Carver Living 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.

54.7% 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 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.7% 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 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 232 beds and averages 175.3 residents a day — about 76% occupied, or roughly 57 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.17 hrs/resident/day on weekends vs 3.71 on weekdays — 15% thinner on weekends. RN hours go from 0.52 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

44 citations, most serious first. The 18 most serious are shown; the remaining 26 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-05-22 · 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 reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a resident's assigned blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer located in the medication cart to check Resident #8's blood glucose (sugar) level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #8's blood glucose level and would have had no way to know if another staff member had previously disinfected the loose, unassigned, and unlabeled glucometer. This occurred while there were 11 residents identified with a known bloodborne pathogen in the facility with 4 of the 11 residents requiring blood glucose levels. Loose, unlabeled glucometers can be contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer has the high likelihood to expose residents to the spread of bloodborne…

  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
• Immediate jeopardy · Jcited before2025-04-11 · 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 reviews, and interviews with staff, Physician Assistant, and responsible party (RP), the facility failed to protect 2 cognitively impaired residents' right to be free from sexual abuse. On 4/4/25 at approximately10:00 PM, a Medication Aide observed a female resident (Resident #1) in a male resident's (Resident #2) room sitting upright on Resident #2's bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis inside of her mouth. When the Medication Aide asked what was going on, Resident #2 backed away from Resident #1 removing his penis from her (Resident #1) mouth. The residents did not have the capacity to consent to sexual relations. Resident #1's RP stated due to Resident #1's advanced dementia she was not aware of her behaviors and had no insight into what happened. A reasonable person expects to be protected from abuse in their home environment and would have experienced trauma with feelings such as fear, humiliation, anger, anxiety, and depressed mood as a…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-02-07 · 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

  Based on record reviews, observations, and interviews with staff and Medical Director, the facility failed to provide an agency nurse (Nurse #1) with orientation and training to meet residents' care needs, including education and verification of the nurse's competency on glucometer (blood glucose meter) disinfection. Nurse #1 used a shared glucometer without disinfecting the meter between residents for 1 of 3 residents (Resident #107) who was observed to have her blood glucose checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. There was a high likelihood that a resident without an existing blood borne pathogen could be exposed to a bloodborne pathogen as a result of staff not using the resident's dedicated glucometer, not knowing how to effectively clean and disinfect a glucometer, and staff not handling and storing the glucometer in a method to protect against cross-contamination via contact with other meters or equipment. Also, Nurse #2 (an agency nurse) failed to demonstrate competency with the disinfection of…

  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
• Immediate jeopardy · Jcited before2025-02-07 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-28 · tag F0561 — failed to honor residents' choices — isolated
  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 observation, record review and staff interview and Nurse Practitioner (NP) interviews, the facility failed to allow 1 of 4 residents the choice to take a shower (Resident #1). Resident #1 was very sad and stated she felt less than a person not being able to get a shower. The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder and spinal stenosis. Review of physician order dated 3/20/20 revealed Resident #1 was to have a shower on Monday, Wednesday, and Friday. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and was dependent on 2 staff for bathing. The MDS assessment also noted it was very important to her to choose between a bed bath, tub bath or shower. Review of Resident #1's care plan dated 7/23/23 revealed she required staff assistance with activities of daily living secondary to impaired mobility and muscle weakness, associated with diagnosis of Multiple Sclerosis. 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
• Actual harm · Gcited before2023-09-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, staff, and Nurse Practitioner interviews, the facility failed to protect 1 of 3 residents (Resident #3) right to be free from physical abuse when Resident #4 assaulted Resident #3 which resulted in chest pain, left thumb pain, swelling and an x-ray being ordered to the chest and thumb. Resident #3 was administered Acetaminophen as needed (PRN) for pain. This assault made Resident #3 feel scared. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #3's annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact, had no behaviors coded, required extensive assistance with bed mobility and transfers. Resident #4 was admitted to the facility on [DATE] with diagnosis that included cognitive communication deficit, muscle weakness, restlessness and agitation, dementia, major depressive disorder and received 7 days of…

  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
• Actual harm · G2023-09-28 · 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 record review, resident interview and staff interview the facility failed to follow the abuse policies in the area of protection after an allegation of abuse for 1 of 3 resident (Resident #3), by not implementing Q 15-minute checks on Resident #4 following a resident-to-resident abuse. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #3's Annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact, had no behaviors coded, required extensive assistance with bed mobility and transfers. Resident #4 was admitted to the facility on [DATE] with diagnosis that included cognitive communication deficit, muscle weakness, restlessness and agitation, dementia, major depressive disorder and received 7 days of antidepressant medication. A review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely…

