University Health 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.

Met the expected recovery: 54.5% 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 22 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% 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 126 beds and averages 103.7 residents a day — about 82% occupied, or roughly 22 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.78 hrs/resident/day on weekends vs 3.53 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% 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 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.

37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · J2024-11-05 · 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 reviews, and staff, Nurse Practitioner (NP), responsible party, and Resident interviews, the facility failed to notify the physician and responsible party of changes in condition for of 1 of 1 resident (Resident #7). Resident #7 had intact cognition and a history of stroke and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. On 10/22/24 between 7:00 and 7:15 AM Unit Manager (UM) #1 was called to the room by an NA and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. The Nurse Practitioner was in the facility and assessed Resident #7 and had him transferred to the Emergency Department (ED) for evaluation of stroke symptoms. There were no nursing progress…

  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 · Jcited before2024-11-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #7 was admitted to the facility on [DATE], with diagnoses of history of right hemiparesis/hemiplegia (partial or complete paralysis of one side) with right side weakness related to a stroke, Type 1 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #7 was cognitively intact and had functional impairment of the lower extremities bilaterally with use of a wheelchair, set up assistance for eating and oral hygiene/care, dependent care for toileting, showers, and lower extremity dressing including shoes, and maximum assistance for repositioning, sitting from lying, and transfers. The care plan dated 9/7/24 indicated that Resident #7 had a communication problem related to hearing loss (Right), hemiplegia/hemiparesis related to a stroke, needed assistance with transfers, mobility. A review of the medical record revealed there were no nursing progress notes entered on 10/21/24. The Medication Administration Record (MAR) indicated Resident #7 had his blood sugar checked at…

  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
• Actual harm · Gcited before2024-05-09 · 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 record review and staff and physician interviews the facility failed to safely transfer a resident when utilizing a sit to stand lift for 1 of 3 residents reviewed for accidents (Resident #1). This unsafe transfer resulted in Resident #1 sustaining a mildly displaced left medial malleolus (boney presence on the inner side of the ankle) fracture and pain of 5 on a scale of 1 to 10 (10 being the worst pain). Finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, contractures to right hand, contractures to right knee and contractures to left knee. Review of Resident #1's care plan (revised date 10/9/23) revealed the focus area for a risk for Activities of Daily Living (ADL) self-care performance deficit related to cerebral palsy, contracture to right hand, right knee and left knee and bipolar disorder. One of the interventions was recommended transfers with stand lift. Resident was total assist with transfer. Review of the nursing note dated…

  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
• Actual harm · G2024-03-06 · 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, resident, staff, Physician, Psychiatric Nurse Practitioner, and Administrator interviews the facility failed to protect a resident's right to be free from employee to resident physical abuse, when an employee (receptionist) threw a plexiglass (acrylic) mask holder hitting Resident #2 on his forehead. The resident had a fall, and a laceration on his forehead. The resident was angry and upset when he was hit by the object thrown by the staff member. Resident #2 was sent to the emergency room and had undergone a procedure for 5 sutures on his forehead. This was for 1 of 2 residents reviewed for abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Resident #2's cumulative diagnoses included Anxiety Disorder, Bipolar disorder, Mood disorder, and Diabetes Mellitus type 2. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was assessed as cognitively intact and independent with Activities of Daily Living. Resident #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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-06 · 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 staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after each of the following surveys with citations that were recited on the current complaint survey of 3/6/24: 1) A complaint investigation survey of 1/14/22. This was evident for one recited deficiency in the area of Freedom from Abuse and Neglect (F600). 2) The annual recertification / complaint investigation survey of 8/18/22. This was for one recited deficiency in the area of Request / Refuse / Discontinue Treatment; Formulate Advance Directives (F578). 3) A complaint investigation survey of 3/16/23. This was evident for recited deficiency in the area of Reporting Alleged Violations (F609). 4) A follow-up, focused infection control, and complaint investigation survey of 4/13/23. This was also for one recited deficiency in the area of Reporting Alleged Violations (F609). 5) The annual recertification / complaint investigation survey of 9/14/23. This was for one recited…

