Willow Creek Nursing and Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.4% 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 284 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 71.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 116 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 200 beds and averages 165.2 residents a day — about 83% occupied, or roughly 35 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.68 on weekdays — 10% thinner on weekends. RN hours go from 0.55 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

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

• Actual harm · Gcited before2026-02-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff and the Medical Director, the facility failed to notify a nurse after an assisted fall and not move the resident after a fall before a licensed nurse's assessment. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out, and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. NA #1 did not report the assisted fall to a nurse and did not get a nurse to assess the resident before transferring to the wheelchair. At approximately 2:50 PM NA #1 asked NA #2 and Medication Aide for assistance with transferring the resident from the wheelchair to the bed; however, NA #1 did not inform NA #2, or the Medication Aide of the resident's…

  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 · Past Non-Compliance
• Actual harm · Gcited before2026-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff and Medical Director, the facility failed to follow the Resident Care Guide and use a mechanical lift prior to the transfer of a resident (Resident #1). On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) did not see any mechanical lifts immediately available and entered Resident #1's room at approximately 2:45 PM. Despite knowing that Resident #1 required a mechanical lift for all transfers, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. At approximately 2:50 PM NA #1 asked NA #2 and Medication Aide for assistance with transferring the resident from the wheelchair to the bed. When Resident #1 was assisted into bed without a mechanical lift, she complained of right…

  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 · Past Non-Compliance
• Potential for harm · F2026-06-11 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff and Physician, the facility failed to ensure a system was in place to check the accuracy of resident care equipment used to check blood pressure readings and temperature readings. Additionally, per interview with a Nurse Practitioner and a Physician, a facility's glucometer reading was difficult to reconcile with other known details regarding a resident's condition and treatment. This affected 1 of 3 sampled residents reviewed for change in condition and had the capability to affect all residents (Resident #2).The findings included:Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26). Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed Resident # 2 had diagnoses including diabetes mellitus.Review of facility blood sugar results on 4/24/26 through 4/26/26 were documented as follows:4/24/26 at 6:00 AM 2914/24/26 at 12:00 PM 2474/24/26 at 6:00 PM 3034/25/26 at 6:00 AM blank4/25/26 at…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-11 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Physicians, and Nurse Practitioner, the facility staff failed to consult with the physician when a resident's fingerstick blood sugar result was 509. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). This was for 1 of 3 residents reviewed for notification to the physician (Resident # 2). The findings included:Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed the following information. Resident # 2 was hospitalized from [DATE] until 4/23/26. Resident # 2 had a history of prior stroke and trigeminal neuralgia (chronic neuropathic pain condition that causes sudden, severe, electric shock-like or stabbing pain in the face). She was hospitalized on [DATE] secondary to worsening weakness and dysphagia (trouble swallowing). Resident # 2 was examined and found to have difficulty…

  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 before2026-06-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Responsible Party, Physician, and Nurse Practitioner, for a newly admitted resident whose insulin orders had recently been changed before facility admission in conjunction with the resident being changed from an oral diet to an enteral feeding (the delivery of nutrition directly into the gastrointestinal tract when a person cannot eat enough by mouth), the facility failed to recheck the resident's finger stick blood sugar result of 509 within the timeframe the resident's prescribed insulin typically worked to cover elevated blood sugar levels. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). This was for 1 of 3 residents reviewed for professional standards of practice (Resident # 2). The findings included:Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed the following…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-11 · 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 interviews with staff, Pharmacists, and Medical Director the facility failed to 1) ensure they obtained medications from the pharmacy or the facility's back up supply for administration for a newly admitted resident and 2) upon admission clarify an order which directed a 12 hour extended release medication was to be administered via way of a gastrostomy tube so that the pharmacy would dispense an alternate form of the medication that was appropriate to be administered via gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach). This was for 1 of 1 resident whose medications were reviewed (Resident # 2).The findings included:Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26). Resident # 2 had diagnoses which included history of stroke, trigeminal neuralgia, diabetes, and dysphagia with a gastrostomy tube placed for nutrition.On 4/23/26 at 4:19 PM Nurse # 4 documented in a nursing note that…

  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 · D2026-06-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interviews, the facility failed to ensure the medical record was complete regarding a change in condition for 1 of 3 residents reviewed for medical record accuracy (Resident #2).The findings included: On 4/25/26 at 8:00 PM Nurse # 3 documented a nursing narrative note on 4/26/26 at 9:26 AM noting that Resident # 2's emergency contact was informed Resident # 2 was being transferred to the hospital Emergency Department (ED). This nursing note and any nursing narrative note before this entry did not include any assessment of the resident on 4/26/26 or reason the resident was being transferred. Review of hospital records for 4/26/26 through 5/8/26 revealed Resident # 2 was assessed in the ED (Emergency Department) and admitted to the intensive care unit for diabetic ketoacidosis with an elevated Beta-hydroxybutyrate (a condition when there is insufficient insulin and an individual starts to break down fat and therefore produce ketones), hyperosmolar hyperglycemic state, febrile illness, leukocytosis (elevated white blood count), dehydration, depressed…

