Pine Acres Center for Nursing and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

23.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.3% 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 28 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 106 beds and averages 102.6 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.42 on weekdays — 12% thinner on weekends. RN hours go from 0.12 to 0.08 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

27 citations, most serious first. The 20 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · K2024-03-28 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident, Emergency Service Services (EMS) Personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner, Medical Director, family, and Physician Assistant interviews the facility neglected to provide intravenous (IV) antibiotic medication as ordered for 14 days to a resident when his IV access became dislodged and neglected to direct him to a higher level of care, to replace the IV access line for 1 of 3 residents reviewed (Resident #244) for abuse/neglect. There was the the high likelihood of physical harm by not administering the IV antibiotic as ordered by the infectious disease clinic. The untreated bacterial infection had the high likelihood of causing loss of function to his extremities or possible amputation of his extremities. The facility also failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents reviewed for abuse/neglect (Resident #38). A cognitively intact male resident (Resident #241) was discovered in the bathroom of his…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. Resident #244 was discharged from the facility on 07/24/23 and followed up at the Infectious Disease office on 07/26/23, had his IV access restored and his IV antibiotics resumed at an outpatient infusion center. This deficient practice affected 1 of 2 residents reviewed 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-03-28 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. Immediate jeopardy began on 07/14/23 when Resident #244's PICC line become dislodged, and the facility failed to direct him to higher level of care to ensure he received the IV antibiotic he required. Immediate jeopardy was removed on 03/28/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal…

  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
• Immediate jeopardy · J2024-03-28 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident, and Physician's Assistant interviews the facility failed to immediately report an allegation of sexual abuse to the administrator for 1 of 3 residents reviewed for sexual abuse (Resident #38). A severely cognitively impaired female resident (Resident #38) was taken by a resident (Resident #241), a cognitively intact male resident, into the bathroom in his room. Resident #241's roommate, a cognitively intact male resident (Resident #47), used his call light to alert Nurse Aide (NA) #1 about Resident #241 and Resident #38. NA #1 did not report the allegation about Resident #241 and Resident #38 to a nurse. During this time when NA #1 did not report the allegation to a nurse, Resident #241 was in the bathroom with Resident #38. It was not until a nurse, who was coming to administer evening medications to Resident #241, discovered Resident #38 with her pants down, brief off, and shirt pulled up to below her breasts, as Resident #241 was standing in the bathroom with 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-03-28 · tag F0660 — isolated
  Plan the resident's discharge to meet the resident's goals and needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective discharge planning process to ensure discharge needs and goals were identified with the resident and the interdisciplinary team (IDT) as active participants in the discharge plan in order to prepare the resident for an effective transition to post-discharge care for a resident who was a planned discharge. On 2/14/24 Resident #241 was discharged without the facility verifying his discharge location and if his care needs were able to be met. In addition, the resident was discharged without adaptive equipment required for ambulation (rolling walker). Resident #241 indicated he was dropped off at a homeless shelter where he continued to reside and felt unsafe and was fearful. These failures created a high likelihood of harm for Resident #241. This deficient practice affected 1 of 4 residents reviewed for discharge. Immediate jeopardy began on 02/14/24 when the facility initiated a…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, family, and Physician Assistant (PA) interviews, the facility failed to provide care safely to a dependent resident. Resident #76 had an impaired gait and she was unable to walk without assistance. On 01/11/25 Nursing Assistant (NA) #1 transferred Resident #76 from her bed to the floor for ambulation to the bathroom. The NA turned away from the resident to place the resident's brief in a trash can leaving the resident in a standing position with no staff support resulting in the resident falling. Resident #76 sustained a left wrist fracture and a left hip fracture. This was for 1 of 4 residents reviewed for accidents (Resident #76). Findings included: Resident #76 was admitted to the facility on [DATE] with diagnosis that included osteoporosis, [NAME] Lymphoma, breast cancer, history of humerus (the long bone that extends from the shoulder to the elbow) fracture, and history of falls. The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident #76's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-22 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, the facility failed to ensure a Nursing Assistant (NA) was trained and competent on utilizing the kardex (a concise, quick-reference system for resident care information) to identify the care needs that residents required prior to providing direct care to residents. This was for 1 of 5 staff reviewed for competency (NA #1). The findings included: This tag is cross-referred to: F689: Based on record review, staff, family, and Physician Assistant (PA) interviews, the facility failed to provide care safely to a dependent resident. Resident #76 had an impaired gait, and she was unable to walk without assistance. On 01/11/25 Nursing Assistant (NA) #1 transferred Resident #76 from her bed to the floor for ambulation to the bathroom. The NA turned away from the resident to place the resident's brief in a trash can leaving the resident in a standing position with no staff support resulting in the resident falling. Resident #76 sustained a left wrist fracture and a left hip fracture. This was for 1 of 4 residents reviewed for accidents (Resident…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-03-28 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interviews the facility failed to treat a resident in a dignified manner when two Nurse Aides (NAs) were talking about the residents' wounds in front of her, but not to her, and were rough during incontinent care, and when the resident was screaming and crying in pain (Resident #35) they did not stop the care. The resident stated the interactions with the NAs made her feel angry and upset that they treated her that way for 1 of 1 resident reviewed for pain. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included: diabetes melilites, chronic obstructive pulmonary disease, respiratory failure, a pressure ulcer to left lower leg, and a pressure ulcer to the right lower leg. An observation and interview were conducted with Resident #35 on 03/18/24 at 12:01 PM. Resident #35 was resting in bed on her back and had a very flat affect, her voice was very soft in tone almost a whisper. Resident #35 stated that two Nurse Aides (NA)…

