River Trace 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.

52.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 121 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.8% 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 84 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 140 beds and averages 121.5 residents a day — about 87% occupied, or roughly 18 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.

Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.54 on weekdays — 9% thinner on weekends. RN hours go from 0.44 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

31 citations, most serious first. The 14 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · J2025-08-22 · 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

  Based on observations, record review, and staff and Medical Director interviews, the facility failed to ensure staff were trained and competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer for 1 of 1 observed (Resident #34). On 8/20/25 Nurse #1 was observed obtaining Resident #34's blood glucose (sugar) level followed by the nurse cleaning the glucometer with an alcohol wipe that was not an Environmental Protection Agency (EPA)-registered disinfectant. Nurse #1 revealed she worked at the facility since March of 2025, had always used an alcohol wipe to clean the glucometer, had not been trained on how to disinfect the glucometer, and was unaware an EPA-registered disinfectant needed to be used. The Infection Preventionist revealed she was unsure what the manufacturer's guidelines were for cleaning and disinfecting a shared glucometer. Resident #34 resided on the locked unit and this shared glucometer was utilized for 2 other residents (Residents #92 and #97) who resided on that unit. Shared glucometers can be contaminated with blood and…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-08-22 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, staff and Medical Director interviews, the facility failed to implement their infection control policies and procedures when Nurse #1 did not follow the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter (glucometer) before and after resident usage for 1 of 1 resident observed whose blood glucose (sugar) level was checked (Resident #34). On 8/20/25 Nurse #1 was observed obtaining Resident #34's blood glucose level followed by the nurse cleaning the glucometer with an alcohol wipe that was not an Environmental Protection Agency (EPA)-registered disinfectant. Nurse #1 then stated that she worked at the facility since March of 2025 and had always used an alcohol wipe to clean the glucometer indicating that she was unaware an EPA-registered disinfectant needed to be used. Resident #34 resided on the locked unit and this shared glucometer was utilized for 2 other residents (Residents #92 and #97) who resided on that unit. Shared glucometers can be contaminated with blood and must be cleaned and disinfected 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and resident, staff, and Medical Director (MD) interviews, the facility failed to provide care in a safe manner. On 6/30/25 Resident #2 rolled off her bed during incontinence care and landed on the floor. Resident #2 sustained a right forearm skin tear and complained of severe pain and was sent to the Emergency Department (ED) for evaluation. The Resident was diagnosed with a closed fracture (the broken bone does not penetrate the skin) at the distal end (just above the knee joint) of the left femur (thighbone) and closed fracture at the distal end of the right femur. In the ED, Resident #2 required intravenous (IV) fentanyl (an opioid drug used to treat severe pain) for pain. The Resident was discharged back to the facility the same day with an immobilizer on her right knee and orders to follow up with orthopedic surgery. Following the incident Resident #2 required oxycodone for pain management with pain levels rated up to a 9 (on a scale of 0 to 10 with 10 being the worst…

  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
• Immediate jeopardy · J2024-06-21 · 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 reviews and interviews with family, staff, Physician Assistant, and Physician the facility failed to monitor and assess a resident's neurological status (an assessment of motor and sensory response to determine if the nervous system is impaired) after an unwitnessed fall for a resident on an anticoagulant (Coumadin) and to recognize the seriousness of a change in condition and immediately seek emergent medical care. On [DATE] at approximately 9:30 AM Resident #1 was found in her room sitting on the floor and was unable to report what happened. At approximately 1:55 PM the resident was identified with lethargy, a change in mental status, and later developed unclear speech. The resident's family requested a transfer to the emergency room (ER) and 911 was called at 5:28 PM. A computerized tomography (CT) revealed multiple abnormalities including a large (9.4 centimeter [cm]) hemorrhagic contusion (bleeding within the skull) and a subdural hematoma (buildup of blood on the surface of the brain) with…

