No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Life Care Center of Hendersonville

400 Thompson Street, Hendersonville, NC 28792 · For profit - Limited Liability company · 80 certified beds · (828) 697-4348 Medicare & Medicaid certified

Call the home — (828) 697-4348 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$40,986 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $40,986 in federal fines (most recent 2024-07-19)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (56%) runs well above the national median (45%)
  • about 18% of its spending goes to commonly-owned related companies

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.

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

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1605 Four Seasons Blvd · (800) 746-7287 · Call to confirm hours
Pharmacy
1605 Four Seasons Blvd · (828) 693-4186 · Call to confirm hours
Grocery
115b four seasons blvd · (828) 697-1287 · Call to confirm hours
Park
712 Martin Cir · Typically dawn to dusk
Place of worship
650 Duncan Hill Rd · (828) 693-4892

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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 improved from 2 to 3 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 rating3★
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 increased13.5%15.6%15.4%better
Long-stay residents who lose too much weight8.1%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.6%2.3%2.0%better
Long-stay residents with depressive symptoms1.2%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 injury3.4%3.5%3.3%typical
Long-stay residents whose ability to walk worsened16.2%18.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.7%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.1%95.3%typical
Long-stay residents with pressure ulcers2.8%5.5%4.7%better
Long-stay residents with worsening bladder/bowel control27.9%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.0%14.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine91.0%78.1%79.4%better
Short-stay residents rehospitalized after admission21.8%22.9%22.6%typical
Short-stay residents with an outpatient ER visit20.7%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.651.781.67typical
Long-stay outpatient ER visits per 1,000 resident days2.011.801.80worse

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.

67.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.0%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
82.0%U.S. median 56.6%
Met the expected recovery
0.97U.S. median 0.31
Therapy hours / resident / day
0.54hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 82.0% 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 89 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 0.97 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF67.0%CMS range 60.7–74.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.6–14.010.7%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 discharge82.0%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 discharge80.9%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 discharge68.5%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 setting100.0%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 discharge98.5%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 stay0.8%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 worsened2.4%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 hospitalization5.2%CMS range 2.8–8.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.76
RN hours/ resident / day
1.30
LPN hours/ resident / day
1.55
Aide hours/ resident / day
3.61
Total nurse hours/ resident / day
0.37
RN hoursweekends
56.5%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 67.0 residents a day — about 84% occupied, or roughly 13 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.55 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 2.93 hrs/resident/day on weekends vs 3.88 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.92 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

5
deficiencies at the latest standard inspection (2025-08-27)
10
at the previous standard inspection (2024-07-19)

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.

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.

32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.

  • Actual harm · G2024-07-19 · 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 observation, record review and Responsible Party, Physician Assistant, resident and staff interviews, the facility failed to include a resident's transfer status in the comprehensive care plan for staff to safely transfer a resident from the wheelchair to bed resulting in the resident falling to the floor (Resident #44) and failed to transfer a dependent resident from the bed to the wheelchair using a mechanical lift and two-person assistance as indicated on the care plan (Resident #8) for 2 of 3 residents reviewed for accidents and mobility. On the evening of 05/17/24, Nurse Aide #1 attempted to independently transfer Resident #44 to the bed resulting in Resident #44 falling to the floor onto her left side. Upon initial nurse assessment, Resident #44 complained of no pain and had a small topical abrasion to the left elbow with no other obvious injuries identified. Later that same evening, Resident #44 complained of hip pain, the on-call provider was notified and new orders for a STAT (immediate) x-ray…

