Greenhaven Health and Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 120 beds and averages 101.5 residents a day — about 85% occupied, or roughly 18 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.450 is at or above 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 3.24 hrs/resident/day on weekends vs 3.60 on weekdays — 10% thinner on weekends. RN hours go from 0.71 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%.

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

Inspection trend

Deficiencies are 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.

34 citations, most serious first. The 14 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-04 · 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 staff, physician, family and law enforcement interviews, the facility failed to supervise a severely cognitively impaired resident from exiting the facility without supervision. On 08/05/25 at approximately 8:30 pm Resident #1 followed Dietary Aide #1 out of the employee exit door and exited the facility. Resident #1 did have a wanderguard bracelet (component of a wander management system) on his left ankle; however, the door Resident #1 exited did not have a transmitter sensor and the magnetic lock was released when Dietary Aide #1 entered a code on the door keypad. Dietary Aide #1 believed Resident #1 to be a visitor (because he was wearing street clothes, had a hat on, and was walking unassisted) and had directed him to exit through the front door and did not realize Resident #1 had followed him out the door until he saw him walking outside the building toward the front as he was driving away. On 08/05/25 Resident #1 was located by local law enforcement at 10:37 pm…

  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 before2025-07-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to lock the brakes on a resident's wheelchair before leaving her unattended on the facility's front patio. Nurse Aide (NA) #5 positioned Resident #102 on the front patio and then walked away from the resident without securing the wheelchair brakes. Due to the brakes not being locked, and the resident's inability to stop the wheelchair when it began to roll due to weakness in all of her extremities, Resident #102 rolled approximately 10 feet across a circle drive and then struck her head on a brick wall which resulted in two lacerations to Resident #102's forehead that required sutures to repair. In addition, the facility also failed to provide care in a safe manner when Resident #310 rolled off the bed while NA #6 was providing a bed bath. This deficient practice occurred for 2 of 10 residents reviewed for accidents (Resident #102 and Resident #310). The findings included:1. Resident #102 was admitted to the facility 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews with staff and family member, the facility failed to protect a resident's right to be free from sexual abuse (Resident #2). Resident #1 sexually abused Resident #2 while he was sleeping in his bed. The resident's family member believed the resident would have rejected a male's sexual advance, would have been angry, and was unable to protect himself. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being sexually abused by a resident in their home environment making them feel angry, dehumanized, and powerless. This deficient practice affected 1 of 2 residents reviewed for abuse. Findings included: Resident #2 was admitted to the facility on [DATE] with the diagnosis of dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented he was severely cognitively impaired. The resident was dependent for all his activities of daily living…

  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
• Actual harm · G2023-01-13 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews the facility failed to maintain the dignity of residents by not providing assistance with Activities of Daily Living (ADLs) when requested for 2 of 5 residents (Resident #19 and Resident #11) reviewed dignity. Resident #19 indicated she waited over 1 hour for her call bell to be answered and this made her feel ignored, bad, and resulted in the resident being tearful, and Resident #11 stated it made them feel mad. Finding included: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis secondary to cerebral infarction, affecting right dominant side, chronic pain, and type 2 diabetes mellitus. A review of Resident #19's quarterly minimum data set (MDS) dated [DATE] identified Resident #19 as being cognitively intact. Resident #19's MDS also indicated that she needed extensive assistance with dressing. During an interview with Resident #19 on 01/09/23 at 1:28 pm she indicated the staff took a long time to help 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-08 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 interviews with staff and record reviews, the facility failed to clarify the dosage of aspirin to administer to 1 of 5 residents reviewed for unnecessary medications (Resident #66). The findings included: Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] documented she had severe cognitive impairment. The MDS noted she had a history of a stroke and she received antiplatelet medications (prevents the accumulation of platelets to prevent blood clots). Resident #66's Medication Administration Records (MAR) from January 2025-July 2025 were reviewed and included an order for staff to administer aspirin once every other day. The MAR did not have a dosage listed on the entry. In an interview on 7/03/25 at 3:30 PM, Nurse #12 stated she was the regular nurse on Resident #66's hallway and routinely gave her the aspirin. She stated she gave Resident #66 an 81…

  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 before2025-07-08 · 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 staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Pneumococcal 20-valent Conjugate Vaccine (PCV20) for 3 of 5 residents reviewed for pneumococcal immunizations (Resident #52, #74, and #66).Findings include:The Center for Disease Control and the Advisory Committee on Immunization Practices (ACIP), last reviewed on 10/26/24, recommends routine vaccination against pneumococcal infection for all adults aged 65 years or older and 19-64 with certain underlying medical conditions. Beginning June 8, 2021, for persons aged 65 years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown, they should receive 1 dose of PCV15 [Pneumococcal 15-valent Conjugate Vaccine] or 1 dose of PCV20.Review of the facility's immunization policy last reviewed 3/4/2024 stated that all residents would be offered a pneumococcal vaccine PCV13 (Pneumococcal 13-valent Conjugate Vaccine) or PPSV23 (pneumococcal…

  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 · D2025-07-08 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 4 of 4 consecutive months: March 2025, April 2025, May 2025, and June 2025.The findings included:A review of the grievance policy that was revised on 10/12/2020 indicated that Resident Council concerns that are voiced through Resident Council are recorded on the Facility Concern/ Grievance Form and are handled in a similar manner to individually voiced concerns., complaints and grievances. The Administrator is informed that the concern is referred to a department head, investigated and resolved, and the Resident Council is informed of the progress of the resolution. a. A review of the Resident Council minutes completed on 3/19/25 had no stated author and revealed the following grievances were expressed: Shower room floor needs to be cleaned more, want better access to the phone, call bells are not being answered…

