Deer Park Health and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

49.8% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 24.6% 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 65 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 140 beds and averages 120.9 residents a day — about 86% occupied, or roughly 19 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.06 hrs/resident/day on weekends vs 3.55 on weekdays — 14% thinner on weekends. RN hours go from 0.84 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 78% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

39 citations, most serious first. The 20 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · J2025-08-14 · 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 record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31 (normal 80-100), was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. An emergency medical services (EMS) report dated 7/17/25 indicated when EMS arrived on scene at the facility at 4:48 PM the patient was found lying in her bed, eyes open but only reactive to pain. The EMS report stated Resident #1 was noted to be comatose with seemingly left gaze with inability to follow any types…

  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
• Immediate jeopardy · Jcited before2025-08-14 · 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 observation, record review, staff, resident, family, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's (Resident #1) right to be free from neglect when the facility failed to ensure Resident #1 received emergent care extending beyond the capabilities of the facility when she had critically low blood sugar and was symptomatic. Symptoms included lack of responsiveness, eyes moving left to right, obtunded, jaw tightness, inability to swallow, tightness of hands, moaning, foaming at the mouth. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brains function is impaired due to metabolic distubance), prolonged hypoglycemia, acute kidney injury (AKI), and urinary tract infection (UTI). 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
• Immediate jeopardy · Jcited before2025-08-14 · 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 observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31 (a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. Symptoms Resident #1 experienced from the initial low blood sugar of 31 at 5:30 AM on 07/17/25 until her discharge at 5:09 PM on 07/17/25 included lack of responsiveness, eyes moving left to right, obtunded (reduced level of alertness), jaw tightness, inability to swallow, tightness…

  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 · Jcited before2025-06-24 · 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 2. Resident #15 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included: displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle wasting/atrophy multiple sites, and primary osteoarthritis. Resident #15's care plan was last updated on 11/08/24 as being at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs, wandering and history of falls and used a reclining chair, with interventions that included fall mat at bedside, anticipate resident's needs, and bed in lowest position while resident is in bed. Resident #15 was also care planned for pain related to arthritis and hepatic (liver) mass with interventions that included administer analgesics as ordered, monitor/document for signs and symptoms of nonverbal pain, monitor/report/record resident complaints of pain to the nurse. Resident #15 had an active physician's order 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-06-24 · 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 reviews, resident, observation, staff, Physician Assistant (PA), Transport Company's Owner, and Driver #1 (Transport Company's Driver) interviews, the facility failed to ensure a resident was safely secured in the transport company's van during the return trip from an appointment back to the facility. On 3/26/25 Driver #1 failed to secure Resident #101 in a specialized wheelchair in the Transport Company's van per manufacturer's instructions and according to Driver #1 when the van hit a bump pulling into facility entrance, Resident #101 fell forward, landing partially out of her wheelchair with her legs under the chair. Resident #101 was assisted back into the wheelchair by facility staff at the facility and was wheeled inside the facility. After being assessed by the nurse, Resident #101 was transported to the Emergency Department (ED) on 03/26/25, evaluated for injury, and then returned to the facility on [DATE] with no injury noted upon assessment at the ED. There was a high likelihood of…

  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 · Jcited before2024-08-16 · 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 observations, record review and staff, Physician Assistant, and Medical Director interviews, the facility failed to supervise a severely cognitively impaired resident with wandering behaviors from exiting the facility unsupervised, without staff knowledge, for 1 of 1 resident reviewed for accidents related to unsafe wandering/elopement (Resident #1). The facility also failed to immediately notify administration of the missing resident. The resident exited the facility which was in a rural residential area and walked 1/3 mile on a two-lane road with no streetlights and no sidewalk without shoes, wearing socks. She was found lying in a ditch beside the road by a neighbor walking his dog. On evaluation by Emergency Medical Service personnel, Resident #1's blood sugar was 500 milligrams per deciliter. She was transported to the hospital for evaluation and treatment where she was given intravenous Insulin and fluids. She was later discharged from the hospital to another long-term care facility's locked…

