Woodhaven Nursing Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

56.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 69.4% 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 36 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% 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 115 beds and averages 103.5 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.65 hrs/resident/day on weekends vs 3.99 on weekdays — 9% thinner on weekends. RN hours go from 0.36 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

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

Inspection deficiencies

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

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

24 citations, most serious first. The 15 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · K2024-07-31 · tag F0607 — failed to have anti-abuse policies — pattern
  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 and staff interviews, the facility failed to follow their abuse policy when Confidential Staff #1 allowed Nurse #3 to continue providing care to residents after witnessing Nurse #3 slap Resident #3. Confidential Staff #1 did not report the abuse to the administration resulting in no protection of residents from further abuse, no investigation, and no notification to the state, adult protective services or law enforcement. A second incident of abuse occurred when Nurse Aide #2 and Nurse Aide #3 did not identify abuse when they witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in the resident experiencing pain and her skin tear reopening and bleeding. Nurse #3 then raised her hand to Resident #3 like she was going to slap her. This resulted in the abuse not being reported to the administration, no protection of the residents from further abuse, no investigation, and no notification to the state, adult protective services or law enforcement. This deficient practice was 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-07-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect Resident #3's right to be free from abuse. In March of 2024 Confidential Staff #1 witnessed Nurse #3 slap Resident #3 across the face during care after Resident #3 spit on Nurse #3 twice. In July of 2024 during a weekly skin check Nurse Aide #2 and Nurse Aide #3 witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in a skin tear reopening and bleeding. Resident #3 repeatedly yelled you're hurting me. Resident #3 then spit on Nurse #3 twice and in response, Nurse #3 raised her hand like she was going to slap Resident #3 when Nurse Aide #2 intervened and Nurse #3 lowered her hand and proceeded to change the dressing. Resident #3 did not have the cognitive capacity to express a psychosocial outcome. A reasonable person expects to be free from abuse in their home. There is a high likelihood that abuse from a caregiver would cause serious psychosocial harm to include feelings such as fear, intimidation, withdrawal, agitation,…

  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 · Jcited before2024-07-31 · 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 reviews and interviews with staff, Emergency Medical Services personnel, and the Medical Director, the facility failed to immediately initiate emergency medical services (EMS) on a pulseless, nonbreathing resident who was a full code. On [DATE] at approximately 12:03 AM Resident #1 was found to be unresponsive, pulseless, and not breathing. Nurse #1 began cardiopulmonary resuscitation (CPR) (a way to try to restart the heart and lungs if they stop) and yelled out Code Blue. After approximately 2 minutes of (CPR) no other staff had come to assist Nurse #1 so she went to the door, saw a nurse assistant and yelled Code Blue she then resumed CPR on Resident #1. Nurse #2 arrived with the crash cart, applied the automatic external defibrillator (AED) pads and 2-person CPR was started. Staff failed to meet EMS at the door that was locked and with non-working doorbell. Emergency Medical Services record revealed dispatch received a call on [DATE] at 12:24 AM for a resident in cardiac arrest and was at 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-15 · 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, staff, and Orthopedic Surgeon interviews the facility failed to perform comprehensive skin assessments, to conduct skin monitoring to the area under an immobilizer and to coordinate care with the resident's orthopedic surgeon to ensure care needs were met when the resident missed her 10/4/23 surgical follow up orthopedic appointment and was not seen by the orthopedist until 11/17/23. At the 11/17/23 orthopedic surgeon visit Resident #1 was identified with a wound on her right knee that appeared necrotic (dead tissue), black in color, and the skin around it appeared darker like a bruise. This was for 1 of 1 resident reviewed for wound care. The findings included: Resident #1 was admitted to the facility on [DATE]. Her diagnoses included right hip prosthetic (previous hip replacement hardware) removal followed by surgical repair of the hip joint (an artificial joint with two bearings replaces damaged joint), chronic kidney disease (CKD) stage 4, and hypertension (high blood pressure). 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-15 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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, family, staff, non-emergency transportation services Manager, Orthopedic Surgeon, and orthopedic surgeon's Office Manager interviews, the facility failed to ensure a resident had transportation arrangements for initial post-operative appointment with the Orthopedic Surgeon on 10/4/2023, resulting in the resident not being seen by the Orthopedic Surgeon until 11/17/2023. At the 11/17/23 orthopedic surgeon visit Resident #1 was identified with a wound on her right knee that appeared necrotic (dead tissue), black in color, and the skin around it appeared darker like a bruise.This occurred for 1 of 1 resident reviewed for medically related social services (Resident #1). The Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include right hip replacement, chronic kidney disease and hypertension. Resident #1 was discharged to the hospital on 9/18/2023 and she was diagnosed with a right femur fracture. Resident #1 was readmitted to the facility on [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
• Potential for harm · E2025-08-29 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of wrong route and medications to be taken with food (5 medication errors out of 31 opportunities), resulting in a medication error rate of 16.13% for 2 of 5 residents observed during medication pass (Resident #24 and Resident #47).The findings included:1. Resident #24 was admitted to the facility on [DATE] with diagnoses that included stroke, hypertension, depression, and respiratory failure. a. A Physician order dated 5/6/25 revealed Resident #24 was to receive folic acid (dietary supplement) one (1) milligram (mg) via gastrointestinal tube (G-Tube) once a day. The order was transcribed on the electronic Medication Administration Record (eMAR) accurately. b. Resident #24's Physician order dated 5/5/25 was reviewed and revealed Resident #24 was to receive docusate sodium liquid (constipation medication) 50mg per 5 milliliters (ml) twice a day via…

