Crestview Health & Rehabilitation

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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.

53.3% 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 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 131 beds and averages 75.7 residents a day — about 58% occupied, or roughly 55 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.51 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.77 hrs/resident/day on weekends vs 3.25 on weekdays — 15% thinner on weekends. RN hours go from 0.44 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 82% is well above the national median of 45%. 3 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.

52 citations, most serious first. The 21 most serious are shown; the remaining 31 are one tap away and print in full.

• Immediate jeopardy · K2024-06-13 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and Medical Director interviews the facility failed to ensure that Nurse Aides (NA) #3 and NA #4 knew how to respond to a medical emergency, and what role to assume during a medical emergency, and were certified in cardiopulmonary resuscitation (CPR) before participating in an emergency situation that resulted in performing CPR on Resident #70. On [DATE] Resident #70 went into sudden cardiac arrest and NA #3, NA #4, and NA #5 began CPR without the use of backboard which creates a hard surface for effective chest compressions that allows for adequate recoil (allow the chest to fully expand after compressions which pushes blood to vital organs). NA #3 and NA #4 were not certified in CPR for Healthcare Providers. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compressions were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching out with the Staff Development Coordinator who…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-06-13 · 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

  Based on record reviews, resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect by failing to comprehensively assess a resident prior to moving the resident off of the floor following a fall with injury, seek immediate medical treatment or hospitalization to provide the necessary care and services to the resident, and provide effective pain management. On 5/27/24 Resident #40 sustained a fall with injury and a comprehensive assessment was not completed prior to transferring the resident to bed. The resident's left leg was observed internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. The resident was medicated with a one-time dose of Ibuprofen (pain medication, decreases…

  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 · J2024-06-13 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers. Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-06-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-06-13 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-02-08 · tag F0802 — failed to prepare enough nourishing food — pattern
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving and did not serve resident mechanically altered diets as ordered. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 9 of 9 residents (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26) for 3 of 3 meals. The staff also prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving for 91 of 91 residents. The Immediate Jeopardy (IJ) began on 1/22/23 when dietary staff did not arrive to work their scheduled shift to ensure meal service was provided by trained and competent staff. This resulted in 9 of 9…

  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
• Immediate jeopardy · K2023-02-08 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual 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 reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Immediate Jeopardy (IJ) began on 1/22/23 when residents with orders for a puree diet were not served 3 of 3 meals pureed to a smooth consistency. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-02-08 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident, staff interviews, the facility Administration failed to provide effective leadership and oversight to ensure effective systems were in place to have trained dietary staff available to prepare meals for residents. On 1/22/23 dietary staff did not arrive to work and the Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without serving 9 of 9 residents mechanically altered meals as ordered (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). This led to the high likelihood of aspiration or choking. The Immediate Jeopardy (IJ) began on 1/22/23 when systems were not in place to ensure trained dietary staff were available to prepare resident meals. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, family, staff interviews and physician interviews, the facility failed to provide care in a safe manner when Resident #1 fell out of her bed during incontinent care. Resident #1 fell from an elevated bed position hitting her head and reported immediate pain in her right lower extremity upon falling. Resident #1 was subsequently transported to the Emergency Department via ambulance and was diagnosed with a right leg bone fracture. The facility also failed to provide a transfer in a safe manner when Resident #3's left eyebrow area was grazed with the mechanical lift during a transfer causing a skin tear. The deficient practice occurred for 2 of 3 residents reviewed for supervision to prevent accidents (Resident #1 and Resident #3). Findings included: 1.Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (a stroke) with left sided hemiparesis and hemiplegia (weakness and paralysis), left above the knee amputation, type II diabetes,…

  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 · Gcited before2024-07-22 · 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 reviews, staff and Resident interviews the facility failed to protect a resident's (Resident #1) right to be free from abuse for 1 of 2 residents reviewed for abuse. Resident #2 was observed to cover Resident #1's mouth with his hand and pinch her nose using his thumb and index finger preventing her from breathing and causing her face to turn bright red and causing her to cry. Resident #1 stated she was afraid of Resident #2. The finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic spinal cord dysfunction, anoxic brain injury and paraplegia (paralysis which can result from a spinal cord injury which can affect all or part of the trunk, legs and pelvic organs). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and required set up to dependent level of assistance from staff with most of her activities of daily (ADL). The care plan revised on 09/28/23 revealed Resident #1…

