Royal Park Rehabilitation & Health 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.

59.5% 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 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.0% 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 76 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 169 beds and averages 143.3 residents a day — about 85% occupied, or roughly 26 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.10 hrs/resident/day on weekends vs 3.62 on weekdays — 14% thinner on weekends. RN hours go from 0.43 to 0.22 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%.

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.

25 citations, most serious first. The 14 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2024-03-25 · 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 Resident, transportation company staff, insurance manager, facility staff, Wound Physician and Medical Director interviews, the facility failed to secure Resident #1 and her wheelchair to the vehicle according to the manufacturer's instructions to prevent her from sliding forward from the wheelchair during a contracted van transport. When the driver applied the brakes in traffic it caused Resident #1 to slide forward from the wheelchair, her face on the back of the driver's seat and pinning her right kneecap on the van floor. Resident #1 was taken to the hospital for evaluation and a computed tomography (CT) scan of her head and spine resulted negative and three x-ray views of the right knee resulted negative. The Resident was returned to the facility the same day. The Resident had moderate to severe pain and her right kneecap developed a blister that resulted in an open wound that continued to require treatment and had not healed as of the survey. This deficient practice…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2025-12-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 Medical Director, Hospital Urologist, Nurse Practitioner (NP), Resident Representative (RR) and staff interviews, the facility failed to follow hospital discharge orders for a urinary catheter to remain in place for 1 of 5 residents reviewed for urinary catheters (Resident #161). Resident #161 was admitted to the facility from the hospital on 9/18/25 with a urinary catheter due to a diagnosis of hydronephrosis (swelling of the kidneys due to urinary retention). Resident #161's urinary catheter was removed at the facility on 9/19/25 at 6:27 AM and subsequently reinserted at 11:09 PM after the Medical Director reviewed the hospital records which indicated the urinary catheter was to remain in place until follow up with urology. On 9/20/25 Resident #161 was complaining of lower abdominal pain, blood was observed in the catheter tubing, and he was transferred to the emergency department (ED) for further evaluation. The Hospital Urologist noted Resident #161's urinary catheter was not…

  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 · H2024-03-25 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's 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, activity calendar and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 7 residents reviewed for activities (Residents #1, #2, #3, #4, #5 and #6). The residents expressed not being able to leave the facility for over a year made them feel like they had lost some of their independence, felt terrible, isolated, confined, sad, trapped, and they missed getting out and socializing with a group and seeing people outside the facility. The findings included: A review of the March 2023 through March 2024 activity calendars revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility for any of these months. Observation on 03/20/24 at 9:30 AM revealed the facility was located within a business and residential area…

  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 · G2024-03-25 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to provide podiatry services and/or toenail care for 2 of 2 sampled residents (Resident #3 and Resident #1) reviewed for foot care. Resident #3 reported difficulty getting his socks on every morning and having to walk differently due to the condition of his toenails and reported the big toenails on both feet were ingrown. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus type II with complications. Resident #3's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was independent with personal hygiene. Review of a visit summary dated 03/08/24 revealed Resident #3 was not seen by the podiatrist on that date and was not on the list of residents not seen on that date. An observation and interview with Resident #3 on 03/20/24 at 4:00 PM out in the courtyard revealed he needed to be…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-05 · tag F0755 — failed to provide safe pharmacy services — pattern
  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

  Based on observations, and facility staff, pharmacy staff and Nurse Practitioner (NP) interviews, and record reviews, the facility failed to have effective systems in place for obtaining medications and to ensure they were available to administer to a newly admitted resident in accordance with the physician's orders. This resulted in multiple doses of eleven (11) medications being omitted for 1 of 6 residents (Resident #172) who were reviewed for the availability of their medications.The findings included: Resident #172's resided in the community with a family member prior to her admission to the facility. A physician's Orders Note dated 10/9/24 revealed plans were made to admit Resident #172 to the facility for respite care from 10/18/24 to 10/23/24. Respite care is temporary care given to a person who is unable to care for himself or herself while providing short-term relief for primary caregivers. The Orders Note included a list of the resident's current medications and provider contact information. The resident was admitted to the facility for respite care on 10/18/24. 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-05 · 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 reviews, observations, and resident and staff interviews, the facility failed to serve food at a palatable temperature, hot foods were served lukewarm or cold and a beverage was served partially frozen for 6 of 6 residents reviewed for food palatability (Resident #8, Resident # 37, Resident #54, Resident #14, Resident #110, and Resident #80).The findings Included:a. Resident 8 was admitted to the facility on [DATE]. Resident #8 had a physician's order dated 2/12/2025 for a cardiac diet with regular texture, a thin consistency, and double portions. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact.An observation and interview of Resident #8 was conducted on 12/01/2025 at 2:14 PM during the lunch meal. Lunch trays arrived at the 200 Hall at 1:50 PM on 12/01/2025 and were delivered to all residents at the 200 Hall by 2:10 PM. Resident # 8 was observed removing the lid of the hot beverage on his lunch tray and no steam was visible. Resident #8…

  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 before2025-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to label and date food items and discard expired items in 2 of 3 nourishment rooms (300/400 hall nourishment room and 500/600 hall nourishment room). These deficient practices had the potential to affect food served to residents. Findings included:1. Observation and interview conducted with the Dietary Manager on 12/1/25 at 10:25 AM revealed Nourishment room [ROOM NUMBER] (300/400 hall) had: an opened container of coffee creamer that was labeled with a name, but no date. a container with noodles labeled with a resident's name but no date. a gallon of iced tea not labeled with the product or resident name and had the best by date of 11/29/25. an opened bottle of prune juice that was not labeled with a resident's name. The Dietary Manager stated during the observation she expected all items to be labeled and expired items discarded. 2. Observation and interview conducted with the Dietary Manager on 12/1/25 at 10:50 AM revealed Nourishment room [ROOM…

