Clear Creek Nursing & Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

47.6% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.1% 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 34 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 0.59 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 120 beds and averages 111.7 residents a day — about 93% occupied, or roughly 8 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 4.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.02 hrs/resident/day on weekends vs 4.31 on weekdays — 7% thinner on weekends. RN hours go from 0.71 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

32 citations, most serious first. The 14 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · Kcited before2023-08-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
  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 reviews, staff, Responsible Party text communication (RP), Nurse Practitioner (NP), physician (MD), and Urology Physician Assistant (PA) interviews, the facility failed to implement the Urology Physician's orders dated 6/9/23 for prophylactic antibiotic treatment for recurrent urinary tract infections (UTI) and to discontinue a medication to treat an overactive bladder. The facility also failed to ensure staff were trained on the correct procedure to collect a urine specimen and ensure the laboratory was notified there was a specimen for pick up. The deficient practice affected 1 of 3 residents reviewed for urinary tract infections (Resident #1). Resident #1 was sent to the emergency department on 7/13/23 due to being found unresponsive, upon examination in the emergency room Resident #1 required hospital admission in the intensive care unit (ICU) for sepsis (a life-threatening emergency to the body's response to an infection) secondary to a Urinary Tract Infection. The immediate jeopardy began…

  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 before2023-11-17 · 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, resident/ family and staff interviews, the facility failed to protect a resident's right to be free from verbal and mental abuse when Nurse Aide #4 and Social Worker confronted Resident #2 in her room and intimidated her into not submitting a grievance. Nurse Aide #4 refused to provide incontinent care for Resident #2 by taking her to her room and yelling at her by stating she could poop in her diaper like everyone else does then slammed the door as she left. Nurse Aide #4 yelled at Resident #2 who requested incontinent care, by stating I am not your CNA and will never be your CNA no more in life. These actions caused Resident #2 to feel intimidated, devalued, deprived of care, ignored, depressed, without control of her life, trapped, upset, and as if she did something wrong. This occurred for 1 of 1 resident reviewed for abuse. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses inclusive of Parkinson's disease, depression, and neurogenic bladder. An…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-11 · 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, resident, Family member, and staff interview, the facility failed to protect a resident right to be free from employee to resident verbal abuse for 1 of 2 residents investigated for abuse (Resident #2). Resident #2 reported needing assistance with toileting when a Nurse Aide (NA #6) entered her room and NA #6 refused to assist her with incontinence care stating she didn't have time. Resident #2 alleged later that same evening NA #6 returned to her room to place her on the bed pan and verbalized threats while shaking her hand at the resident in a manner which made the resident feel deflated, defeated, tearful, and insignificant. She also stated she was afraid to ask for anything else because she was concerned NA #6 would retaliate against her. The findings included: Resident #2 was re-admitted to the facility on [DATE] for rehabilitation services with diagnoses that included displaced avulsion fracture of tuberosity of left calcaneus (a piece of the calcaneus is pulled off when 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-11 · 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 observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #6 from a resident care assignment after NA #6 shook her clinched hands (closed fist) at her and stated, I don't have time to deal with you and if she needed to pee that bad, she should have made her company leave before supper. Resident #2 reported the interaction on the evening of 7/31/23 made her feel deflated, defeated, tearful, insignificant, like I am this big (holding up two fingers close together), and afraid to ask for anything else because she was concerned NA #6 would retaliate against me. NA #6 continued to provide care to other residents in the facility after the incident until the end of her shift at 7:00 pm. This was for 1 of 3 residents reviewed for abuse (Resident #87) . The findings included: A review of the facility policy titled: Abuse, Neglect, or Misappropriation of Resident Property revised 10/15/22 indicated the facility shall take whatever steps are necessary to prevent…