  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 · D2025-07-08 · 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, observations, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication (oxycodone-acetaminophen) prescribed to treat pain for 1 of 1 resident reviewed for misappropriation of property (Resident #56). The findings included:Resident #56 was admitted to the facility on [DATE].A review of Resident #56's quarterly Minimum Data Set assessment, dated 04/26/25, indicated his cognition was intact.Resident #56 had an order dated 5/25/23 for oxycodone-acetaminophen 5-325 milligrams (mg) two times a day every Tuesday, Thursday, Saturday, Sunday, for pain. The second oxycodone-acetaminophen 5-325 mg order dated 6/25/25 for oxycodone-acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain on hemodialysis days on Monday, Wednesday, and Friday.a. A review of Resident #56's June 2024 Medication Administration Record (MAR) revealed the resident received oxycodone -acetaminophen 5-325 mg administered as ordered.A review of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2025-07-08 · 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 record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for 1 of 1 resident reviewed for communication (Resident #57). The findings included:Resident #57 was admitted to the facility on [DATE] with a diagnosis of cardiac arrythmia, dementia, and essential hypertension. A review of Resident #57's electronic medical record (EMR) included an ophthalmology consultation note dated 11/19/24. The assessment revealed a medical condition of cataracts in both eyes and related blurred vision. The consultation note further indicated that cataract surgery was recommended and had been scheduled on 3/26/25 for the left eye and 4/30/35 for the right eye. A review of Resident # 57's Significant Change in Status MDS assessment dated [DATE] was completed by MDS Nurse #2 and revealed the resident had severely impaired cognition , adequate vision and had corrective lenses. Resident #57's most recent Minimum Data Set (MDS) assessment…

  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 · D2025-07-08 · 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 resident and staff interviews, the facility failed to provide a copy of the baseline care plan to the responsible party for 1 of 23 residents reviewed for baseline care plans (Resident #57).Findings included:Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, in part, non-traumatic intracerebral hemorrhage in the hemisphere (bleeding within the brain tissue of one cerebral hemisphere, occurring without any known trauma or injury). A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired.A review of the medical record revealed a baseline care plan was completed by Unit Manager #1 3/13/25.A review of the medical record revealed Resident #57 listed a family member as her own responsible party. A review of the medical record revealed no documented evidence that a copy of the baseline care plan was given to the resident or the responsible party. Multiple…

  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 · D2025-07-08 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot 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 observation, record review, resident and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 5 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #31). The findings included:Resident #31 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, chronic kidney disease and congestive heart failure.Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was dependent on staff for personal hygiene. The MDS further revealed the resident was coded for not being ambulatory. Resident #31 s care plan, revised 6/6/25, revealed the resident had a focus area of activities of daily living/personal care. The goal was for Resident #31 to have staff complete activities of daily living as appropriate to maintain the highest practical level of functioning through the next review. There was no documentation in the medical record the resident…

  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 · D2025-07-08 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with staff and record reviews, the facility failed to address discrepancies identified by the facility consultant pharmacist when a recommendation was made to clarify the dosage of aspirin ordered for 1 of 5 residents (Resident #66) reviewed for unnecessary medications. The findings included: Resident #66 admitted to the facility on [DATE] with diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] documented she had severe cognitive impairment and had no behaviors or refusals of care. The MDS noted she had a history of a stroke and she received antiplatelet medications (prevents the accumulation of platelets to prevent blood clots). Resident #66's Medication Administration Records (MAR)s from January 2025-July 2025 were reviewed and included an order for aspirin once every other day. The MAR did not have a strength listed on the entries. Resident #66's monthly consultant pharmacist reviews 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-25 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews with staff, the facility failed to follow their abuse policy in the area of protection when Nursing Assistant (NA) #3 observed a resident-to-resident sexual assault between Resident #1 and Resident #2 and left the room during the incident to find staff assistance. This deficient practice affected 1 of 2 residents reviewed for abuse (Resident #2). Findings included: The facility abuse policy, last revised on 3/10/2017, documented, in part, The facility believes that our residents have the right to be free from abuse, neglect . Training of Employees: Orientation to the facility's policies and procedures regarding abuse, neglect, exploitation, and misappropriation of resident property will be provided to newly hired employees. Retraining programs for employees will be conducted on a regular basis. Training programs may include Indicators of resident vulnerability to abuse and related interventions. Protection: The facility shall take whatever steps are necessary to prevent further acts of abuse . A review of the staff's written statement by NA #3…

  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 · E2024-03-14 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record reviews, the facility failed to allow residents assessed to be safe to smoke the ability to smoke independently at any time of his/her choice. This occurred for 3 of 3 residents (Resident #47, #8, and #69) who expressed a desire to smoke at times other than the supervised smoking times designated by the facility. This practice had the potential to affect other safe smokers in the facility. The findings included: A review of the facility's Smoking Policy (Revised on 10/15/22) was conducted. A section of the policy entitled Determination of Smoking Residents' Supervision Needs included the following Procedures, in part: #3 (of 6). After completion of each assessment, the interdisciplinary care plan (ICP) team will review and determine the smoking status (supervised/unsupervised) of the resident. a) When the Smoking Evaluation identifies a resident with any potential hazard risk, including but not limited to a cognitive deficit, the resident will be…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$123,126 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $123,126 — penalty dated 2025-07-08
• Medicare payment denial — starting 2025-08-05 for 35 days

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

Part of a chain

This home belongs to 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 9 rows in the source record cover these 6 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.

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.

About 78% 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 $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in NC