    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 · F2025-08-27 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 Registered Nurse (RN) coverage was provided for at least 8 consecutive hours per day for 5 of 6 days reviewed (Dates 02/01/25, 02/02/25, 02/09/25, 03/01/25, and 03/02/25). Findings included:Review of the daily nurse staffing sheets and associated time clock reports for the period 01/01/25 through 03/31/25 revealed the facility did not have the required RN coverage on the following dates: 02/01/25, 02/02/25, 02/09/25, 03/01/25, and 03/02/25.During an interview on 08/27/25 at 1:52 PM, the Central Supply Manager revealed she handled the Skilled Nursing staff schedules in January 2025 through March 2025. She stated there were times when no RN was scheduled daily from 8 to 12 hours, although she could not recall specific dates. The Central Supply Manager stated that when there was no RN scheduled for at least 8 consecutive hours, she notified the Former Administrator, and the Former Administrator handled the situation from that point.A telephone interview with the Former Administrator on 08/27/25 at 2:49 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-27 · 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, record review, and staff interviews the facility failed to discard expired milk in 1 of 1 walk-in cooler; label and date a food item in 1 of 1 walk-in freezer; label and date open food items and store food off the floor in 1 of 1 dry storage room; maintain a clean and sanitary ice machine for 1 of 2 ice machines; and maintain a clean and sanitary refrigerator in 1 of 2 nourishment rooms (500/600 hall nourishment refrigerator). Findings included:1. An initial observation of the walk-in cooler on 08/24/25 at 9:22 AM revealed a 3/4 full box of 8-ounce cartons of 2% milk with a use-by date of 08/21/25. An interview with the Dietary Manager on 08/27/25 at 9:16 AM revealed the milk should have been used or discarded on or before the use-by date. He stated all dietary staff were responsible for checking for and removing expired food and beverage items. An interview with the Administrator on 08/27/25 at 4:25 PM revealed she expected all food and beverages to be used or discarded on or before the use-by date. 2. An observation of the walk-in freezer on 08/24/25 at 9:28…

    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 · D2025-08-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 the Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order to provide double portions (Resident #10) and nutritional supplements (Resident #54) for 2 of 4 residents reviewed for nutrition (Resident #10 and Resident #54). Findings included:1. Resident #10 was admitted to the facility 04/28/25 with diagnoses including diabetes and malnutrition. Review of Resident #10's physician orders revealed an order dated 05/09/25 for a mechanical soft diet (a texture modified diet which restricts foods that are difficult to chew or swallow) and double portions. Resident #10's nutrition care plan initiated 05/16/25 revealed he had a nutritional problem related in part to malnutrition and diabetes. Interventions included having the Registered Dietitian (RD) evaluate and make diet changes as needed and providing and serving Resident #10's diet as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed…

    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 before2025-08-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and staff interviews, the facility failed to follow their infection control policy and procedure to implement Enhanced Barrier Precautions (EBP) for a resident with a diabetic foot ulcer (Resident #10) and failed to wear a protective gown during tracheostomy care (a surgical opening in the neck), and a dressing change for an endoscopic gastrostomy (feeding tube) for a resident on EBP (Resident #3). Additionally, the facility failed to follow their hand hygiene policy and procedure to remove gloves and perform hand hygiene when a soiled dressing was changed from around a feeding tube (Resident #3). The deficient practice occurred for 1 of 3 staff members observed for infection control practices (Treatment Nurse). The findings included: The facility’s EBP policy last revised on 4/22/25 revealed EBP was used as an additional MDRO (multidrug-resistant organism) mitigation strategy for any resident who met the criteria during high-contact resident care activities. Examples that met criteria for the use of EBP included chronic wounds and listed…

    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 · D2024-11-22 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and Physician Assistant (PA) interviews and record review, the facility failed to notify the Physician or Physician Assistant (PA) about a newly identified pressure ulcer for 1 of 4 residents reviewed (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included dementia and protein-calorie malnutrition. Resident #3 was discharged from the facility on 10/31/24. Review of a wound observation tool for Resident #3's sacrum dated 10/24/24 revealed that this was a facility acquired stage 2 pressure ulcer which was first identified on 10/18/24. The Wound observation tool was completed by Nurse #1. A phone interview with Nurse #1 on 11/22/24 at 8:39 AM revealed that she was aware of a new wound for Resident #3 on the sacrum on 10/18/24. She further revealed that she did not document the occurrence or the treatment of the wound, nor did she inform the PA about the wound. She stated that she knew she should have told the PA and obtained an order for…