  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 · E2025-08-29 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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, Resident Council and Resident Representative interviews, and test tray, the facility failed to provide palatable foods for 7 of 7 residents reviewed for food palatability (Residents #14, #41, #50, #63, #96, #107 and #109). The findings included:Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included unspecified dementia and Type 2 diabetes. The medical record indicted Resident #14 resided in the dementia unit. The quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #14 was severely cognitively impaired. During an interview on 8/26/2025 at 10:58 AM, the Representative of Resident #14 stated she was often there at mealtimes and the Resident complained of the food being cold during those visits. She stated this occurred frequently and most often during breakfast. The representative did not say if she touched or sampled the food to confirm that it was cold. She stated that she had observed the staff taking 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-29 · 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 record review, observations, and staff interviews, the facility failed to ensure dishware was clean, in good condition and not stacked wet, failed to maintain food preparation areas clean and free from dried debris, failed to label and date leftover food stored for use in 1 of 1 walk-in cooler and 1 of 2 walk-in freezers, failed to monitor and record the internal temperatures of food for 2 of 2 tray line observations and failed to ensure hot food was served at or above 135 degrees Fahrenheit (F). These practices had the potential to affect food served to residents.The findings included: a. During the initial tour of the kitchen with the Food Service Supervisor, on 8/26/25 from 9:45 AM to 10:00 AM, the following concerns were observed:- Three out of 8 steam pans that were ready to be used contained yellow and white sticky residue when touched. - Two out of 104 plastic dome lids that were on the tray line ready for use were stacked wet.- Seven out of 24 plates on the tray line ready for meal service had dried, yellow and red residue. - Seven out of 21 sectioned plates on 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 · D2025-08-29 · 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, staff and Medical Director interviews, the facility failed to assess whether the self-administration of medication was clinically appropriate before leaving medications at the bedside. This was for 2 of 2 residents reviewed for medication administration (Resident #3 and Resident #35).Findings included: a. Resident #3 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, stage 3 unspecified. A review of Resident #3's medical record did not reveal a self-administration of medication assessment. A review of Resident #3's physician's orders from 5/30/25 to 8/22/25 did not reveal a physician's order for Resident #3 to self-administer any medication. A review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired with no behaviors. The MDS also revealed Resident #3 received antidepressant and hypoglycemic…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-29 · tag F0761 — failed to label and store drugs safely — isolated
  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 observations and staff interviews, the facility failed to secure a cup of medications stored in 1 of 5 medication carts reviewed for medication storage (medication cart for Hall 1600).The findings included: An observation of the medication cart for Hall 1600 occurred on 8/28/25 at 8:15 AM. The Medication Aide (MA) #1 opened the top drawer of her medication cart and an unlabeled cup of medications was observed in the front left corner of the medication cart drawer. On 8/28/25 at 8:36 AM an interview occurred with MA #1 who confirmed she had left the medications in the top drawer of her medication cart for Resident #121. MA #1 explained the medications were centrum (vitamin supplement), clonazepam (seizure medication), fluoxetine (antidepressant medication), MiraLAX (constipation medication), and modafinil (central nervous system stimulant medication). She explained she had poured the medications and then realized the resident was in the shower, so she placed the medications in the medication cart drawer to provide Resident #121 with the medications later. MA #1 stated she…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-29 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse #2 did not don (put on) a gown while administering medications via a gastrointestinal tube (a tube inserted through the abdomen to the stomach) to Resident #37 who required enhanced barrier precautions (EBP) due to the presence of a gastrointestinal tube (G-tube). This practice occurred for 1 of 3 staff members observed for infection control.The findings included: Review of the facility's Enhanced Barrier Precautions door sign dated 1/20/2022 stated that all healthcare personnel must wear gloves and gown for the following High Contact-Resident Care Activities: Device care or use: central line, urinary catheter, feeding tube, and tracheostomy care. Review of the facility's Infection Prevention and Control Standards policy (last approved 11/2024), and the Initiating Transmission Based Precautions policy (last approved 06/2025) stated Transmission-Based Precautions will be utilized…