  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
• Actual harm · Gcited before2023-09-28 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, resident, Nurse practitioner (NP)and staff interview, the facility's quality assurance (QA) program failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 8/12/2021 and 9/29/2022 and complaint surveys dated 3/2/2023 and 5/4/2023 in order to achieve and sustain compliance. These were repeat deficiencies cited during a complaint survey on 9/28/2023. The repeat deficiencies were in the areas of Minimum Data Set (MDS) Accuracy of (F641) and Resident-to-resident abuse (F600). The continued inadequate root cause analysis and lack of sustained compliance during five federal surveys of record shows pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross-referenced to: F 600: Based on record review, resident interview, staff interview and Nurse Practitioner interview, the facility failed to protect 1 of 3 resident's (Resident #3) right to be free from physical abuse when Resident #4 assaulted Resident #3 which resulted in chest pain, left…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · 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 observation, record review, and staff interviews, the facility failed to provide a dignified dining experience by ensuring all residents seated at the same table were served their meals at the same time for 1 of 2 sampled residents (Resident #141).Findings included:Resident # 141 admitted on [DATE] with diagnosis that included Alzheimer's disease, peripheral vascular disease, chronic kidney disease, and blindness in the right eye.Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #141 was cognitively intact, required set-up or clean-up assistance with eating, and ambulated independently with a walker.Record review of Resident #141's care plan initiated 3/25/2026 revealed he required set-up or clean-up assistance with meals and received a therapeutic diet of no added salt for hypertension.Record review of the meal consumption report revealed Resident #141 consumed 75-100% of meals.Continuous observation of the 400 Hall dining room on 5/11/2026 from 12:45 PM through 1:15…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to accommodate food preferences for 1 of 10 residents reviewed for food preferences (Resident #109).Findings included: Resident #109 was admitted on [DATE] with diagnosis that included hypertension.Record review of Physician orders dated 3/10/2026 revealed Resident #109 was prescribed a regular diet with thin liquids.Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. An observation of Resident #109's breakfast tray delivered to the room on 5/11/2026 at 9:30 AM identified bacon on the tray. Resident #109's dietary tray ticket revealed dislikes of pork, peppers, cheese, salt, and gravy. Observation of Resident #109's lunch tray delivered to the room on 5/13/2026 at 12:45 PM identified rice with gravy. Resident #109's dietary tray ticket revealed dislikes of pork, peppers, cheese, salt, and gravy. During an interview on 5/12/2026 at 9:14 AM, Resident #109 stated she received…

  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 before2026-05-14 · 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 interviews with staff and the Medical Director, the facility failed to implement their infection control policies and procedures when Nurse #14 administered medications to Resident #112 through a gastrostomy tube (tube that enters through the abdominal wall into the stomach) and did not wear a gown and gloves and when Nurse #14 failed to wear gloves when handling Resident #75's glucometer after a finger stick with a blood sample on the test strip. The deficient practice occurred for 1 of 4 staff observed for infection control practices (Nurse #14). Findings included:1. The facility Enhanced Barrier Precautions policy dated August 2022 documented in part 3. Examples of high-contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions include g. device care or use (central line, urinary catheter, feeding tube. On 5/11/26 at 10:00 am an observation and interview was completed of Nurse #14 when she checked placement and administered crushed medication into Resident #112's gastrostomy tube (feeding tube)…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-22 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Responsible Party (RP) interviews, the facility failed to notify the Responsible Party (RP) of Resident #1's change in condition after a new diagnosis of peripheral vascular disease (PVD) with the lack of pedal pulses in both feet and failed to notify the Medical Director, who was the resident's attending physician, of a new diagnosis of PVD, and failed to notify the Medical Director of the identification of a new wound and transfer to the hospital for 1 of 8 residents (Resident #1). The findings included: 1a. Resident #1 was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, contractures of the right knee, left wrist, left hip, and left knee, malnutrition, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left side of the body. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired. Review of a…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and staff interviews, the facility failed to protect residents' healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 2 of 5 (upper and lower medication carts on the 100-hall) medication carts observed. Findings included: A continuous observation of the upper 100-hall medication cart occurred on 5/15/25 at 5:15am. The medication cart was in the hallway unattended, and it was observed to have the computer screen showing resident information such as resident name, resident diagnosis, medications, date of birth , and room number. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants walked past the cart. Nurse #5 was interviewed on 5/15/25 at 5:18am. Nurse #5 confirmed she was the nurse responsible for the upper 100-hall medication cart. The nurse immediately stated she knew what was wrong and said, I should have put the privacy screen up on the computer. Nurse #5 explained she did not think about completing the task before leaving the cart to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-22 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interviews, the facility failed to implement their grievance policy and procedures when Resident #2 reported his catheters and wheelchair charger were missing for 1 of 3 residents reviewed for grievances (Resident #2). Findings included: The facility's policy titled Grievances/Complaints, Filing which was not dated read in part Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint Resident #2 was admitted to the facility on [DATE] with diagnoses of heart failure and paraplegia (paralysis that can affect all or part 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 · D2025-05-22 · tag F0711 — isolated
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  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 Medical Director interviews, the facility failed to ensure that during provider visits the provider reviewed the total plan of care for 1 of 8 residents (Resident #1) newly diagnosed peripheral vascular disease (PVD). Resident #1 was examined by the Medical Director and the Medical Director failed to recognize Resident #1 did not have active pedal pulses in both feet. An interview with the Medical Director revealed that there was no examination of the feet during her visit on 3/25/2025. Resident #1 needed an assessment of his feet based on the new diagnosis of PVD to recognize the need for further treatment, review the plan of care, and consultations. This deficient practice occurred for 1 of 3 residents reviewed for Physician visits (Resident #1). The findings included: Resident #1 was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, contractures of the right knee, left wrist, left hip, and left knee, malnutrition, hemiplegia (muscle weakness or partial…

