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Laurel Park Rehabilitation and Healthcare Center

901 Halstead Boulevard, Elizabeth City, NC 27909 · For profit - Corporation · 108 certified beds · (252) 338-0137 Medicare & Medicaid certified

Call the home — (252) 338-0137 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0604) — cited May 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$10,868 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0604), cited May 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,868 in federal fines (most recent 2025-05-21)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
905 Halstead Blvd · (252) 698-0345 · Call to confirm hours
Pharmacy
918 Halstead Blvd · (252) 337-7500 · Call to confirm hours
Grocery
Food Lion0.3 mi
1515 W Ehringhause St · (252) 338-1676 · Call to confirm hours
Place of worship
100 Kathyrn Ct · (252) 335-0015

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.9%15.6%15.4%typical
Long-stay residents who lose too much weight9.1%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.7%0.9%better
Long-stay residents with a urinary tract infection1.6%2.3%2.0%better
Long-stay residents with depressive symptoms5.6%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%3.5%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened32.6%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.6%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine91.6%94.1%95.3%typical
Long-stay residents with pressure ulcers5.9%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control27.6%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine51.1%78.1%79.4%worse
Short-stay residents rehospitalized after admission24.5%22.9%22.6%typical
Short-stay residents with an outpatient ER visit13.1%12.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.651.781.67typical
Long-stay outpatient ER visits per 1,000 resident days2.191.801.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

44.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.1%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
72.7%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 72.7% 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 77 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.1%CMS range 35.5–52.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.7–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge72.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge59.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.2%CMS range 5.6–14.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
0.61
LPN hours/ resident / day
1.78
Aide hours/ resident / day
2.75
Total nurse hours/ resident / day
0.24
RN hoursweekends
64.7%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 100.5 residents a day — about 93% occupied, or roughly 8 beds typically open. It runs fairly full. 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 2.75 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.35 hrs/resident/day on weekends vs 2.91 on weekdays — 19% thinner on weekends. RN hours go from 0.41 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% 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

12
deficiencies at the latest standard inspection (2025-05-21)
6
at the previous standard inspection (2024-05-22)

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.

ABCDEFGHIJKL

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.

33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · G2025-05-21 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, family and Medical Director interviews, the facility failed to protect a severely cognitively resident from physical restraint from a private duty Caregiver and chemical restraint. When Resident #199 refused to take medications from the Nurse the private duty Caregiver offered to assist and forced medications into the Resident's mouth, held her hand over the Resident's mouth, to force her to swallow. When Resident #199 became combative, and kicking and spitting out medications the private Caregiver restrained the Resident by placing her leg over Resident #199 legs to prevent her from kicking. The Nurse asked the Caregiver to stop and left the room to call the on-call provider. The Caregiver continued to restrain the Resident until the Nurse returned to the room and administered an intramuscular antipsychotic medication (chemical restraint) to calm her. Resident #199 was assessed and a pea size discoloration on the bottom side of her lip was observed. A reasonable person would…

    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
  • Potential for harm · F2025-05-21 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of the Facility Assessment the facility failed to identify any cultural considerations for the resident population, failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, and failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies which had the potential to affect 88 of 88 residents. The findings included: Review of the Facility Assessment revealed it was revised on 3/12/25. The Facility Assessment did not include any cultural considerations to meet the needs of the residents of the facility. Further review of the Facility Assessment revealed that the staffing plan listed the number of Nurses (Registered Nurse or Licensed Practical Nurse) and Certified Nursing Assistants (CNAs) noted as the desired number FTE (full-time equivalent, the total number of full-time employees working in an organization) of staff and the professional requirement for those staff members. However, the staffing plan did not…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-21 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 and staff interviews, the facility failed to provide written information to residents and resident representatives regarding advance directive and/or an opportunity to formulate an advance directive for 19 of 22 residents reviewed for advance directives (Resident #1, #5, #8, #21, #25, #26, #29, #33, #37, #40, #50, #52, #58, #72, #73, #75, #91, #95, and #302). The findings included: a. Review of Resident #1's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and hypotension. The review revealed a full code Physician order dated 5/18/25. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive. b. Review of Resident #5's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart failure, Alzheimer's disease, and cystitis. The review revealed a full code…