  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
• Actual harm · G2024-03-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, roommate, staff, Wound Nurse Practitioner, and facility Nurse Practitioner interviews the facility failed to stop incontinent care when a resident (Resident #35) experienced pain and was crying and failed to report to the nurse so that her complaints of pain could be addressed for 1 of 1 resident reviewed for pain management. Resident #35 stated that during incontinent care and while being turned onto her side her pain was an 8 on a pain scale. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included: diabetes melilites, chronic obstructive pulmonary disease, respiratory failure, a pressure ulcer to left lower leg, and a pressure ulcer to the right lower leg. Review of a pain care plan for Resident #35 revised on 01/26/24 read in part, I am on pain medication therapy related to wound to lower extremities. The goal read, The resident will be free of any discomfort or adverse side effects from pain medication through the review date,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-03-28 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident, shelter staff, and facility staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 9/23/2021 Complaint Investigation Survey and the 3/8/2022 Complaint Investigation Survey During the 3/8/2022 Complaint Investigation Survey the facility was cited for Resident Rights (F550) and during the 9/23/2021 Complaint Investigation Survey the facility was cited for Discharge Planning Process (F660). These deficiencies were recited again on the current Recertification Survey and Complaint Investigation Survey of 3/28/2024. The continued failure of the facility to ensure compliance in the two previously deficient areas showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Findings included: This tag is cross referenced to: F660-Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Medical Director interviews, the facility failed to ensure the Nursing Assistant (NA) and/or Medication Aide requested a nurse to assess a Resident who experienced a drop in oxygen saturation on room air to a level of 68 percent where a normal oxygen saturation ranges from 95-100 percent in healthy individuals but may be 90-100 percent in individuals with known respiratory conditions. The deficient practice occurred in 1 of 1 resident investigated for quality of life (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with hemodialysis three times per week, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder and anxiety disorder. Review of hospital records revealed Resident #1 was hospitalized from [DATE] through 12/17/25. A chest x-ray obtained on 12/13/25 revealed pulmonary interstitial edema (fluid in the lung…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Medical Director interviews, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with hemodialysis three times per week, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder and anxiety disorder. Review of hospital records revealed Resident #1 was hospitalized from [DATE] through 12/17/25. Discharge diagnoses included sepsis (a blood infection) resulting from a suspected direct inoculation of her dialysis fistula during hemodialysis, respiratory acidosis (a condition where the blood becomes too acidic rendering breathing difficult and which can result in a respiratory emergency if untreated) and acute respiratory failure (a respiratory emergency where the lungs are unable to oxygenate the body). Hospital…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-22 · 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 code the Minimum Data Set (MDS) assessment accurately in the areas of oxygen use (Resident #7), prognosis (Resident #62), diagnoses (Resident #6) and medications (Resident #85). This was for 4 of 25 residents whose MDS assessments were reviewed. The findings included: 1. Resident #7 was originally admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Resident #7 had a hospital stay from 4/17/25 to 4/21/25. Resident #7's physician orders included an order dated 4/21/25 for oxygen continuous at 3 liters per minute via nasal cannula. A review of the April 2025 Medication Administration Record (MAR) revealed that Resident #7 had oxygen at 3 liters per minute via nasal cannula on 4/21/25, 4/22/25 and 4/23/25. A review of a quarterly MDS assessment dated [DATE] indicated that Resident #7 was cognitively intact and was not coded for the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #20 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including chronic obstructive lung disease (COPD) and respiratory failure. Physician orders for Resident #20 dated 4/26/25 specified oxygen flow rate to be administered at 3 liters per minute (LPM). The quarterly Minimum Data Set, dated [DATE] documented Resident #20 was cognitively intact and used oxygen. Review of the medication administration record for May 2025 indicated by the nursing initials that the oxygen flow rate of 3 LPM was checked by the nurse twice per day (once on each shift). Resident #20 was observed on 5/19/25 at 8:31 AM. She was in bed and had oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. Resident #20 reported she did not know the oxygen flow rate, but sometimes she felt like she was not getting enough oxygen. Resident #20 was observed on 5/20/25 at 11:06 AM in bed with an oxygen nasal cannula in place with the oxygen flow rate set at 5 LPM. On 5/21/25 at 8:50 AM, Resident #20…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interviews the facility failed to discard milk stored past the use by date in 1 of 1 reach-in cooler and failed to label, and date opened left food items in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: Observations during the initial tour of the main kitchen with Dietary Aide #1 on 05/18/25 at 9:56 AM, revealed the following: a. In the reach-in cooler the following leftover beverage was stored past the use by date: -one gallon of whole milk partially consumed with a use by date of 05/15/25. b. In the walk-in cooler the following items were observed on 05/18/25 at 10:02 AM with Dietary Aide #1. -two opened 5 pound bags of leftover shredded cheese with no label or date. An interview was conducted on 05/18/25 at 10:04 AM with Dietary Aide #1. She stated the milk should have been discarded by the use by date. She also stated when staff opened items the date should be written on the item including a use by date. c. In the walk-in cooler the following items were observed on 05/18/25 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · 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 observations, record review, and staff interviews, the facility failed to label enteral feeding formula for 1 of 2 residents reviewed for enteral feeding (method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) (Resident #79) and failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for 2 of 2 residents (Resident #79 and Resident #43) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination. The findings included: 1. Resident #79 was admitted to the facility 8/23/24 with diagnoses including anoxic brain injury. A physician order dated 4/10/25 specified for enteral feeding to be administered at 55 milliliters per hour via j-port (a tube that delivers enteral feeding directly into the small intestine) by pump. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #79 to be severely cognitively impaired. The MDS documented…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, Pharmacist, and staff interviews, the pharmacy failed to label a medication blister package correctly, which resulted in the facility administering 18 doses of oxycodone (an opioid pain medication) to Resident #75 instead of ordered hydrocodone (an opioid pain medication). This was for 1 of 6 residents reviewed for medication administration. The findings included: Resident #75 was admitted to the facility 11/4/23 with diagnoses including stroke, chronic pain, and ovarian cancer. A physician order dated 2/28/24 specified for hydrocodone/acetaminophen 5/325 milligrams (mg) to be given by mouth every 4 hours as needed for pain. A facility incident report dated 4/5/24 and completed by Unit Manager (UM) #1 documented that on 4/5/24 it was discovered that Resident #75 received 18 doses of oxycodone/acetaminophen 5/325 mg instead of hydrocodone/acetaminophen 5/325 mg as the physician ordered. The incident report documented the tablets in the blister packet were scored, round, white…

