanitizing bucket kept under the kitchen's food preparation tables. At 11:45 AM on 08/05/24 strips were used to check the sanitizing solution in the kitchen's only red sanitizing bucket. The solution in…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-12 · 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 observations, record review, resident, staff, and the Nurse Practitioner's interviews the facility failed to implement an order for Metoprolol 50 milligrams daily (a beta blocker indicated for the treatment of hypertension and heart failure) that was prescribed for atrial fibrillation (irregular heart rhythm) following a cardiology appointment. The medication error resulted in 25 missed doses. This occurred for 1 of 1 resident (Resident #55) reviewed for medication administration. Findings included. Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation and chronic systolic congestive heart failure. Review of a cardiology consult report dated 07/11/24 revealed Resident #55 had permanent atrial fibrillation. The electrocardiogram (ECG) showed atrial fibrillation with mildly increased ventricular rate at 114 beats per minute. The recommended best medical therapy was to add Metoprolol Succinate 50 milligrams (mgs) daily to help with ventricular rate…

  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 · E2023-03-23 · 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 and staff and resident interviews, the facility failed to provide an ongoing resident centered activities program based on residents' individual interests for 2 of 7 residents reviewed for activities (Resident #27 and Resident #50). Findings included: a). Resident #27 was admitted to the facility on [DATE] with diagnoses of osteoarthritis with stiffness of right and left hand and glaucoma. Resident #27's 10/28/22 Annual Minimum Data Set (MDS) assessment revealed resident was cognitively intact. Resident #27's activity preferences included keeping up with the news, activities with groups of people, favorite activities, going outside and religious activities were very important. Books and music were not important to Resident #27. Resident #27's care plan revealed an activities focus was added on 5/24/21 and reviewed on 1/28/23. The activities care plan focus stated Resident #27 enjoyed attending and participating in most activities at the facility. Resident #27's goal indicated resident will…

  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 · E2023-03-23 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Consultant Pharmacist interviews, the facility failed to address drug irregularities noted by the Consultant Pharmacist on two consecutive monthly Medication Regimen Reviews for 2 of 5 residents (Resident #43 and Resident #5) reviewed for unnecessary medications. Findings included: 1). Resident #43 was admitted to the facility on [DATE] with readmissions on 12/19/22 and 12/26/22. Resident #43's medical diagnoses included epilepsy, and anxiety. The 12/19/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 milligrams (mg.) give 0.5 tablet three times per day as needed anxiety, agitation, seizure. The 12/26/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 mg. give 0.5 tablet three times per day as needed anxiety, agitation, seizure. A physician order dated 12/19/22 was entered by Support Nurse #1 for lorazepam 0.5 mg. give 0.5 tablet by mouth three times per day. Review of Resident #43's December 2022…

  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 · E2023-03-23 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to 1). accurately transcribe and administer a medication used to treat anxiety resulting in resident was administered antianxiety medication on a scheduled basis instead of as needed per the physician order, and 2) accurately transcribe and administer a medication used to treat depression and insomnia resulting in resident received 22 doses of the medication at a higher dose than ordered for 2 of 5 residents (Resident #43 and Resident #5 ) reviewed for psychotropic medication (a medication used to treat behavior, mood, thoughts, or perception). Findings included: 1). Resident #43 was admitted to the facility on [DATE] with readmissions on 12/19/22 and 12/26/22. Resident #43's medical diagnoses included in part intellectual disability, epilepsy, and anxiety. Resident #43's care plan revealed a focus initiated on 7/24/20 and reviewed on 1/15/23 of received anti-anxiety medication with risk for adverse side…

  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 · Ecited before2023-03-23 · 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, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to follow parameters for administration of a medication used to treat hyperglycemia resulting in 16 doses administered in error for 1 of 1 resident (Resident #5) reviewed for medication error. Findings included: Resident #5 was admitted to the facility on [DATE] with diagnosis which included in part diabetes and long term use of insulin. Resident #5's 2/15/23 quarterly Minimum Data Set (MDS) assessment revealed resident with moderate cognitive impairment and received injections and insulin 7 days during the lookback period. Assessment indicated Resident #5 had orders for insulin changed once in the look back period. Resident #5's care plan indicated a 6/6/19 focus of Diabetes Mellitus with risk for complications. The focus was reviewed on 1/4/23. The goal indicated diabetes would be adequately managed in order to minimize risk for complications. Interventions included Diabetes medication as ordered by…

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

  Pharmacy Service 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

$68,172 in federal fines across 1 penalty.

• $68,172 — penalty dated 2025-08-14

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 LIBERTY SENIOR LIVING — 37 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 18 rows in the source record cover these 11 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.

4 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.

This home reported $5.0M paid to related parties — landlords or management companies under common ownership — equal to about 35% 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