The Greens at Maple Leaf

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.

50.5% 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 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.0% 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 60 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 94 beds and averages 84.8 residents a day — about 90% occupied, or roughly 9 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 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.37 hrs/resident/day on weekends vs 4.20 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% 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.

19 citations, most serious first. The 13 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · Gcited before2025-12-22 · 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 reviews and interviews with staff, Nurse Practitioner (NP) and Medical Director, the facility failed to provide care in a safe manner when Resident #1 rolled out of her bed and hit the floor during incontinence care. Resident #1 was sent to the Emergency Department (ED) and diagnosed with an occult (subtle hip bone break often in older adults that often does not show up on imagining but causes pain, tenderness, and difficulty walking) nondisplaced (the bone breaks but maintains it proper alignment) left hip fracture, distal left femur fracture (fracture of the lower portion of the thighbone near the knee joint) and a left side scalp hematoma (bruise that occurs when blood pools outside blood vessels). The deficient practice occurred for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and dementia with agitation.Review 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 · Past Non-Compliance
• Actual harm · Gcited before2024-05-15 · 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, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction received a small skin tear with a red/purple bruise that was approximately the size of a half dollar on his right forearm for 1 of 3 residents reviewed for accidents. Resident #17 stated that NA #1 ignored his request to let go of his arm and then laughed at him. The skin tear required a treatment with calcium alginate (dressing used for management of draining wounds) three times weekly and as needed. The findings included: Resident #17 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, hypertension, diabetes, heart failure, and chronic obstructive pulmonary disease. Review of a physician…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-03-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to provide supervision to prevent a cognitively impaired resident (Resident #129) from attacking another cognitively impaired resident (Resident #130) in their shared bathroom which result in Resident #130 having a bloody right lower lip, left nare and left cheek. Her right wrist was swollen, bruised, and painful and required evaluation at the emergency room (ER). The Findings included: Resident #129 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #129's diagnoses included schizoaffective disorder, dementia, and bipolar disorder. A care plan created on [DATE] read, Resident #129 is/has the potential to be verbally aggressive, yelling, threatening staff, lying to staff about things related to ineffective coping skill, mental/emotional illness, and poor impulse control. The interventions included: administer medications as ordered, analyze key times, places, triggers and what de-escalates the behavior, assess,…

  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 · Ecited before2025-07-03 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on manufacturer guidelines, observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors from 2 of 6 medication carts (100 and 200 Hall) and failed to label DuoNeb solution (inhalation breathing solution) with a open date and store DuoNeb solution according to the manufacturer's guidelines for 1 of 6 medication carts (200 Hall) reviewed for medication storage. The findings included: 1a. An observation was made of the 100 hall medication cart on 07/02/25 at 10:45 AM accompanied by Medication Aide (MA) #1. The cart yielded 20 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview conducted with MA #1 on 07/02/25 at 10:45 AM. The MA explained that it was every MA's responsibility to keep the carts clean, but he did not know if it was a rule or not. b. An observation was made of the 200 hall medication cart on 07/02/25 at 10:55 AM accompanied by MA #2. The cart yielded 41 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers.…

  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 · D2025-07-03 · 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 record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #1) and 1 of 1 resident (Resident #22) reviewed for anticoagulant medication. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of Resident #1's physician orders revealed orders dated 05/15/23 for gabapentin (an anticonvulsant) 100 milligrams (mg) by mouth twice a day for diabetic neuropathy (nerve damage) and metformin (a hypoglycemic) 500 mg by mouth once a day for diabetes mellitus dated 05/09/23. Review of Resident #1's Medication Administration Record for 04/01/25 through 04/30/25 revealed the Resident received gabapentin 100 mg by mouth twice a day and metformin 500 mg by mouth once a day as ordered. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the MDS was not coded as receiving an anticonvulsant or 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
• Potential for harm · D2025-07-03 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with mental health disorders for 1 of 2 residents reviewed for PASRR (Resident #33). Findings included: A PASRR Determination Notification letter dated 09/23/20 revealed Resident #33 had a Level I PASRR with no expiration date. Resident #33 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder and dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident 33's electronic medical record revealed the following active physician orders: *04/28/25: Quetiapine fumarate (antipsychotic) 100 milligrams (mg) in the evening for bipolar disorder. *04/28/25: Sertraline (antidepressant) 100 mg at bedtime for bipolar/depression. *04/28/25: Trazodone (antidepressant) 100 mg at bedtime 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 · D2024-05-15 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, and staff interview this facility failed to identify abuse and then failed to implement and follow their abuse policy and procedures in in the areas of reporting and protection for 1 of 3 residents reviewed for accidents (Resident #17). The findings included: Review of the facility's Abuse and Neglect Protocol revised on 06/13/21 read in part, any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. A complete copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator immediately after the occurrence. If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours…