  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 · Ecited before2024-09-12 · 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 observations, record reviews, and resident, staff, Physician, and Vascular Clinic Nurse interviews, the facility failed to provide Thromboembolic Deterrent (TED) compression stockings and elevation of the lower extremities when up in her wheelchair which were ordered by the Vascular Nurse Practitioner (NP) on 6/5/2024 for 3 months, for a resident with bilateral lower extremity edema (swelling and puffiness of the lower legs and feet as a result of weakness or damage to veins in the legs), (Resident #27), for 1 of 2 residents reviewed for compression stockings. Findings included: Resident #27 was admitted to the facility on [DATE], with diagnoses to include rheumatoid arthritis, diabetes mellitus type 2 with diabetic neuropathy (nerve damage that causes weakness, numbness, and pain), and atrial fibrillation. A physician's progress note written by Nurse Practitioner (NP #2) dated 1/26/2024 at 12:00 P.M. read in part, History of present illness: Resident has complaints of bilateral feet turning…

  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 before2024-09-12 · 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 observations, record reviews, and staff interviews, the facility failed to discard expired opened multidose medications, date an opened multidose medication and dispose of loose unidentifiable pills in the drawer of the medication cart (1100 Long Hall) and failed to discard an opened multidose medication per manufacturer's instructions stored for use in the medication cart (Memory Care Unit) for 2 of 6 medication carts reviewed. And the facility failed to remove expired medications available for use in the automated medications dispensing machine in 1 of 4 medication rooms (the Rehab Unit) reviewed for medication storage. Findings included: 1) Observation of the 1100 Long Hall medication cart was conducted on 9/9/2024 at 10:47 AM in the presence of Nurse #9 revealed the following medications were stored on the medication cart: 1a. According to the product manufacturer's instructions, in-use Humalog prefilled insulin KwikPen should be stored at room temperature of less than 86 degrees Fahrenheit (F) and used within 28 days. Resident #25's Humalog prefilled insulin KwikPen…

  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 · D2024-09-12 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, pharmacist interview, and staff interviews, the facility failed to act on a pharmacy recommendation to complete an Abnormal Involuntary Movement Scale (AIMS/discus) assessment for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for psychotropic medications, Resident #57. Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety and major depression. Review of the physician orders on 09/10/24 for Resident #57 revealed an order for Risperdal M-Tab tablet Dispersible 0.5 MG (Milligrams) give one tablet by mouth at bedtime related to recurrent major depressive disorder and moderate schizophrenia unspecified. Place on tongue and let dissolve (Order start date 09/25/23). A quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 was reviewed. Resident #57 had intact cognition. He had no moods or behaviors. He had no hallucinations or delusions. He had no extremity mobility…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-05-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and Wound Care Nurse Practitioner interviews the facility failed to perform daily wound care treatments on a stage IV sacral wound and a deep tissue injury to left heel (Resident #4) and a stage IV pressure wound of the right posterior medial heel (Resident #5) according to the physician's order for 2 of 3 residents reviewed for wound care. Findings included: 1a. Resident #4 was admitted to the facility on [DATE] with diagnoses to include, in part, open wound to left foot, dementia and pressure ulcer to left buttock. A physician's order written on 03/26/24 revealed clean sacrum with normal saline, apply alginate calcium with silver, cover with gauze and island border once daily and as needed. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #4 was cognitively intact. She had no behaviors or refusal of care. She had a colostomy and was always incontinent of urine. She had no impairments and used a wheelchair. She was coded has having a pressure…

  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

“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

$128,210 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $94,175 — penalty dated 2024-07-31
• $9,718 — penalty dated 2024-04-24
• $24,317 — penalty dated 2023-12-15
• Medicare payment denial — starting 2024-08-24 for 26 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 LIBERTY SENIOR LIVING — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 17 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

What families pay in NC