  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
• Immediate jeopardy · Jcited before2024-04-25 · 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 observation, record reviews, and resident, resident representatives, staff, psychotherapist, Psychiatric Nurse Practitioner (NP), Physician Assistant and Medical Director interviews, the facility failed to protect a resident's right (Resident #3) to be free of sexual abuse from another resident (Resident #52). Resident #3 had severely impaired cognition and Resident #52 had moderately impaired cognition and a history of sexual behaviors. On 3/25/23 Resident #52 was observed by staff inviting Resident #3 into his room and was told by staff to leave the door open. Shortly after, Resident #52 was observed inappropriately touching Resident #3's leg. On 7/25/23 Resident #52 was found in Resident #3's room looking at her while she slept. On 1/30/24 Nurse Aide (NA) #1 heard yelling coming from Resident #3's room. NA #1 and Nurse #1 found Resident #52 in Resident #3's room with his hand inside of her incontinent brief with skin to skin contact. Resident #3 stated stop you're hurting me. Resident #3 was…

  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 · G2025-06-24 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  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, mobile x-ray company representative, and Physician Assistant and Physician interviews, the facility failed to notify the provider of x-ray results when they were reported to the facility on [DATE], which resulted in Resident #15's right hip fracture not being reported to a provider until 12/30/24 which delayed Resident #15's transfer to the hospital until 12/30/24 for an evaluation and treatment for a right hip fracture that required surgical intervention for 1 of 4 residents reviewed for falls (Resident #15). The findings included: Review of the progress note dated 12/28/2024 written by the Director of Nursing (DON) revealed the DON heard Resident #15 yelling and as the DON arrived at Resident #15's doorway the DON observed Resident #15 as she attempted to get out of bed. The DON was unable to reach Resident #15 before she fell onto her right side onto the floor mat. Resident #15 did not strike her head but yelled out my hip is broken. The DON assessed Resident #15, leg…

