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Ridgewood Living & Rehabilitation Center

1624 Highland Drive, Washington, NC 27889 · For profit - Corporation · 128 certified beds · (252) 946-9570 Medicare & Medicaid certified

Call the home — (252) 946-9570 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Sep 2025Resident-funds citation (F0565)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,868 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2025
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,868 in federal fines (most recent 2025-09-05)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1380 Cowell Farm Rd · (252) 946-2101 · Call to confirm hours
Pharmacy
Kerr Drug0.7 mi
1316 John Small Ave W · (252) 975-1193 · Call to confirm hours
Grocery
Food Lion0.7 mi
1318 John Small Ave · (252) 975-2408 · Call to confirm hours
Park
933-1099 Park Dr · (252) 975-9644 · Typically dawn to dusk
Place of worship

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

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.4%15.6%15.4%better
Long-stay residents who lose too much weight7.0%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.1%0.7%0.9%worse
Long-stay residents with a urinary tract infection1.5%2.3%2.0%better
Long-stay residents with depressive symptoms5.2%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%3.5%3.3%better
Long-stay residents whose ability to walk worsened7.1%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.2%21.3%18.9%better
Long-stay residents given the seasonal flu vaccine87.7%94.1%95.3%typical
Long-stay residents with pressure ulcers5.3%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control22.9%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table16.1%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.4%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine88.6%78.1%79.4%better
Short-stay residents rehospitalized after admission18.7%22.9%22.6%better
Short-stay residents with an outpatient ER visit12.5%12.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.751.781.67worse
Long-stay outpatient ER visits per 1,000 resident days1.801.801.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

54.5% 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 272 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.5%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
58.3%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 58.3% 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 115 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.5%CMS range 49.9–58.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.6–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 5.5–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.44
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.19
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.24
RN hoursweekends
38.2%
Total nursing turnover
9.1%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 113.8 residents a day — about 89% occupied, or roughly 14 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.15 hrs/resident/day on weekends vs 3.60 on weekdays — 12% thinner on weekends. RN hours go from 0.52 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as 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

11
deficiencies at the latest standard inspection (2025-09-05)
10
at the previous standard inspection (2024-06-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner when Resident #74 a) rolled out of bed during care sustaining a left front scalp hematoma (an injury with swelling caused by blood pooling under the skin) requiring evaluation in the emergency room and b) rolled out of bed during care sustaining a 15 centimeter scalp laceration (cut) requiring evaluation in the emergency room and wound closure with 9 sutures (stiches) and 7 staples. This was for 1 of 5 residents reviewed for accidents (Resident #74).Findings included:1a. Resident #74 was admitted to the facility on [DATE] with a diagnosis of muscle weakness.Resident #74's physician's orders revealed she was not receiving any anti-coagulant (blood thinning) medication.A nursing progress note for Resident #74 dated 7/12/24 at 12:30 PM written by Nurse #2 revealed he had been called to Resident #74's room. Resident #74 was on the floor with a bump on her head. Resident #74 told…

    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 · E2025-09-05 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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, staff and physician interviews the facility 1) failed to provide education regarding the benefits and possible side effects of a COVID-19 vaccination, offer a COVID-19 vaccination, and then document either a refusal or the administration of a COVID-19 vaccination in the past 14 months in the resident's medical record for 2 of 5 residents (Resident #54 and Resident #71) and 2) failed to maintain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine and were offered the COVID-19 vaccine or information on obtaining a COVID-19 vaccine in the past 14 months for 156 of 156 facility staff reviewed for COVID-19 immunization.Findings included:A review of the facility's policy titled COVID-19 Vaccine dated 12/28/21 revealed in part the following: COVID-19 Vaccine Education for Staff and Resident 1. COVID-19 vaccinations shall be offered to all staff and residents (or applicable POA [Power of Attorney]/Guardian) .…

    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 · Ecited before2025-09-05 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 ensure nurse aides (NAs) received 12 hours of in-service training annually which included abuse and dementia training. This was for 3 of 5 NA files reviewed (NA#5, NA #6, and NA #7).Findings included: 1a. A review of the employee file and training information for NA #5 indicated a hire date of 2/1/24. There was no dated training to provide evidence NA #2 received 12 hours of in-service training including abuse and dementia training in the previous 12 months.b. A review of the employee file and training information for NA #6 indicated a hire date of 7/11/24. There was no dated training to provide evidence NA #6 received in-service training on abuse and dementia training in the previous 12 months.c. A review of employee file and training information for NA #7 indicated a hire date of 6/20/24. There was no dated training to provide evidence NA #7 received abuse training in the previous 12 months.On 09/5/2025 at 1:06 PM an interview with the Staff Development Coordinator (SDC) indicated she was responsible for tracking…

    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 · D2025-09-05 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews with staff, pharmacy consultant, pharmacy accounts receivable clerk, and Medical Director, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 6 residents reviewed for medications (Resident #22).The findings included:A review of the facility's policy titled Abuse and Neglect Protocol dated 9/24/18 and last revised on 6/13/21 revealed in part Misappropriation of resident property is defined as the deliberated misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Resident #22 was admitted to the facility on [DATE].A physician ordered dated 9/25/24 written by the Medical Director read Oxycodone (controlled pain medication used to treat moderate to severe pain) 5mg (milligram tablet). Take one tablet by mouth every 4 hours as needed.A physician ordered dated 9/25/24 written by the Medical Director revealed Buspirone…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-05 · 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 review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls. This was for 1 of 5 residents (Resident #74) reviewed for accidents.Findings included:Resident #74 was admitted to the facility on [DATE].Resident #74's hospital record dated 7/19/25 revealed she was being seen after a fall from bed at the facility. She had a significant scalp laceration which measured 15 centimeters in length. Her laceration was repaired using 7 staples and 9 sutures (stiches).Resident #74's annual MDS assessment dated [DATE] revealed she had one fall with no injury and one fall with injury since her prior MDS assessment.Resident #74's medical record revealed no other falls since her prior MDS assessment dated [DATE].On 09/05/2025 at 8:03 AM an interview with MDS Nurse #1 indicated she coded the falls section of Resident #74's MDS assessment dated [DATE]. She reported on 7/19/25 Resident #74 had one fall with injury. She stated her coding on Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to develop an individualized, person-centered comprehensive care plan to include the use of side rails for 1 of 2 residents reviewed for side rails (Resident #5).Findings included: 1.Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 5 and generalized muscle weakness. Review of Resident #5's electronic record revealed an assessment titled bed rail/assist device dated 8/24/24 and completed by Nurse #9 that indicated Resident #5 did not need or use side rails. A care plan with the latest review date of 9/9/24 revealed no reference to use of side rails for Resident #5. A quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #5 was cognitively intact. The MDS indicated Resident #5 required partial to moderate assistance with bed mobility, substantial/maximal assistance with lying to sitting on the side of the bed and was non-ambulatory. The MDS revealed Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · 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 observation, record review, staff and Medical Director interviews, the facility failed to maintain the sterility of tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) care when Nurse #4 failed to perform hand hygiene and don (put on) sterile gloves after touching and disposing of a soiled split gauze pad and inner cannula and before placing the new sterile inner cannula and clean split gauze as well as donning sterile gloves over soiled gloves prior to suctioning. This was for 1 of 1 resident reviewed for tracheostomy care (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included persistive vegetative state and tracheostomy status. Resident #9's care plan last revised on 7/12/24 revealed him to have a tracheostomy. Resident #9's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was unable to be assessed for cognition due to comatose state. He was documented to receive…

    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 · D2025-09-05 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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, staff interviews, and record review the facility failed to attempt alternatives prior to installing siderails, complete siderail assessments, assess entrapment risk, review the risks and benefits of siderails with the resident /resident representative and obtain informed consent prior to siderail use for 2 of 2 residents reviewed for siderails (Resident #5, Resident #4).Findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 5 and generalized muscle weakness. Review of Resident #5's information face sheet revealed she was her own Responsible Party. Review of Resident #5's electronic medical record revealed an assessment titled bed rail/assist device dated 8/24/24 and completed by Nurse #9. The response to the question, Bed rails/assist devices are indicated for the resident at this time? was no. In an interview with Nurse #9 on 9/5/25 at 10:29 AM he stated he completed the assessment in Resident #5's room 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-05 · 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, staff and Medical Director interviews, the facility failed to follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) when Nurse #4 provided tracheostomy care without wearing a gown. This was for 1 of 12 staff observed for infection control practices (Nurse #4).Findings included: The facility policy titled Enhanced Barrier Precautions (EBP) dated 4/24/24 stated in part: EBP's are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Gloves and gowns are applied prior to performing high-contact resident care activities such as tracheostomy care. Observation of Resident #9's door on 9/3/25 at 11:53 AM revealed signage for EBP. The signage indicated that staff providing high contact care to Resident #9 were required to wear gowns and gloves. Further observation revealed a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, Responsible Party (RP), staff and physician interview the facility failed to provide education regarding the benefits and possible side effects of a pneumococcal immunization, offer a pneumococcal immunization, and then document either a refusal or the administration of a pneumococcal immunization for 1 of 5 residents reviewed for immunizations (Resident #6).Findings included:The facility's undated policy titled Pneumococcal Vaccine revealed in part: All residents will be offered pneumococcal vaccines to aid in the preventing pneumonia/pneumococcal infections.7. Administration of the pneumococcal vaccines or vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination.The CDC document titled Summary of Risk-based Pneumococcal Vaccine Recommendations dated 5/24/2025 revealed in part the following: Adults aged 19-[AGE] years old; The following guidance applies to adults younger than [AGE] years…

    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 · Ecited before2025-01-17 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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, staff interviews, resident interviews, physician interview, and a pest control supervisor interview the facility failed to maintain an effective pest control program that was free of German cockroaches for 4 (Resident #3, Resident #4, Resident #5, and Resident #6) of 4 residents reviewed for pest control services. Findings included: Documentation on the facility pest control company contract initiated on 6/27/2022 indicated that both interior and exterior pest control services, including cockroaches, were provided weekly to all rooms located on one wing of the facility. Pest control services rotated accordingly, so all wings and facility rooms were serviced at least once per quarter. Documentation on a pest control contract signed on 12/11/2024 revealed that a Roach Cleanout was negotiated for Rooms 409, 413, 415, 417, 419, and 421. Documentation on an unsigned pest control contract revealed a Roach Cleanout was being considered for Rooms 301, 302, 303, 305, 307, and 317. a. An observation…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2024-06-12 · tag F0641 — pattern
    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 review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for oxygen for 4 of 28 residents reviewed for MDS assessments (Resident #3, Resident #75, Resident #121, and Resident #328). Findings include: a.Resident #3 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, oxygen dependence, and hypoxemia (low levels of oxygen in body tissues). Review of physician orders dated 5/5/22 revealed an order for Resident #3 to receive continuous oxygen three liters per minute via nasal cannula (oxygen delivery method) to maintain oxygen saturation (measurement of oxygen in the blood.) above 90%. Review of the annual MDS assessment dated [DATE] for Resident #3 revealed she was cognitively intact. Resident #3 had not been coded for oxygen use on the assessment. Review of Resident #3's June 2024 Medication Administration Record (MAR) revealed that she received continuous oxygen via nasal…

    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 · D2024-06-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observations, record review, and resident and staff interviews the facility failed to keep the call light within reach for 1 of 1 resident (Resident #54) reviewed for accommodation of needs. Findings included: Resident #54 was admitted to the facility on [DATE] with a diagnosis of intracerebral hemorrhage (bleeding in the brain). A review of Resident #54's care plan revealed in part a focus area initiated on 5/7/2019 of at risk for falls. The goal, last revised on 3/15/24, was for Resident #54 not to sustain any injuries related to falls through the next review. An intervention was to be sure Resident #54's call light was within reach and encourage Resident #54 to use it for assistance as needed as Resident #54 required prompt response to all requests for assistance. A review of Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She had functional limitation in range of motion of her upper extremities on one side. On 6/10/24 at 1:22…

    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 · D2024-06-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to provide the opportunity to establish advanced directives and document this in the medical record for 1 of 2 residents (Resident #100) reviewed for advanced directives. Findings included: A review of the facility's policy titled Advanced Directives dated last revised September 2022 revealed, in part, the following: 1. If the resident or resident representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Resident #100 was admitted to the facility on [DATE] with a diagnosis of stroke (disrupted blood supply to the brain). A review of Resident #100's quarterly Minimum Data Set (MDS)…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review the facility failed to have a quarterly interdisciplinary care plan meeting for 1 of 6 residents reviewed for care planning. (Resident #8) Findings included: Resident #8 was admitted to the facility on [DATE]. Her active diagnoses included hemiplegia affecting left nondominant side, diabetes mellitus, unsteadiness on feet, cerebrovascular disease, muscle weakness, hyperlipidemia, and hypertension. Review of Resident #8's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. Review of Resident #8's medical record revealed her last care plan meeting was held on 2/13/24. During an interview on 6/9/24 at 10:37 AM Resident #8 stated she had not had a care plan meeting in a long time and could not remember the date of her last care plan meeting. During an interview on 6/11/24 at 9:28 AM Social Worker #2 stated the last care plan meeting for Resident #8 was on 2/13/24. She stated care plan meetings were supposed to be completed…

    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 · D2024-06-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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, staff interviews, and record review the facility failed to apply a hand splint to a resident as ordered for 1 of 4 residents reviewed for positioning and mobility. (Resident #51) Findings included: Resident #51 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, unspecified sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction, pain in left shoulder, and flaccid hemiplegia affecting left nondominant side. Review of Resident #51's Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He was documented to have no rejection of evaluation or care. He had impairment on one side of his upper extremities. He required set-up or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. Review of an order dated 3/27/23 revealed Resident #51 was ordered for staff 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
  • Potential for harm · D2024-06-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to provide a nutritional supplement as ordered by the physician. This was for 1 of 1 residents (Resident #25) reviewed for nutrition. Findings included: Resident #25 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A care plan focus area initiated on 11/3/23 was at risk for nutritional problems related to poor oral intake. The goal, last revised on 4/22/24, was for Resident #25 to maintain stable weight through the next review. An intervention was to provide nutritional supplements as needed. A review of Resident #25's weight record revealed in part on 2/13/24 he weighed 188 pounds. On 6/11/24 Resident #25 weighed 196.4 pounds. A current active physician's order with a start date of 2/13/24 was for a nutritional shake three times a day with meals for weight loss prevention. A review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He…

    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 · D2024-06-12 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, staff interviews, and record review the facility failed to clean and store a syringe for enteral feeding with the plunger separately to dry for 1 of 1 resident reviewed for tube feeding. (Resident #57) Findings included: Resident #57 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, persistent vegetative state, and anoxic brain damage. Review of Resident #57's Minimum Data Det assessment dated [DATE] revealed he was assessed as having a persistent vegetative state/no discernible consciousness. He was assessed to have a feeding tube in place and 51% or more of total calories the resident received through parenteral or tube feeding, and 501 cubic centimeters or more of fluid intake per day by IV or tube feeding. Review of Resident #57's care plan dated 4/8/24 revealed he was care planned to require tube feeding related to persistent vegetative state. The interventions included to keep the head of the bed elevated 45 degrees during and thirty minutes after…

    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 · D2024-06-12 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to honor residents' food preferences for 2 of 2 residents reviewed for food preferences (Resident #27, and Resident #117). Findings include: a.Resident #27 was admitted on [DATE] and readmitted on [DATE]. Review of the admission MDS assessment dated [DATE] for Resident #27 revealed she was cognitively intact. During an interview with Resident #27 on 6/9/24 at 11:39 am she stated that she did not like green beans or carrots but had been served green beans and carrots up to three times a week since her admission on [DATE]. During an interview with Resident #27 on 6/9/24 at 12:21 pm she stated that she was served mixed vegetables that included large amounts of green beans and carrots. She indicated that she did not like carrots and green beans, and she wished the kitchen would stop sending them. Observation of Resident #27's meal tray on 6/9/24 at 12:21 pm a bowl of mixed vegetables that included green beans and carrots had been served…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-12 · 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 observation, staff interviews, and record review the facility failed to accurately document the use of splints on a resident's Treatment Administration Record (TAR) for 1 of 3 residents reviewed for positioning and mobility and failed to accurately document nutrition supplement intake on the Medication Administration Record (MAR) for 1 of 1 resident reviewed for nutrition. (Resident #51 Resident #25) Findings included: 1. Review of an order dated 3/27/23 revealed Resident #51 was ordered for staff to apply left hand splint after breakfast and remove after supper for contracture prevention. Review of Resident #51's treatment administration record for June 2024 revealed it was documented by the nurse that the resident's left-hand splint had been applied at 8 AM on 6/10/24. During an interview on 6/10/24 at 8:54 AM Resident #51 stated he finished breakfast but had no one had put his left-hand splint on that morning. During observation on 6/10/24 at 8:54 AM Resident #51 was observed to not have his splint on his left hand. During an interview on 6/10/24 at 12:13 PM Resident #51…

    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 · Dcited before2024-06-12 · 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 and staff interviews, the facility failed to handle soiled linen in a manner to prevent the spread of infection for 1 of 1 resident reviewed for infection control and prevention (Resident #44). Findings included: Review of facility policy entitled Laundry and Bedding, Soiled read in part soiled laundry/bedding shall be handled according to best practices for infection prevention and control. Contaminated laundry is placed in a bag or container at the location where it is used. During an observation of incontinence care for Resident #44 on 6/10/24 at 2:11 pm NA #1 laid soiled bath cloths and towels directly on the floor. She then removed her soiled gloves, placed them in the trash receptacle, washed her hands, and left the room. She returned with plastic bags. NA#1 then put on clean gloves and picked the soiled towels and wash cloths up off the floor and placed them in a plastic bag and tied the bag closed, removed her soiled gloves, placed them in the trash receptacle in the room, washed her hands, and disposed the soiled items in a dirty laundry hamper outside…

    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 · E2023-05-24 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interviews the facility failed to honor a residents bathing preference for 2 of 9 residents (Resident #55 and Resident #67) reviewed for choices. Findings included: 1. Resident #55 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia affecting the left nondominant side. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact and required total assistance with one person for bathing. The MDS also documented the resident did not have any behaviors. Resident #55's care plan dated 5-17-23 revealed the resident had an ADL (activites of daily living) self-care deficit due to left sided hemiplegia. The goal for Resident #55 was to maintain the current level of functioning in ADL's. The interventions for the goal included bathing/showering required total assistance with one person explaining all steps of bathing during showers. A review of Resident #55's shower documentation from March 2023 through May 2023…

    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 · E2023-05-24 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interviews, staff interviews and review of the Resident Council meeting minutes the facility failed to resolve a repeat grievance related to call bell responses which was reported during the Resident Council meetings for 3 of 6 months of meeting minutes reviewed (December 2022, February 2023 and May 2023). The findings included: A review of the Resident Council meeting minutes dated 12/1/22 revealed one of the items listed in the section titled old business was residents voiced a grievance related to staff not responding to the call bells or responding and turning the call bell off without providing the care requested. The written response to the Resident Council dated 12/8/22 documented the corrective action was 12/2 in-service held for nursing department addressing answering call lights and not cutting the call light off until the care has been provided. One of the items listed as new business was not getting changed from 11:00 PM-7:00 AM. Resident #3, Resident #2 and Resident #11 were among the residents present for the meeting. A review of the Resident Council…

    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 · E2023-05-24 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, staff, and resident interviews the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for bathing for 2 of 9 residents (Resident #55 and Resident #67). Findings included: This tag is cross referenced to: F561: Based on record review, staff, and resident interviews the facility failed to honor a residents bathing preference for 2 of 9 residents (Resident #55 and Resident #67) reviewed for choices. During an interview with a Nursing Assistant (NA) #10 on 5-22-23 at 1:52pm, the NA discussed having too many residents assigned to her and was unable to complete all her assigned tasks. The NA discussed having 15 residents assigned to her and she was not able to complete shower tasks assigned but was able to complete bed baths. The NA discussed she was assigned 15 or more residents three to four times a week. The Scheduler was interviewed on 5-24-23 at 8:53am. The Scheduler stated she was responsible for scheduling the nurses and NAs but requested help from the Administrator if she was unable 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    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 observations, interviews with residents and staff and record review the facility failed to respond to a call bell for 1 of 4 residents review for dignity (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, high blood pressure and cardiac arrhythmia. The quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #11 was cognitively intact. She was coded as independent with bed mobility, walking in room and in corridors supervision for transfers. She needed limited assistance with toilet use. She had no range of motion limitations. She used a wheelchair. Resident #11s care plan revised on 4/24/23 included a focus area of activities of daily living self-care performance deficit related to a history of stroke with hemiplegia and generalized weakness. The interventions included supervision to limited assistance with toileting and transfers. She also had a focus area of increased risk for falls related to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-24 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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, interviews with residents and staff and record review the facility failed to offer or provide privacy during a bed bath for 1 of 4 residents reviewed for dignity (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE]. Resident #7's minimum data set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired and had verbal behavioral symptoms directed towards others 1 to 3 days of the lookback period. He required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #7's care plan dated 4/4/23 revealed he was care planned for activities of daily living self-care performance deficit related to activity intolerance and impaired mobility. The interventions included to provide one aide to assist Resident #7 to perform bathing, dressing, personal hygiene. During observation on 5/22/23 at 10:51 AM Nurse Aide (NA) #8 was observed providing a bed bath to Resident #7. Upon arriving at the room, the door to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) Assessment in the areas of dental (Resident #102) and Pre-admission Screening and Resident Review (PASRR) (Resident #2) for 2 of 18 resident assessments reviewed. Findings included: 1. Resident #102 was admitted to the facility on [DATE] A review of the Nursing admission Assessment for Resident #102 dated 4/20/23 revealed she had broken or carious (decayed) teeth. A review of her admission MDS assessment dated [DATE] revealed she had no obvious or likely cavity or broken natural teeth. The Care Area Assessment (CAA) for dental care was not triggered. On 5/21/23 at 2:07 PM an observation of Resident #102 revealed she had multiple black and broken natural teeth. On 5/24/23 at 10:11 AM an interview with MDS Nurse #1 indicated she completed the dental section of Resident #102's MDS assessment dated [DATE]. She stated she normally went to the resident, had them open their mouth, and observed…

    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 · D2023-05-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, staff, and resident interviews the facility failed to provide incontinence care (Resident #85) and mouth care (Resident #46) to residents who were dependent on staff for activities of daily living (ADL) care for 2 of 5 residents reviewed for ADL care. Findings included: 1. Resident #85 was admitted to the facility on [DATE] with multiple diagnoses that included congestive heart failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #85 was cognitively intact and required total assistance with one person for toileting. The MDS documented Resident #85 as always being incontinent of urine and bowel. The MDS did not have documentation of any behaviors. Resident #85's care plan dated 4-20-23 revealed the resident had an ADL self-care deficit related to generalized weakness. The goal for Resident #85 was to maintain the current level of function in ADLs. The intervention for the goal was toileting required total dependence with one person. Resident #85 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-24 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 ensure Nurse Aide (NA) #9 received at least 12 hours of in-service training in one year. This was for 1 of 5 NA in-service training records reviewed. Findings included: On 5/24/23 at 1:25 PM a review of NA #9's in-service training record from 2/1/22 through 5/24/23 provided by the facility's Staff Development Coordinator (SDC) revealed NA #9 had a total of 7 hours and 45 minutes of in-service training which included dementia management and abuse prevention. On 5/24/23 at 2:03 PM an interview with the SDC indicated NA's received their in-service training in person at the facility. She stated because NA #9 was only an as needed (prn) staff member she was not always present in the facility when in-service training was provided. She stated as a result, NA #9 did not have the required 12 hours of annual in-service training. On 5/24/23 at 2:04 PM an interview with the Administrator indicated because NA #9 was a prn employee, she was not always present in the facility when in-service training was provided. She stated as 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-09-05 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, staff and pest control contractor interviews, the facility failed to maintain an effective pest control program to prevent brown crawling bugs in 1 of 1 laundry room. The findings included:A review of the Pest Control Service Agreement dated 4/16/25 revealed the company would provide pest control services monthly and every week on 2 out of the 4 halls. An observation was conducted of the facility laundry room on 9/5/25 at 8:40 AM. The area in which the 2 washing machines were located revealed water standing on the floor covered by a flattened cardboard box. There were also 2 brown crawling bugs on the laundry room wall between the laundry chute and the laundry bin that receives soiled laundry. The observation also revealed 3 brown crawling bugs on the floor near the washing machines.An interview with the Housekeeping and Laundry Director was held on 9/5/25 at 8:50 AM. She stated the flattened cardboard box covering the standing water on the floor draining from the washing machines was to prevent the staff from slipping. She also stated she sees…

    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.

    Environmental Deficiencies · No revisit needed

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,868 in federal fines across 1 penalty.

  • $10,868 — penalty dated 2025-09-05

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 →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 32 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Carver Living CenterDurham, NC 1 of 5Countryside Manor Nursing And Rehabilitation LLCFremont, OH 1 of 5Harrison Pavilion Care CenterCincinnati, OH 1 of 5Meadowbrook Care CenterCincinnati, OH 1 of 5Smoky Mountain Health And Rehabilitation CenterPigeon Forge, TN 1 of 5The Greens at GastoniaGastonia, NC 1 of 5Valley Nursing and Rehabilitation CenterTaylorsville, NC 1 of 5Weakley Rehabilitation And Nursing CenterDresden, TN 2 of 5Cedars Of Lebanon Care CenterLebanon, OH 2 of 5Clovernook Health Care And Rehabilitation CenterCincinnati, OH 2 of 5Louisville Gardens Care CenterLouisville, OH 2 of 5Solon Pointe At Emerald RidgeSolon, OH 2 of 5The Greens at HickoryHickory, NC 2 of 5The Greens at LincolntonLincolnton, NC 2 of 5The Greens at ViewmontHickory, NC 2 of 5Willow Ridge Of NCRutherfordton, NC 3 of 5Flint Ridge Nrsg & Rehab CtrNewark, OH 3 of 5Lincoln Crawford Care CenterCincinnati, OH 3 of 5Meadow Wind Health Care CenterMassillon, OH 3 of 5Northcrest Rehab And Nursing CenterNapoleon, OH 3 of 5Pineville Rehabilitation and Living CenterPineville, NC 3 of 5Scarlet Oaks Nursing And Rehabilitation CenterCincinnati, OH 3 of 5The Greens at HendersonvilleHendersonville, NC 3 of 5The Greens at Pinehurst Rehabilitation & Living CePinehurst, NC 3 of 5The Greens at Spruce PinesSpruce Pine, NC 4 of 5Cedarview Care CenterLebanon, OH 4 of 5Sunrise Nursing Healthcare LLCAmelia, OH 4 of 5The Greens at Maple LeafStatesville, NC 4 of 5The Greens at WeavervilleWeaverville, NC 4 of 5Twilight Gardens Nursing And RehabilitationNorwalk, OH 5 of 5Locust Ridge Healthcare LLCWilliamsburg, OH 5 of 5The Greens at CabarrusConcord, NC

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

Owner / managerTypeRoleShareSince
NCNH HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST96%since 06/01/2016
10-26 NATIONWIDE TROrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 06/01/2016
NCNH J-DEK LLCOrganizationDIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF24%since 06/01/2016
STARLIGHT HEALTHCARE LLCOrganizationDIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF36%since 06/01/2016
FORBRIGHT BANKOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/11/2026
STERN, JACOBIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
CCH HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2026
HARTLEY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
LEWIS, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
NCNH PROPCO HOLDING LLCOrganizationADP OF THE SNFsince 06/01/2016
RIDGEWOOD PROPCO LLCOrganizationADP OF THE SNFsince 06/01/2016

CMS files one row per role, so the 22 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$15.0M
Net patient revenuemost recent cost report
+19.0%
Operating marginrevenue minus expenses
$2.5M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 17%Other / private 19%

This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$297per resident / day
operating cost
$9,038per month
≈ monthly operating cost
$367per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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