    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 · Ecited before2025-05-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observation, staff interview, and record review the facility failed to clean and maintain resident rooms for 6 of 29 resident rooms on 1 of 4 halls (300 Hall) observed for environment (Resident #39's room, Resident #29's room, Resident #8's room, Resident #56's room, Resident #92's room, and Resident #25's room). The findings included: The Resident Council meeting minutes dated 7/11/24 revealed there were residents' concerns about housekeeping needing to do a better job cleaning residents' room. The residents reported the housekeeping staff were not sweeping and mopping around or under beds. The Resident Council meeting minutes dated 11/22/24 revealed there were residents' voiced concerns about housekeeping not cleaning residents' rooms or emptying resident trash cans in room. The Resident Council meeting minutes dated 3/21/25 revealed the residents felt the rooms were not being swept or mopped. The residents voiced concern that the floors in their rooms were sticky. The Resident Council meeting minutes…

    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 · D2025-05-21 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 and resident interviews, the facility failed to hold a care plan meeting or invite the resident to participate in the care planning process for 2 of 26 residents whose care plans were reviewed (Resident #26 and Resident #37). The findings included: 1. Resident #26 was admitted to the facility on [DATE]. Resident #26's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderate cognitive impairment. Resident #26 was coded for active participation in the assessment and goal setting. Resident #26's care plans were noted as last reviewed or revised on 3/5/2025. Review of Resident #26's electronic medical record revealed no documentation that a care plan meeting was held or that Resident #26 was invited to participate in a care plan meeting during the time between the 12/4/2024 and 3/5/25 care plan meetings. An interview was completed on 5/18/2025 at 2:24 pm with Resident #26. Resident #26 stated she was unable to recall when she last 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 · Dcited before2025-05-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of smoking and elopement alarms for 1 of 26 residents whose MDS assessments were reviewed (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances and bipolar disorder. Review of the Safe Smoking Screening assessment dated [DATE] revealed Resident #33 was assessed and determined to require supervision while smoking. The assessment further noted the care plan was updated to reflect Resident #33's smoking status. Resident #33 had a physician order dated 4/29/25 for wander guard (elopement alarm) device, check placement every shift. The nursing progress note dated 4/29/25 at 3:32 pm revealed Resident #33 had a wander guard placed on the right ankle. The care plan initiated on 4/29/25 revealed Resident #33 had a care plan in place for smoking with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-21 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to update the care plan to include hearing aids for 1 of 33 residents whose care plans were reviewed (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #29 was seen by audiology for evaluation and treatment on 9/12/24. A physician's order dated 2/5/25 indicated the hearing aids were to be inserted every morning. A physician's order dated 2/6/25 indicated the hearing aids were to be removed at bedtime. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderate cognitive impairment. The resident was coded as having adequate hearing and wore hearing aids. The care plan, updated 3/19/25, did not include a focus area related to hearing loss or the wearing of new hearing aids. An observation of Resident #29 on 05/19/25 at 9:19 AM revealed the resident was not wearing her hearing aids. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, resident, staff, and physician interviews, the facility failed to obtain a physician order for the use and care of an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheter (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder (a condition where the nerves and muscles that control urination were not working properly causing urinary retention) and a history of a spinal fracture. Resident #1's care plan last revised on 4/30/25 revealed he had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder with interventions which included positioning the catheter bag and tubing below the level of the bladder and away from entrance room door. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and was coded for the use of an indwelling urinary catheter. A hospital Discharge summary 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
  • Potential for harm · D2025-05-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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, resident, Pharmacist and Medical Director interviews, the facility failed to have effective systems in place to ensure intravenous (a soft, flexible tube placed inside a vein used to give medicine or fluids) antibiotic medication was available as ordered for a newly admitted resident for 1 of 2 residents reviewed for IV antibiotic therapy (Resident #95). The findings included: Review of the hospital Discharge summary dated [DATE] revealed Resident #95 had an order to administer cefazolin (antibiotic) solution 2 grams intravenous (IV) every 8 hours for 42 days. Resident #95 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) of the left ankle and foot. The Admission/readmission assessment dated [DATE] at 8:52 pm completed by Nurse #3 revealed Resident #95 had a bone infection of the left lower extremity and had IV access in the left arm. Resident #95 had a physician order dated 4/29/25 for cefazolin solution injection 2 grams;…