  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 · Ecited before2026-04-16 · 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, staff interviews and manufacturer recommendations, the facility failed to date opened multi-dose vials of insulin medication in 2 of 4 medication administration carts (carts number 1 and 2) and failed to remove expired multi-dose insulin pens from the medication cart drawer for 3 of 4 medication administration carts reviewed (carts number 1, 2 and 3). Findings Included: A review of the manufacturer's recommendations, dated December 1st, 2021, indicated to discard Lantus insulin multi-dose vial 28 days after opening. A review of the manufacturer's recommendations, dated July 7th, 2023, indicated to discard Humalog insulin multi-dose vial 28 days after opening. On 4/13/26 at 10:35 AM, an observation of the medication administration cart #3 with Nurse #9 revealed one Humalog insulin pen, opened on 3/1/26 and one Lantus insulin pen, opened on 3/12/26.On 4/13/26 at 10:40 AM, during an interview, Nurse #9 indicated that the nurses who worked on the medication carts were responsible for discarding opened and undated or expired multi-dose vials and insulin pens. She…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-16 · 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 label and date leftover frozen food that had been removed from its original packaging and failed to properly seal leftover frozen food stored in 1 of 1 reach in freezer. The facility also failed to clean food debris from under the steam table, black buildup substance around wall edges around kitchen wall perimeter and within floor tile grout lines. In addition, the facility failed to repair open holes under sinks, broken wall tile, damaged door molding, accumulated debris from an air duct vent, and a leaking water pipe under the sink located at the back of the kitchen. The deficient practice had the potential to affect food served to the residents and the cleaning and sanitation practices pose a potential risk for pests and contamination.The findings included:a. Observations during the initial tour of the main kitchen with Dietary Manager (DM) on 04/13/26 at 10:21 AM revealed the following: -One small clear bag with 8-10 breaded chicken strips with no open date labeled on bag. The item was discarded by the DM.-One…

  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 · E2026-04-16 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of roaches for 1 of 3 observations in the kitchen. Findings included:Pest control summary of services from the pest control service were reviewed for the following dates of 09/09/25, 09/16/25, 09/30/25, 10/07/25, 10/14/25, 10/21/25, 11/05/25, 11/21/25, 11/25/25, 12/02/25, 12/10/25, 12/17/25, 12/30/25, 01/06/26, 01/13/26, 01/20/26, 01/28/26, 02/04/26, 02/17/26, 02/25/26, 03/03/26, 03/11/26, 03/24/26, 03/31/26, and 04/09/26.The following general comments/instructions were documented on the summary of services:-09/09/25- Spot treated kitchen, underneath cooking equipment, dishwasher area, restrooms, dining area, and office for general pest control. German roach activity was found in the electrical box in the dishwasher, near the coffee station, and the heating warmer for the food. Cracks in the wall, floor, and ceiling tiles need to be…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · 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 record reviews, and resident, family member, and staff interviews, the facility failed to honor a resident's choice related to shower time for 1 of 5 residents reviewed for choices (Resident #53). Findings include:Resident #53 was admitted to the facility on [DATE] with diagnoses that included contractures of right hand, left and right knees, and chronic kidney disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53's cognition was intact. He had a range of motion impairment on both sides of his lower extremities and utilized an electric wheelchair for mobility. Resident #53 was dependent on staff with toilet hygiene, shower/baths, dressing, personal hygiene, bed mobility, and transfers. Resident #53 had an external catheter and was always incontinent with bowels. Resident #53 was not coded for rejection of care during the look back period.A review of Resident #53's active care plan, last revised 03/20/26, included a focus area for activities of daily living (ADL)…