    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 · D2024-11-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to complete weekly skin assessments and comprehensive assessments including measurements of newly identified pressure ulcer and failed to obtain treatment orders which resulted in no treatment being completed for five days for 1 of 4 residents reviewed for pressure ulcers (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included dementia and protein-calorie malnutrition. Resident #3 was discharged from the facility on 10/31/24. Review of the admission skin assessment dated [DATE] for Resident #3 revealed that there were no skin issues. Review of the admission minimum data set (MDS) dated [DATE] revealed that Resident #3 was severely cognitively impaired. Resident #3 was at risk for pressure ulcers. Resident #3 had no skin issues or injuries and had a pressure-reducing device on her bed. Review of the care plan dated 10/16/24 revealed that Resident #3 was at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews and record reviews, the facility failed to remove an opened eye medication from the medication cart as specified by manufacturer's guidelines and failed to discard expired antiseptic wound care solutions from another medication cart in accordance with the manufacturer's expiration date for 2 of 5 medication carts observed during medication storage checks (200 halls and 600 halls). The findings included: a. The manufacturer's package inserts for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between the temperature of 36° to 46° Fahrenheit (F) and protected from light. Once it was opened, Latanoprost could be stored at room temperature up to 77° F for up to six weeks. A medication storage audit was conducted on 08/22/24 at 10:10 AM for 200 halls medication cart in the presence of Nurse #1. One opened bottle of Latanoprost 0.005% eye drops was found in the medication cart under room temperature and ready to be used. The handwriting on the label indicated it was opened on 04/28/24. An interview was conducted…

    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 · D2024-08-22 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 1 of 6 sampled residents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic health record revealed an annual MDS assessment with an ARD of 08/01/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #6's annual MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS assessments that were currently late…

    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 · D2024-08-22 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the observation period) for 3 of 6 sampled residents (Residents #2, #3, and #5). Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Electronic Health Record (EHR) on 08/22/24 revealed a quarterly MDS assessment with an ARD of 07/23/24 was noted as in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #2's quarterly MDS assessment dated [DATE] was not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late. The Corporate MDS Consultant stated he was actively working on completing the MDS…

    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 · Fcited before2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 a clean fan in the food preparation area of 1 of 1 kitchen; maintain clean walls and a clean ceiling in 1 of 1 walk-in cooler; label and date open food items, discard expired food, and discard food with signs of spoilage in 1 of 1 walk-in cooler; date milkshakes to identify their use-by date in 1of 1 walk-in cooler; date an opened food item in 1 of 1 walk-in freezer; discard expired food items in 1 of 1 kitchen; and ensure food and beverage items were labeled and dated and date milkshakes to identify their use-by date in 2 of 2 nourishment rooms (activity room refrigerator and 500/600 hall). These practices had the potential to affect food served to the residents. Findings included: 1. An initial observation of the kitchen on 07/15/24 at 09:28 AM revealed a fan with gray debris to the front and back covers mounted on the wall near the walk-in cooler blowing toward the food preparation area. An additional observation of the kitchen on 07/16/24 at 12:12 PM revealed a fan with gray debris to the front and back…

    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
Show the remaining 21 citations
  • Potential for harm · E2024-07-19 · 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 record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of falls, functional limitation in range of motion, anticoagulant (blood thinner) use, weight loss, colostomy status, and bowel incontinence for 5 of 18 sampled residents (Residents #44, #17, #2, #7, and #13). Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included abnormal gait and muscle weakness. An incident/accident report dated 05/17/24 revealed Resident #44 had a witnessed fall from her wheelchair to the floor. Upon nurse assessment, Resident #44 had a small topical abrasion to the left elbow, passive range of motion was within normal limits and she voiced no complaints of pain. Approximately 2 hours later, Resident #44 complained of left hip pain, the on-call provider was notified and orders were obtained for a STAT (immediate) left hip x-ray. Review of left hip x-ray results dated 05/18/24 revealed Resident #44 had an acute…