    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 · D2025-05-21 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, and Physician interviews, the facility failed to administer scheduled intravenous (a soft, flexible tube placed inside a vein used to give medicine or fluids) antibiotic medication which resulted in 4 doses of the antibiotic being missed for 1 of 2 residents reviewed for IV antibiotic therapy (Resident #95). The findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) of the left ankle and foot. Resident #95 had a physician order dated 4/29/25 for cefazolin (antibiotic) solution injection 2 grams; administer 2 grams intravenously every 8 hours for bone infection for 42 days. The medication was scheduled to be administered at 6:00 am, 2:00 pm, and 10:00 pm. Review of the Medication Administration Record (MAR) for April 2025 revealed the Resident #95's cefazolin was not administered on the following dates: 4/29/25 at 10:00 pm noted as on order by Nurse #3. 4/30/25 at 6:00 am noted as…

    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 before2024-05-22 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interviews and staff interviews, the facility failed to conduct and document a care plan meeting with a cognitively intact (Resident #86) and moderately impaired (Resident #38) residents newly admitted to the facility and failed to conduct and invite a cognitively intact resident to participate in care plan meetings after two annual Minimum Data Set (MDS) assessments and three quarterly MDS assessments (Resident #26) for 3 of 6 residents reviewed for care planning. Findings included: 1. Resident # 86 was admitted to the facility on [DATE] with diagnoses including multiple fractures. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #86 was cognitively intact. Resident #86's baseline care plan was signed by the Assistant Director of Nursing as completing the plan on 5/3/2024. The MDS Nurse signature was not dated and the Director of Nursing signed the baseline care plan on 5/21/2024. Resident # 86's comprehensive care plan dated 5/4/2024 indicated he…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Ecited before2024-05-22 · 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 maintain 2 of 4 skillets and 9 of 15 baking sheets free from grease build up and failed to maintain one ice scoop holder free of standing water and mold. These practices had the potential to affect ice and food served to residents. The facility census was 91 residents. Findings included: 1. An observation of the kitchen dishware on 5/19/24 at 10:20 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 3 baking sheets with dark grease built up under the rims were observed stacked on the drying rack ready for use A second observation of the kitchen dishware on 5/21/24 at 9:33 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 3 baking sheets with dark grease built up under the rims were observed stacked on the drying rack ready for use A third observation of the kitchen dishware on 5/22/24 at 9:57 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 9 baking sheets with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-22 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of insulin (a medication used to lower the blood glucose [sugar] in the blood) and anticoagulants (a medication use to prevent clotting of the blood) for 1 of 5 residents reviewed for unnecessary medications (Resident #293). Findings included: Resident # 293 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, pulmonary embolism (blockage of a blood vessel) and deep vein thrombosis (blood clot in the blood vessel). Physician's orders dated 5/10/2024 included Apixaban (a medication used to thin the blood) 5 milligrams (mg) twice a day and Humalog 100 units per milliliter sliding scale insulin subcutaneously (under the skin) before meals for blood glucose readings: 0 -150 give 0 units; 151 - 200 give 2 units; 201 - 250 give 4 units; 251 - 300 give 6 units; 301 - 350 give 8 units; 351 - 400 give 10 units and call MD if over…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to implement an individualized person-centered care plan for a resident with impaired vision for 1 of 5 residents reviewed for nutrition (Resident #36). The findings included: Resident #36 was readmitted to the facility on [DATE]. A physician order dated 2/27/24 for Resident #36 revealed that all food was to be placed in individual bowls at all meals to increase with self-feeding secondary to decreased vision. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #36 was cognitively intact, had highly impaired vision, and required setup help for eating. Review of Resident #36's active care plan (last revised on 2/27/24) revealed she had malnutrition risk related to history of coronary artery disease, stroke, mixed hyperlipidemia, vertigo, and hypertension. Interventions included: provide food in bowls to assist with completion of meals related to visual deficits. An observation on 5/20/24 at 12:24 PM revealed Resident #36 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to obtain a physician order on a resident's medical record for the use of supplemental oxygen and apply signage indicating the use of oxygen outside the resident's room for 1 of 2 residents reviewed for oxygen use (Resident #292). Findings included: Resident #292 was admitted to the facility on [DATE] with diagnoses including chronic heart failure and chronic respiratory failure. Discharge orders dated 5/2/2024 included the use of supplemental oxygen to maintain oxygen saturation greater than or equal to 90%. Nursing documentation dated 5/2/2024 recorded Resident #292 on arrival to the facility at 4:40p.m. was receiving oxygen at 2 liters per minute vis nasal cannula. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #292 was cognitively intact and the use of oxygen. Further nursing documentation dated 5/8/2024 recorded Resident #292's oxygen saturation decreased to 80%. The physician was notified…