  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 · D2026-04-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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, resident and staff interviews, the facility failed to provide maintenance services necessary to ensure resident bathrooms were in good repair and maintained in a safe, homelike manner. Damaged sheetrock, damaged floor tile, shower tile with visible blackish-brown substance present, and a broken ceramic toilet tank lid were observed for 1 of 4 sampled residents (Resident #15) on 1 of 4 halls (Hall #1).Findings included: A review of the census showed Resident #15 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 1/28/2026.Resident #15's quarterly Minimum Data Set, dated [DATE] documented that he was cognitively intact.A review of facility work orders from 1/1/26 through 4/15/26 revealed one completed work order for room [ROOM NUMBER] on 3/20/26 (installation of a grab bar in the bathroom). No work orders were found for room [ROOM NUMBER]. No work orders were available prior to January of 2026.During an interview on 4/13/26 at 3:26 PM, Resident #15 stated he was…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · tag F0679 — failed to provide activities — isolated
  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 observations, record review, and interviews with staff and the Nurse Practitioner (NP), the facility failed to provide an ongoing activity program that met the individual interests and needs to enhance the quality of life for 1 of 1 resident reviewed for activities (Resident #13). Findings included:Resident #13 was readmitted on [DATE] with diagnoses including hemiplegia (complete or near-complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left nondominant side, speech and language deficits following cerebral infarction, aphasia (disorder that affects language abilities due to brain damage, usually from a stroke or injuries), schizoaffective disorder, and a cognitive communication deficit.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #13 had adequate hearing, unclear speech, and was assessed as cognitively intact. The assessment showed the resident required…

  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 · Dcited before2026-04-16 · 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, observations, and interviews with the Nurse Practitioner, resident and staff, the facility failed to schedule a follow-up appointment with dermatology for 1 of 3 residents reviewed for non-pressure related skin conditions (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included diabetes and a history of basal cell carcinoma of the skin. A Nurse Practitioner (NP) progress note dated 12/9/25 indicated Resident #35 had a sore on top of the head. The NP documented a dermatology appointment was to be made by nursing. A NP progress note dated 1/27/26 read that Resident #35 was being seen for a wound to the top of his head. Wound was present from scratching and was the size of a nickel. New orders were provided for treatment of the healing wound to the top of his head. Resident #35 had a history of basal cell carcinoma to the head, neck and skin. Consults: dermatology consultation as needed for possible basal cell carcinoma on top 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, Nurse Practitioner and staff interviews, the facility failed to assess and obtain treatment orders for a resident admitted from the hospital with a pressure ulcer for 1 of 8 residents reviewed for pressure ulcers (Resident #125).The findings included: A review of the hospital records for Resident #125 from 12/31/25 to 1/23/26 indicated a hospital-acquired unstageable pressure injury was present to the sacrum. The discharge summary did not contain any type of wound care orders for the sacral pressure injury. Resident #125 was admitted to the facility on [DATE] (Friday) with diagnoses that included end stage renal disease on hemodialysis and pressure ulcer of the sacral region. Review of the admission assessment and nursing progress note dated 1/23/26, completed by Nurse #13, indicated skin impairment to the coccyx was present on admission to the facility and was marked as unstageable. There were no other details in the progress note describing the skin impairment. Attempts to contact Nurse…

  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 before2025-01-16 · 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) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 2 medication (med) carts observed (Med Cart #1); 2) Discard expired medications on 2 of 2 medication carts observed (Med Cart #1 and Med Cart #4) and in 1 of 1 Medication Storeroom (Nurse Station #2 Medication Storeroom); and 3) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (Med Cart #1). The findings included: 1. An observation was conducted on 1/14/25 at 3:50 PM of Medication (Med) Cart #1 in the presence of Nurse #1. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use prefilled pens of Insulin Glargine-yfgn should be stored at room temperature and used within 28 days. An opened and in-use prefilled pen of Insulin Glargine-yfgn was stored on the med cart without a resident's name on the label to indicate who the insulin pen belonged to. An auxiliary sticker placed on the pen included 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observation, record review and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request staff assistance if needed for 1 of 1 resident reviewed for accommodation of needs (Resident #78). Findings included: Resident #78 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated 11/ 5/24 revealed the resident was assessed as moderately cognitively impaired. The assessment indicated Resident #78 had clear speech, could make herself understood and had the ability to understand others. Resident #78 was assessed with impairment on both sides related to functional limitation in range of motion for upper and lower extremities. The resident was dependent on staff for all activities of daily living (ADL) and needed substantial to maximum assistance to roll left or right. An observation of Resident #78 on 1/13/25 at 12:02 PM, revealed the resident's call bell was tied to the bed rail on her right side. It…

  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

“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

$129,754 in federal fines across 3 penalties.

• $86,473 — penalty dated 2024-11-05
• $10,033 — penalty dated 2024-05-09
• $33,248 — penalty dated 2024-03-06

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 LIFEWORKS REHAB — 64 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 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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 $971K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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