Greendale Forest Nursing and 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.

53.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.4% 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 48 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 115 beds and averages 105.3 residents a day — about 92% occupied, or roughly 10 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below 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 3.04 hrs/resident/day on weekends vs 3.45 on weekdays — 12% thinner on weekends. RN hours go from 0.36 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · G2025-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to have effective systems in place for identifying the development of skin breakdown which delayed treatment and interventions. Resident #39's skin was intact on re-admission on [DATE]. On 1/4/25 excoriation was noted on her buttocks. There were no further documented assessments until a wound assessment dated [DATE] recorded Resident #39 developed an unstageable (full thickness skin and tissue loss where the extent of tissue damage cannot be determined due to presence of slough, a yellow/white layer of dead skin tissue, or eschar, dry dead tissue, obscuring the wound bed) 5 centimeter (cm) by 5cm right buttocks pressure wound. Resident #39's right buttocks pressure wound deteriorated and required hospitalization for an infected right buttocks/sacral pressure wound on 2/17/2025. Resident #39 received intravenous antibiotic therapy and a debridement (a medical procedure to remove dead, damaged or infected tissue from a wound to promote healing and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-04-26 · 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 observations, record review, staff and Physician interviews, the facility failed to protect the resident's right to be free from injury of unknown source that resulted in bruising under the eyes and a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1) Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She exhibited no physical or verbal behaviors directed toward others (e.g. hitting, kicking, grabbing, or yelling). She exhibited no other behaviors such as hitting or scratching herself. She required total dependent care by staff for activities of daily living (ADLs). She had no falls and received anticoagulant (prevents clot formation) medications. She had no rejection of care.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · F2026-06-18 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 3 of 119 days (1/4/26, 2/8/26 and 3/15/26) reviewed for sufficient staffing.The findings included:A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 was conducted.A review of the daily census posting sheets for 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 revealed no RN coverage for eight consecutive hours on 1/4/26, 2/8/26, and 3/15/26.On 6/18/26 at 9:53 AM the scheduler was interviewed. She could not recall the details of the dates of 1/4/26, 2/8/26, and 3/15/26 without any RN coverage. The scheduler indicated that she would have notified the Director of Nursing (DON) immediately if she was aware of no RN coverage for those days. On 6/17/26 at 2:51 PM the DON was interviewed. She could not provide a reason why there was no RN coverage on 1/4/26, 2/8/26, and 3/15/26. However, she stated 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-06-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to provide an environment free of wall damage (room [ROOM NUMBER], 707, and #710), failed to ensure pipes around hand washing sinks were sealed (room [ROOM NUMBER] and #307) and failed to provide privacy curtains free of stains (Rooms #408) for 6 of 26 rooms on 4 of 6 hallways reviewed for the environment. The findings included: 1A. An observation of room [ROOM NUMBER], which was occupied, took place on 6/15/26 at 11:58 AM and revealed deep scratch marks on the wall beside the residents bed, including a brownish-red dried substance in one of the marks and a large approximately 2 inch wide by 18 inch long by 1/2 deep gash in the sheetrock on the wall at the head of the bed. 1B. An observation on 6/16/26 at 2:45 PM of room [ROOM NUMBER], which was occupied, revealed the wall behind the head of the bed had 3 approximately 2 feet long gouges in the sheet rock and the paint was gone in an area approximately one foot in diameter. 1C. An observation of room…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-18 · 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, Physician #1, Physician #2, Hospice staff interview and staff interviews the facility failed to implement effective interventions to promote bowel movements. Hospice orders on 2/7/26 included the addition of a stool softener as needed; however, the bowel regimen did not begin until 2/18/26 when the resident returned from the emergency department (ED) on 2/18/26. A pelvic x-ray was performed in the ED on 2/18/26 that displayed fecal impaction. This was for 1 of 1 resident (Resident #16) reviewed for professional standards.The findings included:Resident #16 was readmitted to the facility on [DATE] with diagnoses included failure to thrive, dementia, chronic respiratory failure, diabetes, and congestive heart failure. Resident #16 was admitted to hospice on 2/7/26. She went to the ED on 2/18/26 after a fall and returned to the facility the same day.Resident #16's care plan revised on 2/6/26 included hospice care due to a terminal decline.Interventions included: Consult with hospice and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-18 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, staff and physician interviews the facility failed to arrange podiatry services for 1 of 1 resident reviewed for foot care (Resident #89).Findings included:Resident #89 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease.Resident #89's provider note dated 4/22/26 revealed the physician documented Resident #89 reported overgrown and protruding toenails causing discomfort and difficulty with trimming and was requesting podiatry evaluation. The physician documented he would order a podiatry consult for nail care and evaluation.Resident #89's orders revealed on 4/22/26 he was ordered to have a podiatrist consult. Nurse #2 was documented as the nurse who confirmed the order.Resident #89's quarterly Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He had no moods or behaviors and was assessed to be dependent on staff for personal hygiene.Review of the resident list seen by…