  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 before2024-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Transportation Driver, Dialysis Nurse, and Medical Director (MD) interviews, the facility failed to assess a resident after a fall prior to moving them from the floor. Resident #103 fell during a transfer at the dialysis center and was moved off the floor prior to being assessed for injuries. Resident #103 sustained a clavicle fracture and right ankle strain. This was for 1 of 2 sampled residents reviewed for quality of care (Resident #103). The findings included: Resident #103 was admitted to the facility on [DATE] and had a diagnosis end stage renal disease, cerebral infarction, muscle wasting and atrophy. Resident #103's admission Minimum Data Set (MDS) assessment, dated 2/27/24, coded Resident #103 as severely cognitively impaired and as totally dependent on staff for transfers. A physician's order dated 3/6/24 read the resident receives dialysis on Monday, Wednesday, and Fridays in the afternoon. An interview with the Transportation Driver was conducted on 4/16/24 at 1:20…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-25 · 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, family member, Transportation Driver, Dialysis Center staff, and Medical Director interviews, the facility failed to ensure a resident was transferred safely. Resident #103 sustained a fractured left clavicle and a sprained right foot from a fall when two nurse aides transferred Resident #103 after completion of her dialysis treatment without the use of a total lift. Resident #103 was not cleared by therapy to be transferred manually. The facility also failed to prevent Resident #37 from obtaining skin tears when the nurse aide continued to provide care after the resident became combative and was hitting his arms on the headboard and siderail. This was for 2 of 5 sampled residents reviewed for supervision to prevent accidents (Resident #103, Resident #37). The findings included: 1. Resident #103 was admitted to the facility on [DATE] and had a diagnosis end stage renal disease, cerebral infarction, muscle wasting and atrophy. A review of Resident #103's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  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, resident, staff and provider interviews, the facility failed to administer medications as ordered by the physician for 1 of 2 residents reviewed for pain medications (Resident # 106). The findings included: Resident #106 was admitted to the facility on [DATE] with diagnosis that included nontraumatic subarachnoid hemorrhage from unspecified intracranial artery (a type of stroke where bleeding occurs in the space between the brain and the skull and the source of the bleeding is not due to trauma or a known cause), chronic respiratory failure with hypoxia, pressure ulcer sacral region stage four, chronic pain and persistent vegetative state. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #106 was in a persistent vegetative state and indicated Resident #106 received opioid medication. Review of Resident #106's care plan revealed Resident #106 was care planned for minimal consciousness secondary to subarachnoid hemorrhage and persistent vegetative state 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · 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 review and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 13 of 36 residents reviewed for respiratory care (Resident #78, #90, #45, #32, #4,#10, #27, #61, #3, #36, #26, #57, #67). The findings included: a. Resident #78 was admitted to the facility on [DATE]. A review of Resident #78's physician orders revealed an order dated 5/5/25 for oxygen to be administered continuously via nasal cannula at 4 liters per minute (l/min). A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident # 78 was coded for receiving oxygen during the assessment period. An observation on 6/18/25 at 2:03 PM revealed Resident #78 was lying in bed wearing a nasal cannula with oxygen being administered at 4 l/min. There was no cautionary or safety signage posted at the entrance to Resident #78's room to indicate oxygen was in use. An observation of Resident #78 conducted on 6/19/25 at 11:00 AM…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  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 Consulting Pharmacist, Psychiatric Nurse Practitioner, and Physician interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnosis that included late onset Alzheimer's disease with behavior disturbance, dementia with mood disturbances, recurrent major depressive disorder, major neurocognitive disorder due to dementia, generalized anxiety disorder, primary insomnia. A review of Resident #15's Physician's orders revealed an order dated 2/6/2024 for Zyprexa (an atypical antipsychotic) 2.5 milligrams (mg) give one tablet by mouth two times a day for mood disorders. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and indicated Resident #15 received an antipsychotic on a routine basis during the 7-day look back period…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 record review, and resident and staff interviews, the facility failed to follow their planned menus for 3 of 3 residents reviewed for preferences (Residents #96, #3, #111). The deficient practice had the potential to affect other residents who received food from the kitchen. The findings included: An interview with nursing assistant (NA) #3 on 6/18/25 at 3:15 PM revealed he had noticed residents not getting their dinner meal. He reported the kitchen had ran out of the prepared food items on the menu for the dinner meal. He stated when this happened the residents that had not received the food items on the menu got sandwiches. NA #3 reported it had happened several times although he could not remember an exact number or the exact days it happened on. He did remember it was always the dinner meal. He reported the residents would report to him they did not like getting cold sandwiches and would have preferred a hot meal. He reported the second time it happened he did make the Director of Nursing (DON)…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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, and resident and staff interviews, the facility failed to provide evening snacks to residents when requested for 6 of 6 residents reviewed for frequency of snacks (Residents #3, #37, #44, #96, #105 and #111). This deficient practice had the potential to affect other residents who requested evening snacks. The findings included: a. Resident #3 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #3 was cognitively intact. An interview with Resident #3 on 6/17/25 at 11:15 AM revealed over the past six months she had been offered or received an evening snack once or twice but not on a consistent basis. She stated she believed dietary staff were supposed to restock the snack rooms at least twice a day but there were never any snacks available during the evening shifts or anytime during the weekends. Resident #3 revealed when she would ask staff about receiving an evening snack, they would tell…

  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 before2025-06-24 · 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 food and failed to date perishable food stored for use in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: During the initial tour of the kitchen, with the Dietary Manager, on 6/16/25 from 9:45 AM to 10:15 am, an observation of the walk-in cooler revealed the following: a. a plastic container with cranberry thickener was opened and no date was written on the container b. a plastic container with lemon thickener was opened and no date was written on the container c. a box of blueberry muffins, resealed with plastic wrap had no date written on the container d. an opened bottle of orange flavored juice was opened and no date written on the container. An interview with the Dietary Manager on 6/18/25 at 11:30 AM revealed all food items should be sealed, labeled, and dated when stored. She stated all dietary aides should be checking food items on a regular basis and discard any items that are were not sealed, labeled, dated, or have expired…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-24 · 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