  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
• Potential for harm · E2026-05-15 · 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 store, label and date food in 1 of 1 freezer and 1 of 1 walk-in cooler and failed to remove produce with signs of spoilage in the walk-in cooler. These practices had the potential to affect food served to residents.Findings Include:a. During an initial kitchen tour of the walk-in cooler, conducted with the Dietary Manager on 05/11/2026 at 10:25 AM, the following concerns were identified:- Two packages of strawberries were stored in their original packaging. Four strawberries in one package were observed covered with a white, fuzzy substance. The second package contained one visibly spoiled strawberry.- One pack of blueberries was stored in its original packaging. Five blueberries were observed covered with a white, fuzzy substance. - Thirty-eight yellow squash stored in a box was observed wilted and brown in color.- One box containing 30 oranges stored in a box was observed. Five oranges were observed covered with a white, fuzzy substance.- One box containing loose mushrooms was observed with dark brown and wilted…

  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 · D2026-05-15 · 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, observation, and staff interviews, the facility failed to change the pressure ulcer dressing as ordered for 1 of 3 residents reviewed for pressure ulcers (Resident #11). The findings included:Resident #11 was readmitted on [DATE] with diagnoses which included pressure ulcer of the sacral (triangular bones located below the lumbar spine) area (stage 4), neurocognitive disorder with Lewy Bodies, abnormal posture, and chronic obstructive pulmonary disease. Resident #11 was admitted to hospice care on 12/26/25.The care plan revised 6/26/25 revealed Resident #11 had an ulceration or interference with structural integrity of layers of skin of the sacral area caused by pressure related to friction, incontinence of bowel and/or bladder, and immobility. The goal was Resident #11's pressure ulcer would not worsen through review. Interventions included administer medications as ordered, administer treatments as ordered, utilize enhanced barrier precautions, turn and reposition the resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-15 · 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 observation and staff interviews, the facility failed to label an in-use insulin pen with the opened and expiration date information for 1 of 4 medication carts (200-hall medication cart). The findings included:An observation was conducted of the 200-hall medication cart with Nurse #5 on 5/14/26 at 12:47 PM. The observation revealed one opened and in use Lantus Solostar insulin pen not labeled with an opened or expiration date. The insulin pen was stored in a clear zippered bag labeled with the resident's name and prescribing information. Nurse #5 was interviewed during the cart observation and stated insulin pens were supposed to be dated with the date they were opened. She further stated insulin pens should be discarded 28 days after being opened. Nurse #5 stated she was unsure when the Lantus insulin pen was opened or why the insulin pen was not dated.On 5/14/26 at 3:47 PM the Director of Nursing (DON) was interviewed and stated she expected nursing staff to label insulin pens with the date they were opened and discard them 28 days after the opened date.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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-15 · 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 review, and resident, staff, Dietary Manager, and Registered Dietitian (RD) interviews, the facility failed to provide food that accommodated a documented allergy to pineapple for 1 of 4 residents reviewed for nutrition (Resident #61).Findings included: Resident #61 was admitted to the facility on [DATE]. Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors. Resident #61's electronic health record revealed an undated area on the clinical dashboard listed food allergies as pineapple and tree nuts and listed the severity as unknown. A review of Resident #61's care plan document which was last reviewed on 3/9/26, stated at the bottom of the document, the resident's food allergies included pineapple and tree nuts. There was no separate care plan for the allergy.A review of a history and physical note written by the Internal Medicine Nurse Practitioner, dated 4/10/26 indicated Resident #61 had 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-21 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 4 of 6 monthly Resident Council Meetings. The Resident Council had concerns during resident council meetings that revealed no follow up resolutions (09/19/24, 11/14/24, 12/11/24, and 01/16/24.) The findings included: On 09/19/24 the Resident Council Meeting Minutes noted music not being played during meals, getting assistance to go to the beauty shop, and residents wants DNR above their bed. The Resident Council Follow-Up for 09/19/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 11/14/24 the Resident Council Meeting Minutes noted call lights were not being answered. The Resident Council Follow-Up for 11/14/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 12/11/24 the Resident Council Meeting Minutes noted call lights were not being answered and residents had issues with…