  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 · D2026-06-18 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Physician #1, Physician #2, Hospice Clinical Manger, the Hospice Nurse and staff interviews, the facility failed to have effective systems in place to ensure hospice orders were processed when a resident was admitted to hospice services for 1 of 1 resident reviewed for hospice services (Resident #16). The findings included:Resident #16 was readmitted to the facility on [DATE] with diagnoses including failure to thrive, congestive heart failure, dementia, chronic respiratory failure, and diabetes. She was admitted to hospice services on 2/7/26. On 2/18/26, Resident #16 was sent to the emergency department after a fall and returned to the facility the same day.The Hospice Physician Order form dated 2/7/26 by the Hospice Nurse and the Hospice Physician revealed that Resident #16 was admitted to hospice for hypertensive heart disease with heart failure and to begin receiving the following medications as of 2/7/26:Acetaminophen, 650 milligrams (mg) rectal suppository every 6 hours as needed…

  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 · Dcited before2025-05-01 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure an accurate Medication Administration Record (MAR) when staff documented a scheduled blood draw (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) was completed twice a week instead of once a week for 1 of 3 residents reviewed for blood draws (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. His diagnosis included myelodysplastic syndromes (a group of blood cancers where the bone marrow does not produce enough healthy blood cells), anemia and diabetes. The April 2025 MAR revealed a scheduled CBC blood draw order for every Thursday one time a day for monitoring with a start date of 12/19/2024. It also showed a CBC blood draw order every Wednesday for monitoring with a start date of 3/26/2025. The CBC blood draw was marked as completed on Wednesday, April 2, 2025, Thursday, April 3, 2025. Wednesday, April 9, 2025, Thursday, April 10, 2025, Wednesday, April…

  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 · E2025-03-27 · tag F0657 — failed to keep the care plan current — pattern
  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 record reviews and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and/or annual Minimum Data Set (MDS) assessments for 6 of 31 residents reviewed for care planning (Resident #27, Resident #100, Resident #91, Resident #45, Resident #18, and Resident #21). The findings included: 1. Resident #27 was admitted to the facility on [DATE]. The last care plan meeting documented in Resident #27's medical record was dated 7/9/2024. MDS assessments were completed for Resident #27 on the following dates: 9/16/2024 (quarterly), 11/11/2024 (quarterly), 1/10/2025 (quarterly) and 3/21/2025 (significant change). The significant change MDS dated [DATE] indicated Resident #27 was moderately cognitively impaired. On 3/27/2025 at 1:37 pm in an interview with the MDS Coordinator, she explained the Social Worker was sent the scheduled timeframe for completion of MDS assessments monthly to use for scheduling care plan meetings. On 3/26/2025 at 9:41 am in an…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 3 of 3 residents reviewed with urinary catheters (Resident # 8, Resident # 5 and Resident # 14). The findings included: 1. Resident # 8 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, urinary retention, and acute cystitis without hematuria (a lower urinary tract infection without blood in the urine). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 8 had severely impaired cognition. The assessment indicated Resident # 8 was dependent upon staff for all of his activities of daily living (ADL). Resident # 8 was coded for an indwelling urinary catheter. Resident #8's care plan dated 3/12/25 revealed Resident #8 was at the risk for infection due to the alteration pattern of urinary elimination with the use of an indwelling urinary catheter. Interventions included maintaining a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician for 1 of 1 resident reviewed for oxygen use (Resident #27). Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD and congestive heart failure (CHF). Physician orders dated 3/20/2025 included an order for continuous oxygen at four liters per minute by nasal cannula every shift for respiratory disease. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was moderately cognitively impaired and was receiving oxygen therapy. Resident #27's care plan dated 3/25/2025 included a focus for the potential or actual ineffective breathing pattern related to COPD and CHF. Interventions included oxygen at four liters per minute by nasal cannula. A review of Resident #27's March 2025 Medication Administration Record (MAR) recorded Resident #27 received four…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observation and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen for 1 of 31 residents whose medical records were reviewed (Resident #27). Findings included: Physician orders dated 3/20/2025 included an order for continuous oxygen at four liters per minute by nasal cannula every shift for respiratory disease. A review of Resident #27's March 2025 Medication Administration Record (MAR) recorded Resident #27 received four liters of oxygen via nasal cannula each shift on 3/20/2025 through 3/26/2025 and recorded oxygen saturations (measurement of how much oxygen present in the blood) ranged from 95% to 99%. On 3/25/2025 at 9:04 am, Resident #27 was observed lying in bed with the head of bed elevated and receiving oxygen by nasal cannula at two liters per minute. Resident #27 was observed with no signs or symptoms of respiratory distress. On 3/26/2025 at 6:20 am, Resident #27 was observed lying in the bed with her eyes closed and receiving oxygen at two liters per minute by nasal cannula.…

  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

$18,132 in federal fines across 2 penalties.

• $9,620 — penalty dated 2025-03-27
• $8,512 — penalty dated 2024-04-26

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

Part of a chain

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

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

Who owns this facility

CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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