    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 before2024-07-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and interviews with staff the facility failed to date two open and in use bottles of medicated eye drops being stored at room temperature on 1 of 4 medication carts (Hall 400 med cart) and failed to date three in use multi-dose vials of tuberculin purified protein derivative (a diagnostic antigen used in testing for tuberculosis) and failed to remove expired medications and influenza vaccines from 2 of 2 medication room refrigerators (medication room for halls 200, 300, 400, 500, and 600) reviewed for medication storage and labeling. Findings revealed: a. Review of manufacturer's package insert for latanoprost eye drops read in part, store unopened bottle(s) under refrigeration at 36 to 46°F. Once it was opened for use, it may be stored at room temperature for 6 weeks. An observation of the Hall 400 med cart and interview with Nurse #1 were conducted on 07/18/24 at 4:26 PM. Two opened bottles of latanoprost 0.005% were being stored at room temperature with no open date of when it was put in use. Nurse #1 stated latanoprost eye drops were kept in…

    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 · E2024-07-19 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation of the meal service tray line, record review, and Registered Dietician and dietary staff interviews the facility failed to provide all food items as specified by the planned menu for residents receiving a pureed (foods that have a smooth consistency and don't have to be chewed) diet. This practice had the potential to affect 6 of 6 residents receiving a pureed diet. Findings included: During a continuous observation of the lunch meal tray line on 07/17/24 from 11:50 AM until 12:50 PM [NAME] #1 plated pureed chicken and dumplings and pureed beets using a 4-ounce serving utensil. No pureed bread was provided on pureed meal trays. Review of the menu revealed the following portions were to be served on 07/17/24 for the lunch meal: -pureed chicken and dumplings 4-ounce serving -pureed beets 4-ounce serving -1 serving of pureed bread mix Cook #1 was unable to be interviewed during the survey. An interview with the Dietary Manager on 07/17/24 at 1:05 PM revealed [NAME] #1 was responsible for following the menu and he was not sure why she had not prepared pureed bread.…

    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 · D2024-07-19 · tag F0578 — failed to honor advance directives / code status — isolated
    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 The facility failed to ensure the physician's order for an advanced directive matched the medical orders for scope of treatment (MOST) form signed by the resident's family for 1 of 18 residents (Resident #270) reviewed for advanced directives. The findings included: Resident #270 was admitted to the facility on [DATE]. Review of the brief interview for mental status (BIMS) interview dated [DATE] revealed that Resident #270 was moderately cognitively impaired. Review of the baseline care plan dated [DATE] revealed resident #270 was documented as a full code (lifesaving efforts such as Cardiopulmonary Resuscitation (CPR) were to be conducted). Review of the physician's orders dated [DATE] revealed an order for the resident to be a full code. Review of the MOST form dated [DATE] revealed (section A) do not resuscitate (DNR) (lifesaving efforts such as CPR are not to be conducted) with (section B) limited interventions to use medical treatment, intravenous (IV) fluid and cardiac monitoring as indicated. Do not use…