    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 before2024-05-22 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 provide all food in bowls as ordered by the physician for 1 of 1 residents requiring adaptive equipment for meals (Resident #36). Findings included: Resident #36 was readmitted to the facility on [DATE]. A physician order dated 2/27/24 for Resident #36 revealed that all food was to be placed in individual bowls at all meals to increase with self-feeding secondary to decreased vision. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #36 was cognitively intact, had highly impaired vision, and required setup help for eating. An observation on 5/20/24 at 12:24 PM revealed Resident #36 was observed to have the lunch meal served on a flat plate in her room. The meal ticket stated all food was to be served in bowls. Only the dessert item was placed in a bowl. Resident #36 stated that her lunch meal should have been served in bowls. A new meal placed in bowls was offered to Resident #36, but she declined. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-02 · tag F0867 — failed to act on quality-improvement findings — pattern
    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 record review, staff, and the facility ' s Quality Assessment and Assurance (QAA) Committee, the facility failed to maintain implemented procedures and monitor interventions the committee put into place following the 7/14/20 complaint investigation survey, 9/20/20 complaint survey, 5/10/21 complaint survey, and the 3/30/22 recertification and complaint investigation and survey. This was for 5 deficiencies cited on the current recertification and complaint investigation survey of 3/2/23. A deficiency was cited on 3/30/22 in the area of safe/clean/ homelike environment (F584). A deficiency was cited on 9/20/20, 5/10/21, and 3/30/22 in the area of accuracy of assessments (F641). A deficiency was cited on 5/10/21 and 3/30/22 in the area of develop/implement comprehensive care plan (F656). A deficiency was cited on 7/14/20 in the area of bowel and bladder incontinence, catheter, urinary tract infection (F690). A deficiency was cited on 5/10/21 in the area of influenza pneumococcal immunizations (F883). The continued failure during two or more surveys of record shows a pattern 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-02 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations upon admittance into the facility (Resident #47) and offer annual influenza vaccine (Resident #40) for 2 of 5 residents reviewed for immunizations. The Findings included: The facility policy for Pneumococcal Vaccine with the revised date October 28,2020 read in part Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. The resident's medical record shall include documentation that indicates at a minimum the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. The facility policy for Influenza Vaccine with the revised date October 27, 2020, read in part Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview the facility failed to develop an individualized person-centered care plan for 3 of 32 residents whose care plans were reviewed. (Resident #48, Resident #36, Resident #14) The findings included: 1.Resident #48 was admitted to the facility on [DATE] and had a diagnosis of malignant neoplasm of the esophagus. Review of a physician order dated 1/27/23 revealed an order for Hydrocodone-Acetaminophen Oral tablet 5-325 mg (milligram) - Give 0.5 tablet via G-tube (a surgically placed device used to give direct access to the stomach) every six hours as needed for pain. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. The MDS indicated Resident #48 had received opioid pain medication 5 days of the look back period. A review of Resident #48 ' s active care plan dated 2/16/23 did not reveal a care plan for pain management. On 3/2/23 at 3:44 PM the MDS nurse stated Resident #48 should have been care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview the facility failed to provide hair washing for 1 of 3 residents (Resident #43) reviewed for Activity of Daily Living (ADL) care who required assistance with bathing. The findings included: Resident #43 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included osteoarthritis, coronary artery disease, and congestive heart failure. Review of the most recent Minimum Data Set, dated [DATE] revealed Resident #43 was cognitively intact. She had no behaviors or rejection of care. She required total assistance, one-person physical assistance with bathing. An observation on 2/27/23 at 11:08 AM revealed Resident #43's hair appeared to be greasy, tangled and matted. During an interview on 2/28/23 at 8:33 AM Resident #43 stated she would like her hair washed and the matted hair on the back of her head addressed. She stated that the staff had not washed her hair in a long time and only partially brushed her…

