Rich Square Health & Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

50.7% 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 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.5% 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 37 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% 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 69 beds and averages 66.2 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 2.69 hrs/resident/day on weekends vs 3.36 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.48 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

Deficiencies are 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.

27 citations, most serious first. The 17 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2023-12-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician, the facility failed to identify the seriousness of seizure activity on 12/4/23 and the need for medical intervention for a resident with a history of seizures who had not been provided with his anti-seizure medication (Vimpat) since 11/25/23. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency Ativan medication supply to treat the resident in the facility. Emergency Medical Services (EMS) was contacted, and the resident was transported to the emergency room (ER) and Resident #3 experienced a fifth seizure upon arrival in the emergency room (ER). Intravenous (IV) Vimpat was administered in the ER and the resident had no further…

  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 · K2023-12-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to provide safe transportation in the facility's transportation van and to ensure wheelchairs were utilized during transportation in accordance with manufacturer's instructions for 2 of 4 residents reviewed for accidents (Resident #1 and Resident #2). On 11/1/23 Transportation Assistant #1 utilized a geriatric chair (a padded chair with a wheeled base) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. These incidents had the high likelihood of serious harm, injury or death. Immediate jeopardy began on 11/1/23 when Transportation…

  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 · K2023-12-28 · 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

  Based on observation, record reviews and interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to ensure Transportation Assistant #1, who was also a facility Nurse Aide, was trained by staff who was aware of the facility's transportation van's manufacturer's instructions for safe securement when Nurse Aide #1 provided her with training. Nurse Aide #1 was not aware that transporting a resident in a geriatric chair (a padded chair with a wheeled based) was not in accordance with the transportation van's manufacturer's instructions. In addition, the facility failed to verify Transportation Assistant #1's competency to ensure resident safety during transportation for 1 of 1 staff who transported residents in the facility's transportation van. On 11/1/23 Transportation Assistant #1 utilized a geriatric wheelchair (geri chair) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-12-28 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, pharmacist, and physician, the facility failed to obtain an anti-seizure medication for a resident with a history of seizures resulting in 22 missed doses of the medication and to have staff capable of accessing the emergency medication supply to treat a medical emergency. Resident #3 was ordered Vimpat two times a day for seizures and from 11/25/23 through 12/5/23 the resident did not receive the medication as it was not obtained from the pharmacy. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency medication supply. EMS was contacted and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat and 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-12-28 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician interviews, the facility failed to administer an anticonvulsant medication to a resident for a period of 10 and half consecutive days and doses (11/25/23 through 12/5/23). Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. EMS was contacted on 12/5/23 and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat in the ER and was discharged back to the facility the same day. Upon return to the facility the resident was not administered one dose of the anticonvulsant on 12/6/23 for a total of 22 missed doses. This occurred for 1 of 3 residents (Resident #3) whose medications were reviewed. Immediate Jeopardy began on 11/25/23, when the facility failed to administer Resident #3's antiseizure medication. The immediate jeopardy was removed on 12/22/23 when the facility…

  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
• Immediate jeopardy · K2023-12-28 · 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 observation, record review, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, pharmacist and physician, the facility failed to provide effective leadership and oversight to ensure systems and processes were in place as evidenced by numerous deficient practices in multiple regulatory groupings resulting in immediate jeopardy and substandard quality of care. These high severity deficiencies were in the areas of physician notification, management of change in condition, safe transportation of residents, competent nursing staff, routine and emergency medication availability, accessibility and administration. Residents #1 and #2 were not transported in the van safely using transport chairs and fastening seat belts. Resident #3 did not receive his seizure medication as ordered and experienced seizure activity. These incidents had the high likelihood of serious harm, injury, or death. These deficient practices affected three of 46 residents residing in the facility and had a high likelihood of affecting other facility residents.…

  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
• Immediate jeopardy · J2023-12-28 · 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 and interviews with staff and physician, the facility failed to notify the physician of a medical emergency when Resident # 3 had seizure activity. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Emergency Medical Services (EMS) was contacted and the resident was transported to the emergency room (ER) where Vimpat (anti-seizure medication) was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. This occurred for 1 of 3 residents (Resident #3) reviewed for notification of change. Immediate Jeopardy began on, 12/04/23, when the facility failed to notify the physician when Resident #3 had seizure activity. The immediate jeopardy was removed on 12/23/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a D (no actual harm with potential for more than…

  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 · F2025-07-02 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in the development the Facility Assessment, failed to: have an accurate facility assessment that recorded the current administrative staff and Medical Director, ensure the staffing plan considered specific staffing needs for each unit and shift as required, provide information regarding the skills and competencies that were required for licensed nursing staff and Certified Nurse Aides (CNAs), and have an accurate staff type and position list. This deficient practice had the potential to affect 54 of 54 residents. The findings included: The Facility Assessment was reviewed and was noted to have been updated and reviewed with the facility's Quality Assurance Performance and Improvement (QAPI) committee on 1/28/25. The persons involved in completing the assessment were listed as the Administrator, the Director of Nursing (DON), the Medical Director, Social Service Director, Dietary Manager, Therapy Director, and a Governing Board Member. There was no…

  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
• Potential for harm · D2025-07-02 · tag F0578 — failed to honor advance directives / code status — isolated
  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 reviews, and staff and Nurse Practitioner interviews, the facility failed to provide written information to the resident and/or resident representative pertaining to their right to accept or refuse medical/surgical treatment and the opportunity to formulate an Advance Directive for 1 of 7 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and a history of a stroke. A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of Resident #1's electronic medical record revealed a full code Physician order dated 4/22/2025. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered to the resident or resident representative. An interview was completed on 7/1/2025 at 10:35 am with Resident #1. The Resident was unable to recall if she received…