  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 before2024-05-15 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record reviews and staff interviews, the facility failed to remove expired medications available for use from a medication refrigerator in 1 of 1 medication room reviewed for medication storage. The findings included: A review of the manufacturer's recommendation for Purified Protein Derivative (PPD) storage, PPD vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 05/14/24 at 11:25 AM during an observation of the medication room refrigerator with Nurse #2 and Unit Manager (UM) #1 the observation yielded 2 open vials of PPD solutions. One vial was in a box with an open date of 04/01/24 printed on the box and one vial was in a box in a plastic pouch with an open date of 04/03/24 printed on the box. During interviews with both the Unit Manager and Nurse #2 on 05/14/24 at 11:25 AM neither nurse knew how long the PPD solution could be used after opening. The UM explained that she inspected the refrigerator the previous evening and there was one PPD vial in the refrigerator, but the solution 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
• Potential for harm · Dcited before2024-05-15 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Recerfification and Compliant Survey on 03/01/23. This failure was for 2 deficiencies that were originally cited in the areas of (F600) Free from Abuse and Neglect and (F880) Infection Control that were subsequently recited on the current Recertification and Complaint Survey on 05/15/24. The repeat deficiencies during the 2 surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The findings include: This tag is cross referenced to: F-600: Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-15 · 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 reviews and interviews the facility failed to follow their infection control policy when the Wound Nurse failed to change her gloves after removing a soiled dressing that contained a moderate amount of brown drainage and before cleansing a sacral wound on 1 of 4 residents (Resident #18) reviewed for pressure ulcers. The facility also failed to follow their hand hygiene policy when the Unit Manager failed to change her gloves and preform hand washing hygiene after she provided incontinent care of stool and before she applied a moisture barrier cream and touched other environmental surfaces for 1 of 3 residents (Resident #54) reviewed for incontinence care. The findings include: 1. A review of the facility's policy on Dry Clean Dressing dated 09/2013 revealed steps in the procedure, 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull gloves over dressing and discard them into plastic or biohazard bag. 8. Wash and dry hands thoroughly. On 05/14/24 at 2:02 PM an observation of wound care was made by the Wound Nurse. The Nurse washed her…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-15 · 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 reviews and staff interviews, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without knowledge of the staff. On 04/23/24 between the hours of 6:00 PM and 7:00 PM Resident #325 was observed by Nurse Aide (NA) #2 in the back parking lot walking away from the building approximately 30 yards away from the exit door. The findings include: Resident #325 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, hypertension, atrial fibrillation and cerebral vascular accident (CVA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #325's cognition was severely impaired, and she ambulated independently with a walker. No wandering behaviors were noted during the observation period. On 05/12/24 at 6:30 AM during an interview with Nurse Aide (NA) #2 the NA explained that one evening of 04/23/24 he was working second shift instead of his normal third shift…

  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
• Potential for harm · E2023-03-01 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Resident, and Staff interview the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested (Resident #22) and for not providing showers as the resident preferred (Resident #15) for 2 of 3 residents reviewed for dignity. The Finding included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses of heart disease, diabetes, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was cognitively intact for daily decision making, required extensive assistance with toileting, and was frequently incontinent of bladder and occasionally incontinent of bowel. No refusal of care was noted during the assessment reference period. Resident #22 was interviewed in her room on 02/28/23 at 1:33 PM. Resident #22 stated that on 02/04/23 in the early evening hours she turned her call light on and when Nurse Aide (NA) #1 responded she made her aware she needed incontinent care and needed to be…

  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 · E2023-03-01 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews the facility failed to ensure code status information was available for use for Resident #68 and Resident #14 and failed to ensure the code status information was accurate throughout the medical record for Resident #35. This affected 3 of 3 residents (Resident #68, #35 and #14) reviewed for advanced directives. The findings include 1. Resident #68 was admitted to the facility on [DATE]. A review of Resident #68's electronic medical record revealed a physician order for a Full Code dated 11/06/22. A review of the Code Status notebook kept at the nursing station revealed there was no advanced directive in the notebook for Resident #68. An interview was conducted with the Admissions Director (AD) on 02/28/23 at 11:08 AM. The AD explained that she addressed the residents' advanced directive, do not resuscitate or full code while in the admission meeting with the resident and or responsible party and put the paperwork in the big red code status notebook at the nursing…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$18,655 in federal fines across 2 penalties.

• $9,620 — penalty dated 2025-12-22
• $9,035 — penalty dated 2024-05-15

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 CCH HEALTHCARE — 33 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 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

This home reported $1.4M 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