  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 · D2025-12-05 · 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 staff interviews, the facility failed to store a syringe used for enteral feedings (also known as tube feeding, is a method of delivering nutrition directly into the gastrointestinal tract) dry and with the plunger separated from the syringe and free from moisture for 1 of 3 residents reviewed for enteral feeding management (Resident #73). This practice had the potential for bacterial growth and contamination.Findngs included: Resident #73 was admitted to the facility on [DATE] with diagnoses of diabetes, stroke, hypertension, hemiplegia, malnutrition, difficulty swallowing, esophageal web, gastrostomy status (indicates the presence of a gastrostomy tube, which is surgically placed to provide direct access to the stomach for nutrition and hydration when oral intake is insufficient or unsafe), dysphagia, and oropharyngeal. Review of Resident #73 order dated 03/16/24 revealed the resident was ordered to receive 250 milliliters of Glucerna (tube feeding formula) 1.5 through…

  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 · D2025-12-05 · tag F0759 — failed to keep medication error rate low — isolated
  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 observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5% for 3 of 5 residents (Resident #24, Resident #53, and Resident #168) observed during the medication administration observation.The findings included: 1. Resident #24 was admitted to the facility on [DATE]. Her cumulative diagnoses included end stage renal disease requiring hemodialysis. On 12/3/25 at 4:50 PM, Nurse #2 was observed as she began to prepare medications for administration to Resident #24. The medications were administered at 5:05 PM and included two tablets of 800 milligrams (mg) sevelamer. Sevelamer is a phosphate binder used to control blood phosphorous levels for patients with chronic kidney disease on dialysis. A review of Resident #24's December 2025 Physician Orders included a current order for 800 mg sevelamer to be given as two tablets by mouth with meals 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-05 · 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 observations, record reviews, and resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 3 residents reviewed for food preferences (Resident #136).Findings included:Resident #136 was admitted to the facility on [DATE].Review of Resident #136's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Review of Resident #136's undated preference sheet revealed that she disliked grits and hot cereal (oatmeal) for breakfast.An interview and observation with Resident #136 on 12/03/25 at 9:15 AM revealed she had received hot cereal for breakfast. Resident #136 stated she disliked hot cereal and had informed both dietary and nursing staff on multiple occasions, expressing a preference for yogurt instead.An interview and observation with Resident #136 on 12/04/25 at 9:00 AM revealed she had received grits for breakfast. Resident #136 reiterated that she disliked grits and had communicated this to dietary and nursing staff…

  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 · D2024-08-08 · 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 reviews and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 out of 1 sampled resident observed with medications left at bedside (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] showed that Resident #42 was cognitively intact. Review of Resident #42's care plan dated 7/29/24 revealed there was no focus area for self-administering medications. Upon review of Resident #42's medical record, there was no Self Administration assessment for any prescribed medications. Resident #42's Medication Administration Record (MAR) revealed that Medication Aide #1 signed off administering the following medications to Resident #42 on 8/5/24 and 8/7/24 at 9:00 AM. Medication Aide #1 administered aspirin 81mg (milligrams), Flomax 0.4mg, loratadine 10mg, potassium chloride, vitamin C 5000mg, vitamin D3 2000 units, zinc 25mg, docusate sodium…

  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 before2024-08-08 · 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 record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations on 1 of 2 residents reviewed (Resident #25). The findings included: The facility's policy entitled Hand Hygiene last revised on 10/2022 indicated the following: Specific indications for hand hygiene included after contact with body fluids or excretions, non-intact skin, wound dressings, and after removing gloves. Gloves - If gloves are worn for a procedure, hand hygiene is to be completed before putting on gloves and after removal and deposit of gloves in appropriate container. The use of gloves does not replace hand hygiene. A continuous observation of wound care on 8/7/24 from 9:08 AM through 9:40 AM revealed Nurse #1 applying hand sanitizer to both hands, and putting on gloves and a gown before entering Resident #25's room. She removed the old dressing on Resident #25's wound to her left…

  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 · D2024-06-07 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident (Resident #4) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised in February 2024, revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. A review of the physician's order dated 11/22/23 revealed Resident #4 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once daily in the morning for knee pain. A review of the medication administration records (MARs) revealed Resident #4 had received 1 tablet of oxycodone 5 mg once daily as ordered throughout the month of November 2023. The initial allegation report dated 11/27/23 revealed the facility became aware of the misappropriation of residents' property on 11/27/23 at 7:00 PM when…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2024-03-25 · 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 observations, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 2 of 3 residents on the 500 Hall (Resident #1 and Resident #8) reviewed for food palatability. This practice had the potential to affect other residents on the 500 Hall. The findings included: A kitchen observation of the breakfast meal before being plated on 03/21/24 at 8:15 AM along with the Food Service Director. On 03/21/24 at 8:35 AM the breakfast meal cart was delivered to 500 Hall from the kitchen. The first breakfast tray was removed from the enclosed cart at 8:40 AM and the last breakfast tray removed from the cart at 8:59 AM. The test tray which had an insulated dome lid and bottom was taken to the nearest nourishment room at 9:00 AM. A test tray of grits, scrambled eggs and sausage was tested along with the Food Service Director at 9:00 AM on 03/21/24. Butter was placed on the grits that did not melt. The taste test yielded the food…

  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

“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

$39,811 in federal fines across 2 penalties.

• $23,010 — penalty dated 2025-12-05
• $16,801 — penalty dated 2024-03-25

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 28 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in NC