    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 before2024-07-19 · 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 record review, observations, and interviews with staff, the facility failed to provide oral hygiene assistance for a dependent resident with visibly dirty dentures and teeth for 1 of 11 residents reviewed for activities of daily living (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses including dementia and seizure disorder. The admission Minimum Data Set assessment dated [DATE] revealed Resident #64's cognition was severely impaired and setup assistance was needed with oral hygiene. The activities of daily living care plan last reviewed on 06/18/24 revealed Resident #64 required assistance to maintain or attain the highest level of functioning. Interventions included to assist with activities of daily living care as needed. Observations on 07/15/24 at 2:20 PM and 07/16/24 at 3:27 PM revealed Resident #64's upper denture and lower teeth appeared dirty with a visible white colored buildup of debris on several of the front upper and lower teeth. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, Registered Dietitian, Physician Assistant, and staff interviews, the facility failed to follow a physicians order to administer the correct amount of a high protein, fiber fortified nutritional supplement as recommended by the Registered Dietitian for 1 of 2 residents reviewed for tube feeding (Resident #15). Findings included: Resident #15 was admitted to the facility on [DATE] with multiple diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely impaired with cognitive skills for daily decision making and was dependent on staff assistance for all self-care tasks, bed mobility and transfers. Resident #15 received tube feeding while a resident and received 51% or more of total calories and 501 cubic centimeters (cc) or more of fluid intake via tube feeding. Review of Resident #15's comprehensive care plans, last…

    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 · D2024-07-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff and resident interviews the facility failed to honor food preferences for 1 of 3 residents reviewed for food preferences (Resident #9). Findings included: Resident #9 was admitted to the facility 06/12/22 with diagnoses including anemia and malnutrition. Review of Resident #9's Physician orders revealed an order dated 06/08/24 for a regular diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact, required set-up or clean-up assistance with eating, and no weight loss or weight gain. Resident #9's nutrition care plan last revised on 06/18/24 revealed she had a potential nutritional problem related to coughing during meals. Interventions included providing and serving diet as ordered and assuring Resident #9 was out of bed for all meals. An interview with Resident #9 on 07/15/24 at 11:47 AM revealed she had asked dietary staff (the Dietary Manager and other dietary employees) multiple times for yogurt with each…

    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 · D2024-07-19 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and resident and staff interviews, the facility failed to offer and provide nighttime snacks for 3 of 4 sampled residents (Residents #2, #9 and #44). The findings included: During a resident council meeting on 07/17/24 at 3:05 PM, Resident #2, Resident #9 and Resident #44 all stated they were not offered nighttime snacks and when they did ask staff if there were any snacks available in the nourishment room, there wasn't much of a variety. The residents also stated they would enjoy receiving a healthy snack in the evenings because they usually ate dinner around 5:00 PM and sometimes they got hungry before breakfast was served the next morning around 8:45 AM to 9:00 AM. Observations of the 500/600 Hall nourishment room and activity nourishment room were conducted on 07/18/24 at 7:15 AM. The 500/600 Hall nourishment room revealed the only snacks available were a container of individually packaged peanut butter crackers and saltine crackers. The activity nourishment room revealed the only snacks available were two bags of saltine crackers. During an interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-10 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with staff, the facility failed to dispose of trash and keep the area surrounding the dumpster free of debris for 1 of 2 dumpsters reviewed. The findings included: An observation was made on 02/06/23 at 9:36 AM of the dumpster area. The dumpster doors were closed. Three clear plastic bags of garbage were laying on the ground below the closed doors of dumpster. The garbage bags contained what appeared as soiled briefs and personal protective equipment including disposable gloves and gowns. On the side of the dumpster 2 personal protective (PPE) gowns were laying directly on the ground. An interview was conducted on 02/06/23 at 9:36 AM with the Dietary Manager (DM). The DM explained the garbage thrown on ground was from nursing staff and they were responsible for ensuring the trash was placed inside the dumpster. An interview was conducted on 02/09/23 at 4:30 PM with Assistant Director of Nursing (ADON). The ADON explained housekeeping staff disposed of the trash for nursing until 5:00 PM but after that the Nurse Aides (NA) were responsible for it.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-10 · tag F0886 — failed to test for COVID-19 as required — widespread
    Perform COVID19 testing on residents and staff.
    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 follow their COVID-19 testing policy and the nationally recognized standard to test residents and staff immediately, but not earlier than 24 hours after the exposure, for 4 of 4 residents (Resident #12, Resident #56, Resident #59, Resident #60) and 5 of 5 staff members who tested positive for COVID-19 (Nurse Aide #2, Nurse Aide #6, Nurse Aide #7, Nurse #3, and Receptionist #1) and were identified through contract tracing as having close contact. Findings included: The facility's COVID-19 Testing policy, last revised on 12/01/22, noted testing must be conducted according to nationally recognized guidelines as outlined by the CDC. The facility's resident and staff COVID-19 infection surveillance spreadsheet revealed the facility was currently in a COVID-19 outbreak that started on 01/27/23. Further review revealed the following: • Resident #12 was tested for COVID-19 on 01/26/23 due to confusion and increased temperature with negative results. On 01/27/23 she was sent out to the hospital for evaluation and tested…