  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 · Ecited before2025-03-21 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 record reviews and staff interviews, the facility failed to maintain psychiatric progress notes in the electronic medical record (Residents #21, # 31, #37 and #90), and to accurately document the completion of an order on the medication administration record (Resident #36). This deficient practice occurred for 5 of 5 residents (Resident #21, # 31, #36, #37 and #90) reviewed for accurate medical records. The findings included: 1a. Resident #21 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbances. A physician order for Resident #21 dated 10/24/24 ordered psychiatric services for evaluation and treatment. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicted Resident #21 had severe cognitive impairment and received antipsychotic, antianxiety and antidepressant medications. A review of Resident #21's electronic medical record (EMR) did not include any psychiatric progress notes. A request for psychiatric progress notes was made to 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 before2025-03-21 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. According to the facility's infection control policy subsection titled Enhanced Barrier Precautions dated 4/03 and revised 6/13/24, personal protective equipment (PPE) including a gown and gloves was to be worn during high contact care for a resident with an indwelling medical device such as a feeding tube. On 3/19/25 at 10:06 AM Nurse #1 donned a gown and gloves at the doorway of Resident #100's room due to the resident being on enhanced barrier precautions. Nurse #1 was observed as she provided a dressing change of the (PEG) percutaneous endoscopic gastrostomy tube (a thin, flexible tube inserted through the skin and into the stomach) insertion site. After cleansing the insertion site and applying a clean dressing, Nurse #1 removed her gloves and took a pen out of her pocket. Without performing hand hygiene or donning a clean pair of gloves, she then used her bare left hand and stabilized the newly applied dressing against the resident's stomach and wrote her initials and date on the tape of the dressing.…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-21 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was made after a resident was given new mental health diagnoses for 1 of 3 residents (Resident #71) reviewed for PASRR. The findings include: Review of Resident #71's medical record revealed the resident was originally admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with depression on 04/20/23, delusional disorder on 12/4/23, and insomnia on 12/04/24. Review of Resident #71's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident was not coded for a level II PASRR. During an interview on 03/19/25 at 1:00 PM with the Social Worker (SW) she revealed a PASRR level II referral should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. It was further revealed by the SW Resident #71…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-21 · 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 observations, record review, and staff and Nurse Practitioner interviews, the facility failed to remove an indwelling urinary catheter per the physician's order and failed to keep a urinary catheter drainage bag and tubing from touching the floor to reduce the risk of infection for 1 of 4 residents reviewed for urinary catheters (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included history of stage 3-4 pressure ulcer. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was moderately cognitively impaired and was coded for having an indwelling urinary catheter. The care plan dated 01/02/25 revealed Resident #36 had an indwelling urinary catheter due to a stage 4 sacral wound and the interventions included providing catheter care per the physician orders. Resident #36 had a physician order dated 03/11/25 that read; discontinue the indwelling urinary catheter on 03/15/25. The order was entered by Nurse #3.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-21 · 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 observations, record review, and family member and staff interviews, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for respiratory care (Resident #72). The findings included: Resident #72 was admitted to the facility 1/18/25 with diagnoses including chronic lung disease and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #72 to have oxygen therapy. A physician order dated 1/18/25 read (for) cyanosis or dyspnea: oxygen at 2 liters per minute, notify the provider. A care plan dated 1/21/25 addressed Resident #72's potential for breathing issues related to his lung disease and specified to administer oxygen at 2 liters per minute by nasal canula. Review of the physician orders for Resident #72 revealed no order for oxygen therapy. The significant change MDS dated [DATE] assessed Resident #72 to not have oxygen therapy. Resident #72 was observed on 3/17/25 at 2:16 PM. Resident #72 had an oxygen concentrator…

  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

$105,396 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $16,801 — penalty dated 2024-04-23
• $88,595 — penalty dated 2023-11-17
• Medicare payment denial — starting 2023-12-20 for 7 days

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

Part of a chain

This home belongs to PRINCIPLE LONG TERM CARE — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

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