  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 · Past Non-Compliance
• Potential for harm · E2024-03-28 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to included documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and Pneumococcal immunization for 5 of 5 residents reviewed (Resident #10, Resident #21, Resident #34, Resident #35, and Resident #41.) The findings included: a. Resident #10 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact and received the Influenza immunization in the facility on 10/16/23 and Resident #10's Pneumococcal immunization was up to date. A review of Resident #10's medical record revealed that there was no information in the medical record that the Resident or their legal representative was provided education regarding the benefits and potential side effects of the Influenza or Pneumococcal immunization. b. Resident #21 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed that…

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

  Infection Control Deficiencies · Past Non-Compliance
• Potential for harm · D2024-03-28 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting group grievances for 4 of 6 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding evening snacks and ice water being delivered in the evening (11/9/2023, 12/7/2023, 2/22/2024, and 3/21/2024). Findings included: On 11/9/2023 the Resident Council Meeting minutes noted residents continued to have issues with ice water not being passed out. A Complaint/Grievance Report dated 11/9/2023 indicated the Resident Council reported ice water was not being passed out at night. The Complaint/Grievance Report noted the Director of Nursing (DON) had monitored and re-educated the evening shift staff on passing out snacks and ice water before bedtime. The Resident Council Minutes for 12/7/2023 were reviewed and noted the residents talked about having issues with ice water not being passed out on night shift. A Complaint/Grievance Report dated 12/7/2023 indicated the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-03-28 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for accidents (Resident #79). Findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses of agitation and a neurodegenerative disease. A Care Plan initiated on 7/6/2023 noted Resident #79 was at high risk for falls due to deconditioning and psychoactive medication use. The Care Plan was updated on 12/25/2023 for a fall without injury with interventions of repositioning on care rounds and neuro-checks for an unwitnessed fall. During a review of Resident #79's medical record, Fall Reports were found for a fall without injury on 11/15/2023 and a fall without injury on 12/26/2023. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79 was severely cognitively impaired and had not had a fall since his last MDS assessment dated [DATE]. The Minimum Data Set (MDS) Coordinator was interviewed on 3/21/2024 at 3:15 pm and…

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

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

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

Fines & penalties

$122,460 in federal fines across 2 penalties.

• $15,028 — penalty dated 2025-05-22
• $107,432 — penalty dated 2024-03-28

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 ALLIANCE HEALTH GROUP — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in NC