    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 · E2023-02-10 · tag F0756 — failed to review each resident's drug regimen — pattern
    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 record review and staff, Consultant Pharmacist, and Medical Director interviews, the facility failed to follow-up on the monthly pharmacist consultation reports for 2 of 5 residents reviewed for unnecessary medications (Residents #32 and #27). Findings included: 1. Resident #32 admitted to the facility on [DATE] with diagnoses that included depression. An active physician's order dated 04/06/22 for Resident #32 read, Zoloft (antidepressant medication) 75 milligrams (mg) by mouth one time a day for depression. Review of a Consultation Report issued on 10/20/22 read, Resident #32 has received an antidepressant, Sertraline (generic form of Zoloft medication) 75 mg one time a day for management of depressive symptoms, since 04/07/22. Please attempt a Gradual Dose Reduction (GDR) for Sertraline to 50 mg one time a day. The bottom of the form where the provider would accept or deny the GDR recommendation and sign the form was blank. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed…

    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 before2023-02-10 · 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, record review, and staff interviews the facility failed to ensure foods were dated after opened and failed to ensure thickened liquids were discarded prior to the use by date after being opened. These failures occurred in 1 of 1 walk-in refrigerator and 1 of 2 nourishment room refrigerators (500/600 Hall). The findings included: 1. A tour of kitchen was conducted on 02/06/23 from 9:02 AM through 9:36 AM with the Dietary Manager (DM). Observation of the walk-in refrigerator in the kitchen revealed opened containers included mayonnaise dated 01/27, Tuscan dressing dated 11/08, teriyaki marinade dated 05/17, chunky salsa dated 10/31, and a large block of cream cheese half used dated 01/03. During an interview on 02/06/23 at 9:02 AM the DM explained the dates on the open containers in the walk-in refrigerator indicated the date the items were delivered not the date the items were opened or the use by date. The DM revealed the open containers in the walk-in refrigerator were kept in use until the expiration date on the container. It was pointed out to the DM 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 · Ecited before2023-02-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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 implement their policy for Personal Protective Equipment (PPE) when 2 of 2 staff members (Health Information Manager and Nurse Aide #7) failed to don N95 masks and goggles or faceshield before entering and change facemasks upon exiting 2 of 2 resident rooms who were positive for COVID-19. Findings included: The facility's policy, Transmission-based Precautions and Isolation Procedures, last revised 08/22/22, read in part, For a resident with known or suspected COVID-19, associates should wear gloves, isolation gown, eye protection, and a N95 or higher-level respirator if available. An observation of the 500 Hall on 02/06/23 at 11:00 AM revealed rooms [ROOM NUMBERS] were on droplet/contact precautions and both residents were positive for COVID-19. 1. During an observation on 02/06/23 at 11:08 AM, the Health Information Manager went into room [ROOM NUMBER] to answer the call light. The Health Information Manger wore a surgical face…