  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
• Potential for harm · Dcited before2025-05-22 · 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 observation and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 2 of 5 (upper and lower carts on hall 100) medication carts reviewed. Findings included: a. A continuous observation of the upper 100-hall medication cart occurred on 5/15/25 at 5:15am. The medication cart was in the hallway unattended and was observed to have a resident's insulin pen sitting on top of the cart, the cart was unlocked, and the bottom drawer of the medication cart was open. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants walked past the cart. Nurse #5 was interviewed on 5/15/25 at 5:18am. Nurse #5 confirmed she was the nurse responsible for the upper 100-hall medication cart. The nurse immediately stated she knew what was wrong and said, I should have put the medication away, closed the drawer and locked my cart. Nurse #5 explained she did not think about completing the tasks before leaving the cart to provide medication to a resident. b. A continuous observation of the lower 100-hall medication cart…

  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 before2025-02-07 · 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 record review, and resident, staff and Nurse Practitioner interviews, the facility failed to protect the rights of residents from resident to resident abuse for 4 of 5 residents reviewed for abuse. (1) On 8/2/2024, two residents, Resident #52 and Resident #104, who had a previous history of a resident-to-resident altercation on 6/9/2024, were involved in a resident to resident altercation in the smoking area. Nursing staff responded to a loud noise from the smoking area and observed Resident #52, who had a history of aggressive behavior, lying on the concrete floor of the smoking area. Resident #104 was observed sitting in his wheelchair. Resident #52 and Resident #104 were observed swinging their arms and hitting each other. The nursing staff immediately separated Resident #52 and #104. (2) On 10/20/2024, Resident #47 struck Resident #17 in the face when Resident #17 did not move for Resident #47 when Resident #47 entered the smoking area. Findings included: 1. Resident #52 was admitted to the facility…

  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 · Ecited before2025-02-07 · tag F0761 — failed to label and store drugs safely — pattern
  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: 1) Discard expired medications on 2 of 5 medication (med) carts observed (Front 200 Hall Med Cart and Back 200 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom); and 2) Date medications as to when they were opened to allow for the determination of its shortened expiration date for meds stored on 2 of 5 med carts (Front 200 Hall Med Cart and Front 400 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom). The findings included: 1. An observation was conducted on 2/3/25 at 1:24 PM of the Front 200 Hall Medication (Med) Cart in the presence of Nurse #4. The observation revealed the following medications were stored on the med cart: a. One bubble-pack card containing 29 tablets of 0.125 milligrams (mg) hyoscyamine (a medication that may be used to treat muscle spasms in the bowel or bladder) was stored past its expiration date. The pharmacy labeling on the bubble-pack card indicated this medication was dispensed for Resident #46 on 5/23/23 and had an…

  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

$128,554 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $13,855 — penalty dated 2025-05-22
• $14,511 — penalty dated 2025-04-11
• $17,345 — penalty dated 2025-02-07
• $82,843 — penalty dated 2023-09-28
• Medicare payment denial — starting 2023-10-28 for 38 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 CCH HEALTHCARE — 33 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

2 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 79% 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 $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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