    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 · D2023-03-02 · 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 observations, record review, and staff, Nurse Practitioner, and Medical Director interviews the facility failed to follow physician orders for turning and repositioning and failed to monitor specialty air mattress settings to ensure set to correct weight for 1 of 6 residents reviewed for pressure ulcers (Resident #42). Findings included: Record review of the hospital Discharge summary dated [DATE] revealed Resident #42 had a large right ischium (buttock/hip area) pressure ulcer and a large sacral pressure ulcer. Resident #42 was admitted to the facility on [DATE] with diagnoses which included dementia, protein calorie malnutrition, and pressure ulcers to sacrum and right ischium. The care plan dated 1/06/23 and last updated 1/19/23 revealed Resident #42 had multiple pressure ulcers and potential for new pressure ulcer development related to immobility with interventions which included turn and reposition at least every 2 hours by staff and a pressure relieving air mattress on bed. The admission Minimum…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 place hand/wrist splint to the left hand for contracture management for 1 of 4 residents reviewed for limited range of motion (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy and abnormal posture. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, had limited range of motion (ROM) of the upper and lower extremities, and was totally dependent on staff members for bed mobility and transfers. Resident #2 was not coded for behaviors. A physician order dated 2/07/23 for Resident #2 to wear her left upper extremity (LUE) hand/wrist orthosis during 7-3 shift. The resident was also able to remove the orthosis herself. Resident #2's care plan last revised on 2/17/23 revealed a care plan for the left resting hand splint to be applied during AM dressing. A care plan for potential pressure ulcer…

    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 before2023-03-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, staff interviews, and physician interviews, the facility failed to maintain an indwelling urinary catheter drainage bag below the bladder to allow for proper drainage and reduce risk for urinary tract infection (Resident #42) and failed to obtain a physician order for indwelling urinary catheter for 2 of 2 residents (Resident #42 and Resident #170) reviewed for urinary catheter. Findings include: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses which included dementia and retention of urine. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #42 had severe cognitive impairment, required assistance by 2 staff member for bed mobility, and was coded for an indwelling urinary catheter. Resident #42's care plan last revised on 1/19/23 revealed she had an indwelling urinary catheter due to urine retention with interventions which included to position the catheter bag and tubing below the level of the bladder and away from entrance…