    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 · D2023-02-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 resident and staff interviews the facility failed to assess the ability of a resident to self-administer medications for 1 of 1 resident reviewed for self-administration of medication (Resident #27). Findings included: Resident #27 was admitted to the facility 10/06/22 with diagnoses including hyperlipidemia (high cholesterol) and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. Review of the medical record revealed no documentation that Resident #27 had been assessed for self-administration of medications. An observation of Resident #27's overbed table on 02/06/22 at 10:38 AM revealed 1 white pill and 1 green pill lying on a napkin on the table. An interview with Resident #27 on 02/10/23 at 10:39 AM revealed the green pill was for cholesterol and she wasn't sure what the white pill was for. She stated the nurses usually stayed with her while she used her inhaler but frequently left 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 · D2023-02-10 · 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 observations, record review, and interviews with staff, the facility failed to ensure the comprehensive care plan was updated in the area for the use of palm guards for 1 of 1 resident reviewed for limited range of motion (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses including bilateral contractures of multiple sites and paralytic syndrome following a cerebrovascular accident. Review of the physician's order dated 09/23/22 provided instructions for Resident #15 to wear bilateral palm guards. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #15 was assessed as having moderately impaired cognition and needed extensive to total assistance with activities of daily living. Review of the care plan revised on 01/17/23 revealed Resident #15 was at risk for alterations in skin integrity related to decreased and impaired mobility and fragile skin. An observation of Resident #15 was made on 02/06/23 at 2:38 PM. Resident #15'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-10 · 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, and interviews with Family Members, residents, and staff the facility failed to provide oral hygiene assistance for 2 of 8 dependent residents reviewed for activities of daily living (Resident #20 and #41). The findings included: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and hemiplegia (paralysis on one side of the body). Review of the care plan initiated on 08/18/22 revealed Resident #20 had oral and dental health problems. Interventions included provide mouth care daily. Review of the significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was assessed as having severely impaired cognition and needed extensive assistance with personal hygiene. The MDS revealed the oral and dental status of Resident #20 included obvious or likely cavities or broken natural teeth. An observation on 02/07/23 at 8:39 AM revealed Resident #20's upper and lower teeth had a white colored buildup…

    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 · D2023-02-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with the Medical Director and staff the facility failed to monitor the water flush settings on the feeding pump to ensure those were consistent with the physician's order as transcribed on the Medication Administration Record to flush 23 milliliters every hour for 1 of 1 resident reviewed for tube feeding (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses including dysphasia, tracheostomy, and paralytic syndrome following a cerebrovascular accident. Review of the care plan initiated on 09/07/22 revealed Resident #15 required tube feedings via percutaneous endoscopic gastrostomy tube (a feeding tube placed in the stomach) related to swallowing problems. Interventions included review physician orders for current feeding orders and indicated Resident #15 was dependent with tube feeding and water flushes. Review of the physician order for Resident #15's water flush dated 10/17/22 provided directions to flush…

    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
  • No harm found · C2025-08-27 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 daily nurse staffing sheets accurately reflected the nursing staff who worked for 4 of 6 days reviewed (02/01/25, 02/02/25, 02/09/25, and 03/02/25).Findings included:Review of the facility's daily nurse staffing sheet revealed underneath the facility's name was a space to specify the date along with columns to specify the resident census, number of staff and hours worked for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) for each 12-hour shift, 7:00 AM to 7:00 PM (day shift) and 7:00 PM to 7:00 AM (night shift). a. The daily nurse staffing sheet dated 02/01/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time clock report for 02/01/25 revealed there were 3 LPNs and no RN.b. The daily nurse staffing sheet dated 02/02/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time clock report for 02/02/25 revealed there were 3 LPNs and no RN. c. The daily nurse staffing sheet dated 02/09/25 revealed on day shift there was 1 RN and 3 LPNs. The nursing staff time…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-08-22 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 and staff interviews, the facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) within 14 days of the discharge date and an entry tracking record within 14 days of the admission date for 1 of 6 sampled residents (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's electronic health record on 08/22/24 revealed the following: a. A discharge-return anticipated MDS assessment dated [DATE] noted a status of in progress. b. An entry tracking record dated 07/24/24 noted a status of in progress. During a telephone interview on 08/22/24 at 6:09 PM, the Corporate MDS Consultant confirmed Resident #5's entry tracking record and discharge MDS assessment were not completed within the regulatory timeframe. He explained the facility had been without a MDS Coordinator for some time and the staff that had been assisting from other facilities had focused on current MDS assessments to prevent more from being completed late.…