  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 · D2025-07-02 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary notification (Resident #19 and Resident #108). The findings included: 1. Resident #108 was admitted to the facility on [DATE]. Medicare Part A services began on 11/7/24. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #108 on 1/28/25, which indicated Resident #108's Medicare Part A coverage for skilled services would end on 1/25/25. Resident #108 remained in the facility. Review of Resident #108's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #108. An interview was conducted with the Business Office Manager 7/01/25 at 1:32 PM. He revealed that when Resident #108 was admitted from the hospital on [DATE], she was billed…

  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 · D2025-07-02 · 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 Based on observations, record review, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of anticonvulsant medication (Resident #45), resident prescribed diet (Resident #6), and use of a hearing aid (Resident #25) for 3 of 21 residents whose MDS assessments were reviewed. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and cerebrovascular disease. Resident #45 had a physician order dated 2/01/24 for gabapentin (an anticonvulsant medication also used to treat pain) capsule 300 milligrams (mg) give one capsule by mouth at bedtime for pain. Resident #45 had an active physician order dated 2/29/24 for divalproex sodium tablet delayed release (an anticonvulsant medication) 250 mg; give 2 tablets once time a day for mood disorder related to dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #45 had severe cognitive…

  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 · D2025-07-02 · 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 observations, record review, and resident and staff interviews, the facility failed to develop a person-centered care plan in the areas of use of side rails for positioning (Resident #45), and hearing loss with use of a hearing aid (Resident #25) for 2 of 21 residents whose care plans were reviewed. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. The Side Rail Use assessment dated [DATE] revealed Resident #45 requested side rails related to weakness to assist with turning, repositioning, and transfers. Resident #45 was noted to have 1/4 side rails to the upper bed bilaterally (both sides) while in bed. Review of Resident #45's care plan reviewed and updated on 5/08/25 revealed no care plan for the use of side rails for positioning. Observations were conducted on 6/30/25 at 10:50 am, 7/01/25 at 12:35 pm, and 7/02/25 at 9:03 am and Resident #45 was observed to be in bed with side rails to the upper portion of the bed…

  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 · D2025-07-02 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 revise the care plan in the areas of pain management, hypertension management, and anticoagulant (blood thinner) medication use (Resident # 18) and the use of a wander/elopement alarm (Resident #45) for 2 of 21 residents whose care plans were reviewed. The findings include: 1. Resident #18 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) with dependence on hemodialysis (HD), hypertension (HTN), and diabetes. Resident #18's physician orders revealed the following: - 9/10/24 Roxicodone oral tablet 5 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain - 1/10/25 Amlodipine Besylate tablet 10 mg, give 1 tablet by mouth at bedtime for HTN - 6/6/25 Eliquis oral tablet 2.5 mg, give 1 tablet by mouth two times a day for Pulmonary Embolism (blockage of a lung artery) Review of Resident #18's care plan reviewed and updated on 5/8/25 revealed no care plan for the use 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · tag F0658 — failed to meet professional standards of care — isolated
  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 observations, record review, and staff, Pharmacy Consultant and Nurse Practitioner (NP) interviews, the facility failed to clarify the physician orders for lidocaine 4% external pain patches that resulted in the pain patches remaining on the resident's skin over the manufacturer's recommended duration of 12 hours. This deficient practice was for 1 of 3 residents observed for medication administration (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses which included pain unspecified and diabetes with neuropathy (nerve pain). Review of physician orders revealed an active physician order dated 2/18/24 for lidocaine 4% external pain patch. Apply to the left side topically one time a day for pain at 9:00 am; apply in the am and remove at bedtime and per schedule. The order noted the removal time as 8:59 am. In addition, there was an active physician order dated 4/30/25 for lidocaine external patch 4%. Apply to the right side topically one time a day for…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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, Nurse Practitioner and Registered Dietitian (RD) interviews, the facility failed to provide nutritional supplements to prevent further weight loss as recommended by the RD and prescribed by physician (Resident #45) for 1 of 3 residents reviewed for nutrition. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and diabetes. An active physician order dated 6/22/24 to add ice cream to lunch tray every day to aid with prevention of further significant weight loss per RD recommendation. An active physician order dated 11/03/24 to add nutritional shake supplement to lunch tray daily to aid in the prevention of further weight loss per RD recommendation. An active physician order dated 4/28/25 for a consistent carbohydrate (CCD), no added salt (NAS) diet. Regular texture, thin (regular) liquid consistency. Review of Resident #45's electronic health record revealed the following weights were…

  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 · D2025-07-02 · 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 observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse #2 failed to perform hand hygiene between glove changes during the observation of medication administration for 1 of 4 staff observed for infection control practices (Nurse #2). The findings included: The facility's Infection Prevention and Control Program (IPCP) policy implemented 10/04/23 and reviewed annually indicated in part that the facility established and maintained an (IPCP) to prevent the development and transmission of communicable diseases and infections. The policy further noted that hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's Hand Hygiene Policy, no date, indicated that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy further noted that the use of gloves did not replace hand hygiene and that staff were to perform hand hygiene prior…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-06 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  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 staff interviews and record review the facility failed to perform a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice care (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included hypertension and dementia. Review of Resident #38's medical records revealed she was receiving hospice services prior to admission to the facility and continued to receive services upon admission. Review of a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC, form 10123) dated 12/21/23 revealed Resident #38's hospice services were ending on 12/23/23. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she received hospice services during the lookback period. Resident #38's quarterly MDS assessment dated [DATE] revealed she did not receive hospice services during the lookback period. Review of Resident 38's MDS assessments revealed 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.

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

Fines & penalties

$190,684 in federal fines across 1 penalty.

• $190,684 — penalty dated 2023-11-21

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 72% 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 $862K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in NC