  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 · Ecited before2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interviews the facility failed to label or date food items stored in 1 of 1 walk-in cooler. This had the potential to affect food served to residents.Findings included:On 3/16/26 at 10:31 AM during the initial kitchen tour an observation of the facility's walk-in cooler was conducted with the Dietary Manager. An unlabeled and undated rectangular metal container covered with clear plastic wrap was observed to contain what the Dietary Manager described as being about 10 ounces of pudding. An additional unlabeled and undated rectangular metal sheet pan covered with aluminum foil was observed to contain what the Dietary Manager described as being about 20 turkey sandwiches. The Dietary Manager reported that when she left the facility at 4:00 PM on Friday 3/13/26, neither the pudding nor the sandwiches were present in the walk-in cooler. She stated they must have been prepared and placed there sometime over the weekend, but because they were not labeled or dated, she could not say for sure. She indicated she and her Assistant Dietary Manager monitored 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-24 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a significant change in a resident's condition that included transport and admission to the hospital for 1 of 4 residents reviewed for notification of change (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's medical record revealed his family member was his RP. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The discharge MDS dated [DATE] showed Resident #1 was moderately cognitively impaired. Resident #1's active diagnoses included delirium. A nursing note dated 12/18/24, written by Nurse #1 revealed Resident #1 requested to be transported to the emergency room. At 11:40 PM the resident was transported to the hospital via stretcher. A nursing note dated 12/19/24, written by Nurse #2 documented she called the hospital to get a status update on Resident #1. The nurse documented…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to replace a damaged bed mattress for 1 of 32 residents reviewed for environment (Resident #9). The findings included: Resident #9 was admitted on [DATE] with diagnoses that included right sided hemiplegia (paralysis), neuropathy (nerve pain), artificial knee joint, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Work order # 9213 created on 11/15/24 revealed a request had been entered by Med Aide (MA) #1 for Resident #9's current room for mattress extremely uncomfortable, has a deep dip in it. The notes stated Resident #9 is requesting a new mattress, it causes his back to hurt. He is out of bed right now if you can change it. The work order was assigned to the Maintenance Assistant, who referred the work order to central supply and set the status to completed. In an interview with MA #1 on 12/04/24 2:44 PM she stated on 11/15/24 Resident #9 told her he felt like he was…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-06 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, pharmacist and physician interviews, the facility failed to protect a resident's right to be free from the misappropriation of medication for 2 of 2 residents (Resident #116, Resident #163) reviewed for misappropriation of resident property. Findings included: 1. Resident #116 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #116's orders revealed on 1/16/24 she was ordered Ozempic inject 0.25 mg (milligrams) subcutaneously one time a day every Tuesday for diabetes mellitus. A review of Resident #116's Medication Administration Record (MAR) revealed on 4/23/24 Nurse #8 documented Ozempic was not available to be administered. During an interview on 12/4/24 at 2:49 PM Nurse #8 who documented Ozempic as unavailable and not administered to Resident #116 on 4/23/24 stated she did work with Resident #116 on night shifts in 4/2024. She further stated at that time Resident #116's Ozempic was being administered once a…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2024-12-06 · 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 interview the facility failed to develop a comprehensive care plan in the area of fall risk for 1 of 3 residents reviewed for accidents (Resident #81). The findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left radius, unspecified dementia and history of falling. A review of Resident #81's Minimum Data Set (MDS) dated [DATE] revealed he was coded as having had a fall in the previous 30 days. A review of Resident #81's comprehensive care plan did not reveal a care plan in the area of falls risk. In an interview with the Minimum Data Set (MDS) nurse on 12/5/24 at 8:04 AM she looked for Resident #81's falls risk care plan in his record and stated he did not have one. She stated the MDS nurse is responsible for completing the comprehensive care plan and the missing falls risk care plan was an oversight. An interview with the Director of Nursing (DON) on 12/5/24 at 10:45 AM revealed the MDS nurse…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$15,358 in federal fines across 3 penalties.

• $4,394 — penalty dated 2026-02-13
• $4,394 — penalty dated 2026-02-13
• $6,570 — penalty dated 2024-12-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 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 $4.5M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC