Valley 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.

52.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 112 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 29.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 88 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 183 beds and averages 115.6 residents a day — about 63% occupied, or roughly 67 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 4.04 hrs/resident/day on weekends vs 4.57 on weekdays — 12% thinner on weekends. RN hours go from 0.87 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above 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 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.

28 citations, most serious first. The 19 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · J2025-01-13 · 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 Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. The facility also failed to notify the NP that an ordered venous doppler study (an ultrasound used to diagnose blood clots) on 12/27/2024 could not be completed until the following week. On 12/28/2024, Resident #1 and the RP requested Resident #1 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
• Immediate jeopardy · Jcited before2025-01-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Resident, Responsible Party (RP), Nurse Practitioner, and Medical Director interviews, the facility failed to protect a resident's right to be free from neglect when they failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin with a history of gastrointestinal bleed, recent fall with fracture, and new immobility on 12/11/24 when Resident #1's family expressed concerns to the Director of Nursing (DON) that Resident #1 was not receiving anticoagulant. The Nurse Practitioner instructed the Assistant Director of Nursing to reach out the Medical Director for guidance an anticoagulation and failed to communicate or collaborate with the Medical Director herself. The facility further failed to recognize the seriousness of pain and leg swelling that started on 12/11/2024 and neglected to act on the severity of a potential blood clot when a resident (Resident #1) continued to experience increased pain and swelling to her left lower extremity. On…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered. On 12/28/2024,…

  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 · J2025-01-13 · tag F0714 — isolated
  Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist.
  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, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. The NP instructed the ADON to consult the Medical Director for further guidance regarding anticoagulation for Resident #1 and failed to reach out to the MD herself. On 12/27/2024 Resident #1 was evaluated by the NP at which time Resident #1 had…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-10-08 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, crash cart checklist, and staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. Resident #103 was pronounced deceased and resuscitative efforts were stopped. This affected 1 of 1 resident reviewed for CPR. Immediate jeopardy began on 7/18/2024 when the staff failed to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-10-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, staff, Nurse Practitioner (NP), Medical Director (MD), and Pharmacist interviews the facility failed to assess a resident and initiate the sepsis protocol when Resident #96, who was continuously ventilator dependent, was found by Nurse #1 between 8:00 and 9:00 pm on 9/16/2024 to have a fever of 100.4 degrees Fahrenheit (F) (normal is 98.6 degrees), a heart rate of 116 beats per minute (normal is 60-100 beats per minute), and a respiratory rate of 24 breaths per minute (normal is 12-20 breaths per minute). Nurse #1 did not initiate the sepsis protocol when Resident #96 met two criteria on the Ventilator Unit Sepsis Protocol (a heart rate greater than 90 beats per minute and a respiration rate of greater than or equal to 20 breaths per minute), failed to re-check Resident #96's temperature for the remainder of the shift, and did not administer fever reducing medication. Then on 09/17/24 at approximately 6:30 AM to 7:00 AM Nurse Aide (NA) #1 obtained another set…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-10-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews the facility failed to ensure that a nurse was competent in responding to medical emergencies and activating emergency procedures with emergency medical services (EMS). Resident #103 was a Full Code and experienced sudden cardiac arrest on [DATE]. Nurse #3 was unable to locate the crash cart, the automated external defibrillator and did not immediately call 911. Resident #103 was pronounced deceased by EMS on [DATE] at 7:50 pm. The deficient practice was identified for 1 of 5 nurses (Nurse #3) reviewed for competency and had the high likelihood for causing serious harm to other residents. Immediate jeopardy began on [DATE] when Nurse #3 did not demonstrate competency in responding to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-26 · 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 record review, staff, family, police department and Medical Director interviews, the facility failed to protect a resident's right to be free from physical abuse when Resident #1 became combative during incontinence care and Nurse Aide (NA) #1 forcibly continued to provide care and grabbed [the resident] by the lower thigh and back and then gave him a hard push in an attempt to finish care. This resulted in the resident suffering a broken femur (thighbone) in the resident requiring traction (the application of a slow, steady pulling force to a part of the body) and 200 micrograms (mcg) of Fentanyl (an opioid medication given for pain) while in transit to the emergency room. The resident was administered Dilaudid (another opioid medication) while in the emergency room for pain, and required surgical intervention. This was for 1 of 3 residents reviewed for prevent employee-to-resident abuse. (Resident #1). The findings included: Resident #1 was an [AGE] year old resident who admitted to 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-01-13 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Nurse Practitioner (NP), Resident, Resident Responsible Party (RP), and staff interviews, the facility failed to manage a resident's pain (Resident #1) when she experienced increased pain combined with swelling and redness on 12/18/2024 in her left lower extremity. Resident #1 reported she had experienced pain to her left leg on 12/18/2024 and it got worse until she called her family and requested to go the hospital on [DATE]. Resident #1's RP called the facility on 12/28/2024 and requested that Resident #1 be sent to the hospital due to increased pain and swelling in her left leg. Emergency Medical Services (EMS) were called to the facility and noted Resident #1 to have an elevated blood pressure of 182/74 (normal is 120/80) and pain of 8 out of 10 on a numerical pain scale (indicative of severe pain). EMS administered morphine (narcotic pain medication) 4 milligrams (mgs) to Resident #1 before arriving at the hospital. Resident #1 experienced pain at 8-9 out of 10 on the numerical pain…

  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 before2026-01-08 · 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 observation, record review, and resident and staff interviews, the facility failed to follow professional standards of practice for the safe administration of medications for 1 of 1 resident reviewed for self-administration of medications (Resident #65). Resident #65, who had been assessed as unable to self-administer medications, had medications left at his bedside without nursing supervision.The findings included:Resident #65 was admitted to the facility on [DATE] with diagnoses that included respiratory failure and generalized muscle weakness. Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and had no behaviors or rejection of care. A Self-Medication assessment dated [DATE] revealed Resident #65 was assessed as unable to self-administer medications. An observation on 1/05/26 at 8:42 AM revealed Resident #65 lying in his bed with his head raised. A medication cup, on his bedside table within reach, contained 3 round light green pills, 3 round…

  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 · D2026-01-08 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 and Nurse Practitioner interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.69% for 1 of 4 residents observed during the medication administration (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses that included hypertension.Review of Resident #6's physician orders revealed an order dated 11/07/25 for folic acid (a vitamin critical for making new cells to prevent anemia) 800 micrograms (mcg) by mouth once a day. There was an order dated 11/26/25 for carvedilol (used to treat high blood pressure) 6.25 milligrams (mg) by mouth twice a day for hypertension. Hold for systolic blood pressure below 100 and heart rate below 60.On 01/06/26 at 8:30 AM an observation of a medication pass was conducted with Nurse #1. The Nurse prepared medications for Resident #6 which included carvedilol 6.25 mg…

  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 before2026-01-08 · 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 observation, record review and staff interviews, the facility failed to secure controlled substance medications under a double lock in 1 of 3 medication rooms reviewed for medication storage (Main medication room).The findings included:On 01/07/26 at 11:15 AM the unlocked refrigerator in the Main medication room was checked for medication storage along with the Director of Nursing (DON). The observation yielded four bottles of liquid lorazepam (benzodiazepine) with 30 ml each and two bottles of liquid morphine (opioid pain reliever) with 30 ml each, which are controlled substances. The liquid lorazepam and the liquid morphine were in a box affixed to the inside of the refrigerator, but the box was unlocked. The DON explained that Nurse #2 had the key to the box and the box should be always locked.At 11:30 AM on 01/07/26 an interview was conducted with Nurse #2 who confirmed that she had the key to the controlled substance locked box in the refrigerator that contained the lorazepam and morphine. The Nurse explained that she counted the medications with the third shift nurse…

  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 before2026-01-08 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Wound Nurse did not doff (remove) her gloves, perform hand hygiene and don (put on) clean gloves before moving to a second wound on Resident #10. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (Wound Nurse).The findings included: Review of the facility's policy and procedure entitled Hand Hygiene and dated October 2023 read in part:Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:Immediately before touching a resident.Before performing an aseptic taskAfter contact with blood, body fluids, or contaminated surfaces.After touching a residentAfter touching the resident's environmentBefore moving from working on a soiled body site to a clean body site on the same resident; andImmediately after glove removal. A wound treatment observation was made on 01/06/26 at 10:01 AM on Resident #10 with 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-26 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and resident representative interviews, the facility failed to complete a comprehensive discharge summary that included the name of the home health company and their contact information and failed to ensure education regarding catheter care was provided to the Resident Representative prior to discharge for 1 of 3 residents reviewed for discharge (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included stroke and neuromuscular dysfunction of bladder.Review of Resident #1's discharge Minimum Data Set assessment revealed him to be severely cognitively impaired and was coded as having an indwelling urinary catheter.Review of Resident #1's electronic medical record revealed a discharge summary document dated 08/07/25 and titled CCH Bridge to Home Discharge Summary - v2 that it was still in progress.Additional review of the document revealed there was no information in the Social Services section regarding home health nor 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-13 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, and staff interviews, the facility failed to report an allegation of neglect to the state survey agency for 1 of 3 residents reviewed for neglect (Resident #1). The findings included: The Administrator, Assistant Administrator, and Regional Nurse Consultant #1 were notified by a State Surveyor on 1/6/2025 at 6:08 pm of neglect that affected Resident #1. An interview was conducted on 1/13/2025 at 2:00 pm with the Assistant Director of Nursing (ADON). The ADON stated that when anyone reported an allegation of abuse or neglect, the abuse coordinator (the Administrator) was responsible for filing a report with the state survey agency. The ADON stated she was not sure if the Administrator had filed an Initial Allegation Report following the notification of allegation of neglect on 1/6/2025. Verification with the Complaint Intake Unit for the State Survey Agency was conducted on 1/13/2025 at 12:48 pm revealed the facility had not filed a report for an allegation of neglect related to Resident #1. An interview was conducted on 1/13/2025 at 2:07 pm with the Director…

  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 · E2024-10-08 · tag F0607 — failed to have anti-abuse policies — pattern
  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 record reviews and staff interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to screen a new employee and initiate protective measures to safeguard residents from potential abuse and neglect when they hired Dietary Aide (DA) #1 with one pending allegation of Abuse of a Resident on the North Carolina Nurse Aide Registry for 1 of 5 employees reviewed for screening of employees (DA#1). The facility also failed to implement their abuse policy and procedures in the areas of reporting by not submitting an initial allegation report to the Division of Health Service Regulation (DHSR) within 2 hours of the facility being made aware of an allegation of abuse (Resident #81) and not notifying local law enforcement of an allegation of neglect (Resident #225) for 2 of 3 sampled residents reviewed for abuse. The findings included: Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy reviewed on 3/28/2023 revealed the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-08 · 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 observations, record reviews, and resident and staff interviews, the facility failed to keep an accurate account of controlled substances (Resident #90 and Resident #110), failed to remove discontinued controlled substances from the medication cart (Resident #90), and administered medications to Resident #113 from a bottle that was labeled for another person. This affected 3 of 3 residents reviewed for pharmacy services. The findings included: 1. Resident #90 was admitted to the facility on [DATE] with diagnosis that included pain. A physician order dated 03/18/24 read, hydrocodone/acetaminophen (controlled pain medication) 5/325 milligrams (mg) by mouth every 6 hours as needed for pain for 5 days. The Medication Administration Record (MAR) dated March 2024 revealed the order was present from 03/18/24 through 03/23/24 and Resident #90 had received none of the hydrocodone/acetaminophen during those 5 days. The control drug record dated 03/18/24 contained a label with Resident #90's name and dosing…

  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 · Ecited before2024-10-08 · 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 observations, record reviews, and staff interviews, the facility failed to: 1) dispose of loose and unidentified tablets of various shapes and sizes from medication cart (300 Hall Bottom), 2) discard expired medications from medication cart (600 Hall), 3) store medications in accordance with the manufacturer's storage instructions (300 Hall Bottom and 100 Hall), and 4) properly store and date a open vial of Tuberculin Purified Protein Derivative (PPD) (600 hall) for 3 of 8 medication carts reviewed for medication storage. The findings included: 1. On 09/20/24 at 9:20 AM an observation was made of the 300 Hall Bottom medication cart accompanied by Medication Aide (MA) #1. The observation yielded 5 loose and unsecured tablets of varying shapes and sizes in the bottom of the middle drawer. When the MA was asked about the loose tablets, she replied she did not work the 300 hall Bottom medication cart often, but it was the third shift nurses' responsibility to clean the medication carts. The MA could not identify the loose tablets. 2a. The manufacturer's storage instructions…

  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 · D2024-10-08 · tag F0606 — failed to not employ staff found guilty of abuse — isolated
  Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interviews, the facility failed to ensure a staff member had no pending or substantiated allegations of Resident Abuse or Neglect on the North Carolina Nurse Aide Registry for 1 of 5 employees (Dietary Aide #1) reviewed for resident abuse. The findings included: Review of Dietary Aide #1's employee file revealed he was hired on 9/6/2024 and was terminated on 9/12/2024. A background check had been completed, and there were no criminal charges. A report from the North Carolina Nurse Aide Registry revealed Dietary Aide #1 had one pending allegation of Abuse of a Resident. An interview was conducted on 9/17/2024 at 12:49 pm with the Human Resources (HR) Director. The HR Director stated when a person was hired, she completed a background check to ensure there were no criminal charges. The HR Director stated she also searched each new hire employee's name on the North Carolina Nurse Aide Registry to ensure there were no allegations of abuse or neglect. The HR Director stated if either the criminal background check or North Carolina Nurse Aide Registry reports…

  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

“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

$88,557 in federal fines across 3 penalties.

• $5,122 — penalty dated 2025-08-26
• $48,380 — penalty dated 2025-01-13
• $35,055 — penalty dated 2024-10-08

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 5 rows in the source record cover these 4 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 $196K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in NC