    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
  • No harm found · B2023-02-10 · 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 observations and staff interviews, the facility: 1) failed to ensure personal care equipment was labeled and covered and a bathroom was clean that had a strong odor of urine for 3 of 22 resident bathrooms (Rooms 501, 510 and 305) and 2) failed to maintain a homelike environment in 1 of 12 resident rooms observed to have debris and stains on the floor (room [ROOM NUMBER]). This deficient practice affected 2 of 5 resident halls (300 and 500 Halls). Findings included: 1. a. An observation of the shared bathroom of room [ROOM NUMBER] on 02/06/23 at 10:49 AM revealed 3 gray bath basins, unlabeled and uncovered, stacked inside each other and sitting on the bathroom shelf. Additional observations conducted of the shared bathroom of room [ROOM NUMBER] on 02/07/23 at 8:29 AM, 02/08/23 at 5:43 PM, and 02/09/23 at 12:24 PM revealed the gray bath basins remained stacked inside each other on the shelf, unlabeled and uncovered. b. An observation of the shared bathroom of room [ROOM NUMBER] on 02/06/23 at 10:44 AM…

    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
  • No harm found · B2023-02-10 · tag F0661 — pattern
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 complete a recapitulation of stay for 3 of 4 closed records reviewed for discharge (Resident #264, Resident #63, and Resident #61). Findings included: 1. Resident #264 was admitted to the facility 03/04/22 with diagnoses including hypertension (high blood pressure) and heart failure. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired and was discharged to the community. Review of the medical record revealed Resident #264 was discharged home 07/04/22. Review of the Discharge Information Summary dated 07/04/22 for Resident #264 revealed the only areas completed under section E titled Recapitulation of Stay was the Dietary Discharge Summary which stated Resident #264 was on a regular diet with easy to chew foods and thin liquids and Activity Discharge Summary which stated Resident #264 could complete activities with assistance. The areas of Social Service Discharge Summary, Nursing (course 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.

    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.

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

$40,986 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $10,527 — penalty dated 2024-07-19
  • $30,459 — penalty dated 2024-07-19
  • Medicare payment denial — starting 2024-08-16 for 110 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 LIFE CARE CENTERS OF AMERICA — 194 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 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 2 of 53.3-1.3 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; lowest-rated first.

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 / managerTypeRoleSince
DEVELOPERS INVESTMENT COMPANY INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2006
PRESTON, FORRESTIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/1986
BURNETT, OLIVIAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/12/2025
HUNT, WINDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/31/2025
SOLOMON, JENNIFERIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2019
CROSS, CINDYIndividualCORPORATE OFFICERsince 01/01/1995
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
LAY, LISAIndividualCORPORATE OFFICERsince 02/09/2018
SWANKER, RICHARDIndividualCORPORATE OFFICERsince 04/01/2011
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/22/2000
HENDERSONVILLE MEDICAL INVESTORS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1995
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1995
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2006
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
ROHRER, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/12/2025
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024

CMS files one row per role, so the 25 rows in the source record cover these 16 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.

3 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.

$8.4M
Net patient revenuemost recent cost report
-7.6%
Operating marginrevenue minus expenses
$1.6M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 36%Medicare 13%Other / private 52%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2024. 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

$412per resident / day
operating cost
$12,525per month
≈ monthly operating cost
$383per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 345463. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, 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.

What to do next