    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 · D2023-03-02 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 the facility failed to follow physician ' s order to administer as needed pain medication to control a resident ' s pain for 1 of 1 residents reviewed for pain management. (Resident #48) The findings included: Resident #48 was admitted to the facility on [DATE] and had a diagnosis of malignant neoplasm of the esophagus and Stage 4 pressure ulcer. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. The MDS indicated Resident #48 had received opioid pain medication 5 days of the look back period. Review of the physician ' s orders revealed an order with a start date of 1/27/23 that read as follows: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligrams)-Give 0.5 tablet via G-Tube every 6 hours as needed for pain. Hydrocodone is a narcotic medication used to treat moderate to severe pain. An observation and interview were conducted of Resident #48 on 3/2/23 at 1:45 PM. Resident #48 was grimacing and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 the facility failed to document an assessment of the resident ' s status, shunt cite, and vital signs upon returning to the facility after dialysis for 1 of 2 residents reviewed for dialysis. (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. Review of the physician ' s orders with a start date of 2/1/23 read in part the following: Dialysis, Monday, Wednesday, Friday. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was cognitively intact. The MDS noted Resident #18 received dialysis while residing in the facility. Further review of the medical record revealed there were no orders for dialysis access care. An interview was conducted with Resident #18 on 2/28/23 at 3:39 PM. Resident #18 stated that the nurses did not consistently look at his dialysis shunt site when he returned from dialysis. Resident #18 stated he had…

    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 · D2023-03-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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 interviews, Physician interview, and Pharmacy Consultant interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications were time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, bipolar disorder, and anxiety. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact. She was coded as having behaviors which included rejection of care and yelling at others. Resident #5 was coded for antipsychotic and antianxiety medication use during the lookback period. A physician order dated 1/27/23 for Diazepam (anxiety medication) 5 milligram (mg) tablet every 12 hours as needed for anxiety was ordered without a stop date. Record review of the January 2023 Medication Administration Record (MAR) revealed Resident #5 was administered the PRN Diazepam on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 provide adaptive eating utensils and equipment as ordered by the physician for 1 of 3 residents requiring adaptive equipment for meals (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. A physician order dated 1/02/23 for regular diet, puree texture, thin liquids, resident uses personal sippy cups, continue built-up utensils, plate guard. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, had limited range of motion (ROM) of the upper and lower extremities, and required setup help only for eating. An observation on 2/27/23 at 12:33 pm Resident #2 was observed to have no built-up utensils or plate guard on meal tray. No built-up utensils or plate guard were observed in the resident's room. Review of Resident #2's printed dietary meal ticket on 2/28/23 revealed two handle cup on tray, built-up utensils, and plate guard. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observation, and staff interviews the facility failed to maintain 1of 1 nourishment refrigerator in a clean and sanitary manner to prevent cross contamination by failing to clean up liquid spills. The findings included: On 2/28/23 at 2:15 PM an observation of the nourishment refrigerator revealed a clear liquid was pooled underneath the 2 clear drawers. When the empty drawer was pulled out, liquid sloshed out onto the refrigerator frame. On 3/1/23 at 9:35 AM an observation of the nourishment refrigerator revealed a clear liquid was pooled underneath the 2 clear drawers. When the empty drawer was pulled out, liquid sloshed out onto the refrigerator frame and floor. An interview on 3/1/23 at 10:39 AM the dietary manager revealed she would remind staff to check and completely wipe down the nourishment refrigerator. An interview on 3/2/23 at 4:55 PM the Administrator revealed dietary staff had defrosted and drained the nourishment refrigerator and would wipe it down.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-05-21 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 Representative interviews, the facility failed to notify the resident, Resident Representative and Ombudsman in writing of the reason for transfer/discharge to the hospital and failed to fully complete the bed hold policy document when a resident transferred to the hospital. The deficient practice affected 3 of 3 residents reviewed for hospitalization (Resident #72, Resident #21, Resident #52). The following included: 1. Resident #72 was admitted to the facility on [DATE]. A review of Resident #72's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. A review of Resident #72's nursing progress notes revealed she was discharged to the hospital on 4/30/25 and returned on 5/15/25. a. A review of the bed hold policy dated 4/30/25 revealed Resident #72's Resident Representative had signed the document. Further review of the bed hold policy revealed there were no dates of hospitalization completed and…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Bcited before2025-05-21 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 interviews, resident and Responsible Party (RP) interviews, the facility failed to provide the resident or the RP a written summary of the baseline care plan and medication list for 2 of 4 residents reviewed for care planning (Resident #75 and Resident #91). The findings included: 1. Resident #75 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #75 had severe cognitive impairment. Resident 75's electronic health record revealed no documentation that Resident #75 or his RP received a written summary of the baseline care plan and medications. During an interview on 5/18/25 at 12:23 pm with Resident #75's RP she revealed was at the facility almost every day and she had not been given any information regarding the plan of care or medications for Resident #75. An interview was conducted with the Social Worker on 5/20/25 at 12:04 pm who revealed she was responsible to provide a written summary of the care plan and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Bcited before2023-03-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observation and staff interviews the facility failed to provide a clean and sanitary environment by failing to clean a tube feeding pump and pole for 1 of 1 resident observed with a tube feeding pump and pole. (Resident #34) The facility also failed to provide a safe and sanitary environment when food and other debris was found lodged in 1 of 1 resident ' s HVAC (system used to heal and cool an area) unit. (Resident #15) The findings included: 1.On 2/27/23 at 11:51 AM Resident #34 was observed lying in bed and a pole with a tube feeding pump and a bag of milky tan tube feeding formula was connected to Resident #34 and infusing near the head of the resident ' s bed. The four legs of the pole were observed to have a milky tan substance on all four legs of the pole. The bottom of the tube feeding pump was observed to have a tan substance on the bottom of the pump. On 3/1/23 at 9:08 AM a second observation was conducted of the tube feeding pump and pole. There was a dried milky tan substance on all four…