  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 · G2024-06-13 · tag F0626 — isolated
  Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Resident Responsible Party (RP) interviews the facility failed to permit a resident (Resident #346) who required skill nursing services to return to the facility after being sent to the Emergency Department (ED) for evaluation on 07/08/2023 after he cut himself with a soda can. On 7/11/2023, Hospital Social Worker #1 contacted the Admissions Coordinator at the facility and informed her that Resident #346 had been cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued involuntary commitment (IVC) paperwork had been reversed. The facility did not accept Resident #346 for readmission. The hospital sent Resident #346's skilled nursing referrals to 50 other skilled nursing facilities and was unable to place Resident #346. Resident #346 remained in the Emergency Department until he was discharged home on 7/19/2023 with his elderly parents who were not physically able to care for him. Emergency Department…

  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 before2025-09-11 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews, the facility failed to maintain accurate advance directive information throughout the medical record (Resident #50) and failed to have a signed Medical Orders for Scope of Treatment (MOST) form (Resident #13, Resident #74, Resident #84). This deficient practice affected 4 of 8 residents reviewed for advance directives (Resident #50, Resident #13, Resident #74, Resident #84).The findings included: Resident #50 was admitted to the facility on [DATE]. Review of Resident #50’s quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. Review of the Code Book (a binder that contained paper copies of residents’ advanced directives and code status) revealed Resident #50’s paper medical record contained a signed MOST form that indicated Resident #50’s preference for a DNR (Do Not Resuscitate) status in the event she had no pulse and was not breathing. The form was signed by Resident #50’s Resident Representative and dated…

  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 before2025-09-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, the facility failed to post cautionary signage outside of resident rooms that indicated the use of oxygen for 4 of 5 residents reviewed for respiratory care (Resident #2, Resident #55, Resident #87, and Resident #88).Findings included: 1. Resident #2 was admitted on [DATE] with diagnoses that included heart failure, asthma, and dependence on supplemental oxygen. Resident #2’s physician orders revealed an order dated 09/11/24 for oxygen via nasal cannula as needed for shortness of breath at 3 liters per minute. A review of Resident #2’s care plan updated on 05/28/25 revealed a plan for oxygen therapy for respiratory disease. The stated goal was that Resident #2 would be free from respiratory complications. Interventions included oxygen via nasal cannula as ordered, monitor for signs of respiratory distress and notify provider if indicated, and administer medications as ordered. Resident #2’s admission Minimum Data Set (MDS) dated [DATE] revealed that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · 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 remove expired milk from 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator. This failure had the potential to affect all resident who eat food items prepared with milk and all residents who may ingest milk as fluid.The findings included:An observation of the facility's kitchen on 09/08/25 at 10:23 AM revealed one gallon of whole milk with a use by date of 09/02/25 was found in the reach-in refrigerator. The gallon of milk was opened, with approximately 1/5 of it remained and was available for use. Additionally, one unopened gallon of whole milk and one opened gallon of whole milk with expiration dates of 09/02/25 were located in the facility's walk-in refrigerator along with one individual carton of 2% milk with an expiration date of 09/03/25 observed in the same walk-in refrigerator.An interview with the Dietary Manager on 09/11/25 at 10:34 AM revealed the dietary aides were typically responsible for checking the kitchen areas daily for foods that were expired or were approaching their expiration 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0700 — isolated
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 assess a resident for the use of side rails prior to installation of bed rails on the resident's bed for 1 of 1 resident reviewed for side rails (Resident #4).The findings included:Resident #4 was most recently readmitted to the facility on [DATE] with diagnoses that included dementia with behaviors, bipolar disorder, polyneuropathy, and anxiety disorder.Review of Resident #4's annual Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. He was coded as requiring limited assistance with bed mobility and was not using any restraints or alarms.Review of Resident #4's physician orders revealed an order dated 04/07/25 for 1/4 side rails to be up while in bed to promote independence.Review of Resident #4's treatment administration record indicated Resident #4 had side rails installed on his bed on 07/12/25. The treatment administration…