  Based on observations, record review, and staff interviews, the facility staff failed to implement infection control policy and procedures when Nurse #12 did not don personal protective equipment (PPE) for enhanced barrier precautions (EPB) when providing high-contact resident care activities for Resident #106 who had a gastrostomy tube (g-tube-a tube that goes into stomach), an indwelling urinary catheter, and a tracheostomy tube (a tube in the throat for breathing). The facility also failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 3 residents whose blood sugar levels were checked (Resident #96, Resident #10). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There…

  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 · D2025-06-24 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and resident, staff, Physician Assistant (PA), and Physician interviews, the facility failed to protect resident's right to be free of misappropriation of controlled substances for 1 of 3 residents reviewed for misappropriation of resident property (Resident #117). The findings included: The facility's Abuse, Neglect, Exploitation, and Misappropriation policy, last revised on 09/01/2024, revealed in part the facility would ensure all residents were free from misappropriation of property. Resident #117 was admitted to the facility on [DATE] with diagnoses of left clavicle fracture, multiple fractures of the pelvis, left hip fracture, left leg fracture, and chronic pain. A review of the physician's order dated 11/25/2024 revealed Resident #117 had an order for 10 milligrams (mg) of Methadone (an opioid that acts on the central nervous system to relieve pain); give 35 mg/3.5 tablets twice a day for pain (9:00 AM and 9:00 PM). A review of Resident #117's quarterly Minimum Data Set (MDS)…

  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 · Dcited before2025-06-24 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #126 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 04/10/25. A progress note dated 04/10/25 indicated Resident #126 was discharged home with a friend and his medications were given to him upon discharge. Resident #126's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed he was discharged to short term general hospital. During an interview on 06/20/25 at 3:19 PM with the MDS Coordinator and the Regional MDS Coordinator they stated Resident #126 was discharged home with a friend and his assessment was miscoded as being discharged to short term general hospital. The MDS Coordinator stated she would amend the discharge assessment and correct the assessment to reflect the resident was discharged to the community. An interview on 06/20/25 at 4:00 PM with the Administrator revealed she felt like the error was a keying error and the MDS Coordinator was modifying the MDS for resubmission. Based on record reviews and staff interviews, the facility failed to…

  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 · D2025-06-24 · 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, observation, and resident and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan in the areas of pain management and opioid (pain medication) use for 1 of 4 residents whose comprehensive care plans were reviewed (Resident #117). Findings included: Resident #117 was admitted to the facility on [DATE] with diagnoses of left clavicle fracture, multiple fractures of the pelvis, left hip fracture, left leg fracture, and chronic pain. A review of Resident #117's medication orders revealed: 1. Methadone 35 milligrams (mg) twice a day for pain; start date: 11/25/2024. 2. Cyclobenzaprine 10 mg three times a day for muscle spasms; start date: 11/25/2024. 3. Gabapentin 600 mg three times a day for neuropathy (nerve pain); start date: 11/25/2024. 4. Tylenol 650 mg every 8 hours as needed for pain; start date: 02/14/2025. Review of Resident #117's comprehensive care plan dated 02/01/2024 and revised on 03/01/2025 did not reveal a care plan had…

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

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

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

Fines & penalties

$273,467 in federal fines across 5 penalties.

• $8,672 — penalty dated 2025-06-24
• $8,673 — penalty dated 2025-06-24
• $175,643 — penalty dated 2025-06-24
• $16,801 — penalty dated 2024-07-02
• $63,678 — penalty dated 2024-04-25

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 BRIGHTON HEALTHCARE — 8 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 21 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 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 $690K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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