    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 plan of correction
  • No harm found · Bcited before2023-03-02 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately for 2 of 2 residents in the areas of pressure ulcer (Resident # 59) and mechanically altered diet (Resident #14). The findings included: 1.Resident #59 was admitted to the facility on [DATE] with diagnoses that included femur fracture. Review of the admission assessment dated [DATE] revealed Resident #59 had a surgical wound and no other skin impairment. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had severe cognitive impairment. Resident #59 was coded as having one Stage 3 pressure ulcer that was present on admission. Review of a nursing note dated 2/17/23 revealed Resident #59 had a new skin breakdown to her right buttocks. An interview was conducted with the MDS nurse on 3/2/23 at 3:39 PM. The MDS nurse stated she had coded Resident #59 with a pressure ulcer on the admission MDS. The MDS nurse stated she got the information from 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 Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Bcited before2023-03-02 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 the facility failed to complete a baseline care plan within 48 hours of admission to address the immediate needs for 2 of 2 residents reviewed for new admission. (Resident #18, Resident #170) The findings included: 1.Resident #18 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and type 2 diabetes mellitus. Review of the medical record revealed Resident #18 had a baseline care plan dated 2/6/23. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and on dialysis. An interview was conducted with the Director of Nursing (DON) on 3/2/23 at 12:02 PM. The DON stated it was the receiving nurse ' s responsibility to initiate the baseline care plan within 48 hours to meet the resident ' s immediate needs. 2.Resident #170 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer and type 2 diabetes mellitus with foot ulcer. Review 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 Assessment and Care Planning Deficiencies · Deficient, Provider has plan 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,868 in federal fines across 1 penalty.

  • $10,868 — penalty dated 2025-05-21

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 YAD HEALTHCARE — 13 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 →

RatingThis homeChain avg
Overall 1 of 51.7-0.7 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 12 homes this chain runs (chain average 1.7★, per CMS)

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

Owner / managerTypeRoleShareSince
LAUREL PARK OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 03/20/2023
ALTER, TZVIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 03/20/2023
KINTYHTT, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 03/20/2023

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$5.8M
Net patient revenuemost recent cost report
+12.8%
Operating marginrevenue minus expenses
$290K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 14%Other / private 16%

About 70% 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 $290K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$330per resident / day
operating cost
$10,024per month
≈ monthly operating cost
$378per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345184. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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