  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 · D2025-09-11 · 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 observation, record review, and staff interviews, the facility failed to implement their infection control policy for Enhanced Barrier Precautions (EPB) when the Wound Nurse did not don (put on) a gown when performing wound care for Resident #44. The Wound Nurse also failed to perform change gloves and perform hand hygiene between wound sites. This occurred for 1 of 3 staff members observed for infection control practices (Wound Nurse).Findings included:Review of the facility's Enhanced Barrier Precautions (EBP) dated 03/28/24 revealed it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident activities such as wound care.A review of the facility's Infection Prevention and Control Policy revised 06/01/23 revealed hand hygiene should be completed after contact with non-intact…

  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 · Dcited before2025-07-11 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and resident interviews, the facility failed to provide notification of an accident that resulted in Resident #3 being hit in the eye area with the mechanical lift handle causing a skin tear with a small amount of bleeding that required a wound covering to the resident's family member or resident representative for 1 of 4 residents reviewed for notification of change (Resident #3).Resident #3 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type II diabetes mellitus, atherosclerotic heart disease, and hypertension.Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact.Review of Resident #3's electronic health record revealed Family Member #1 as his resident representative.Review of facility incident accident logs revealed an incident with Resident #3 on 04/20/25. Per the facility's handwritten incident/accident report, Resident #3 suffered a skin tear to his left eye area after…

  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 before2025-07-11 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  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 implement care planned interventions by not placing a fall mat at the bedside of a resident with a history of falls. This occurred for 1 of 3 residents reviewed for care plan implementation (Resident #2). Findings Included: Resident #2 was admitted to the facility on [DATE] with Parkinson’s disease, epilepsy and dementia. A care plan revised on 5/7/25 indicated Resident #2 was at risk of falls related to cognitive impairment and impulsively attempting to get up without assistance at times. An intervention noted was to have a fall mat at the right side of the Resident’s bed. Review of the Quarterly MDS assessment dated [DATE] revealed Resident was cognitively intact. On observation of Resident #2 on 6/26/25 at 10:45 AM, Resident was asleep in the center of her bed, the bed was in the lowest position and the left side of bed was against the wall. The head of the bed was elevated approximately 30 degrees. There was no fall mat 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-07-22 · 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

  Based on record review and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating. When there was an allegation of abuse, an initial report was not submitted to the State Agency, a 5 day investigation was not submitted to the State Agency, law enforcement and Adult Protective Services (APS) were not notified for 1 of 2 residents reviewed for abuse (Resident # 1). The finding included: The facility's policy titled, Abuse, Neglect and Exploitation, revised 10/22/23 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for investigation; identifying and interviewing all persons, including…

  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 · F2024-06-13 · tag F0841 — widespread
  Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and Medical Director (MD) interviews the facility failed to ensure the MD was aware of resident care policies related to Cardiopulmonary Resuscitation (CPR) and Emergency Response. This deficient practice had the potential to affect all current residents in the facility. The findings included: A review of the Medial Director service agreement signed by the facility's Medical Director (MD) on [DATE] included the following under duties and obligations of Medical Director: Medical Director shall be responsible for implementation of resident care policies, coordination of medical care in the facility and shall perform such other duties and responsibilities customary for a medical director in a facility of comparable size to the facility. The Medical Director (MD) was interviewed on [DATE] at 2:55 PM. The MD stated she was not familiar with the protocol for CPR or Emergency Response in the building, but she had always told the facility to call EMS before calling her. The Administrator…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-06-13 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of the facility's Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a resident's code status election was evident and accurately documented in the medical record for 6 of 6 (Resident #81, #83, #86, #68, #32, and #72) residents reviewed for advance directive. Findings included: 1. Resident #81 was admitted to the facility on [DATE]. A review of Resident #81's electronic health record revealed an advanced directive order for Full Code dated 02/24/23. A review of Resident #81's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #81 was severely cognitively impaired. A review of the Code Status notebook maintained at the nursing desk on 06/04/24 revealed there was no advanced directive in the code status notebook for Resident #81. During an interview with the Physician Assistant (PA) on 06/04/24 5:34 PM she explained…

  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

“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

$144,008 in federal fines across 4 penalties. 2 Medicare payment denials on record.

• $4,833 — penalty dated 2025-07-11
• $4,833 — penalty dated 2025-07-11
• $15,015 — penalty dated 2025-07-11
• $119,327 — penalty dated 2024-06-13
• Medicare payment denial — starting 2025-08-09 for 35 days
• Medicare payment denial — starting 2024-07-04 for 40 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.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.5M 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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