  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 · E2025-08-22 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  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 review, and resident, staff, Medical Director, and Pharmacist interviews, the facility failed to protect the resident's right to be free from the misappropriation of their narcotic medications (oxycodone and hydrocodone) prescribed to treat pain for 4 of 8 residents reviewed for misappropriation of property (Residents #38, #24, #50, and #107).Findings included:1a. Resident #38 was admitted to the facility on [DATE] with a diagnosis of chronic pain.A physician's order for Resident #38 dated 10/17/24 revealed oxycodone 10 milligrams (mg) take 1 tablet orally every 8 hours for chronic pain. A review of a Packing Slip proof of delivery from the facility's Pharmacy revealed 90 tablets of Oxycodone 10 mg were delivered to the facility on [DATE] for Resident #38's prescription number. The packing slip was signed by Nurse #2 and Nurse #3 acknowledging this medication was received. Nurse #2's Interviewee Statement dated 12/23/24 indicated Nurse #2 verified she received 3 cards of 30…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · E2025-08-22 · 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 review, and resident, staff, Medical Director, and Pharmacist interviews, the facility failed to have effective safeguards and systems in place to prevent drug diversion of discontinued controlled narcotic and antianxiety medications (hydromorphone, oxycodone, morphine and lorazepam). This was for 3 of 8 residents reviewed for misappropriation (Residents #8, #115, and #141).Findings included: 1a. Resident #8 was admitted to the facility on [DATE] with a diagnosis of arthritis. A physician's order for Resident #8 dated 11/13/24 revealed hydromorphone (narcotic medication) 2 milligram (mg) tablet take 1 tablet every 4 hours as needed for mild hand amputation pain and 2 tablets as needed every 4 hours for moderate to severe pain. A Packing Slip proof of delivery from the facility's Pharmacy revealed 60 tablets of hydromorphone 2 mg were delivered to the facility on [DATE] for Resident #8. The packing slip was signed by Nurse #6 acknowledging this medication was received. Nurse #6's…

  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 · Past Non-Compliance
• Potential for harm · Ecited before2025-08-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and staff interviews, the facility failed to ensure facial hair was covered during food preparation for 1 of 1 cook observation in the kitchen. This practice had the potential to affect food served to residents. Findings include:An observation was conducted on 8/18/2025 at 10:30am revealed the [NAME] was wearing a facial covering however his mustache and sides of his beard were exposed while preparing/cutting food.An interview was conducted on 8/18/2025 at 1:04pm with Dietary Manager Consultant revealed all staff should have a beard restraint that covered all facial hair.An interview was conducted on 8/21/2025 at 8:56pm with Administrator revealed that she was unaware that proper beard restraint was not practiced in the kitchen. She stated it was expected that all staff wear hair restraints and covered all facial hair while in the kitchen and when preparing foods.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-22 · 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 observation, record review, and staff and resident interviews, the facility failed to treat a resident with dignity and respect when a staff member did not knock or announce their presence before entering a resident's room (Resident #49) and failed to maintain residents' dignity when a resident had an uncovered urinary catheter drainage bag, leaving the urine visible to the public (Resident #7). The reasonable person concept was applied for Resident #7 as individuals have the expectation of being treated with dignity and would not want urine visible to visitors, staff and other residents. This was for 2 of 7 residents reviewed for dignity (Resident #49, Resident #7).Findings included: 1. Review of Resident #49’s Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. During observation on 8/19/25 at 8:08 AM Housekeeper #1 was observed to enter Resident #49’s room without knocking or announcing her presence. Resident #49 was in the bed closest the door and the door 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 · Dcited before2025-08-22 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 and resident interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 6 residents reviewed for self-administering medications (Residents #101).Resident #101 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, anxiety, depression and insomnia.Review of Resident #101's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #101 was cognitively intact with no delusions, behaviors, or rejection of care.Review of Resident #101's medical record revealed no documentation that Resident #101 had been assessed to self-administer medications.Further review of Resident #101's medical record revealed no care plan for self-administration of medications.An observation of Resident #101 on 8/19/25 at 1:00 PM revealed her to be in her room, sitting on the side of the bed eating her lunch. On Resident #101's overbed tray was a medicine cup that contained 8 pills.An interview with…

  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 · D2025-08-22 · 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 resident, staff and Responsible Party (RP) interviews, the facility failed to ensure a copy of the Medical Power of Attorney advanced directive document was obtained and in the resident's medical record. This was for 1 of 3 residents reviewed for advanced directives (Resident #99).Findings included:Resident #99 was admitted to the facility on [DATE] with a diagnosis of dementia.A physician's progress note for Resident #99 dated 8/1/24 revealed in part her family member was listed as her medical power of attorney.Resident #99's care conference record dated 8/2/24 listed her family member as her medical power of attorney.Resident #99's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact.Resident #99's facility face sheet listed her family member as her medical power of attorney and RP.There was no evidence in Resident #99's facility medical record of a copy of her medical power of attorney document.On 8/19/25 at 2:47 PM a telephone interview with…

  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 before2025-08-22 · 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 anticoagulant medication (Resident #54) and diabetes mellitus type II (Resident #97) for 2 of 5 residents reviewed for comprehensive care plans (Resident #54 and Resident #97).The findings included: 1. Resident #54 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and coronary artery disease. Resident #54's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and was prescribed an anticoagulant (blood thinning) medication. The comprehensive care plan initiated on 8/4/25 did not reveal a care plan indicating Resident #54 took anticoagulant medication. An interview was conducted with the MDS Nurse on 8/20/25 at 11:43 AM. She indicated the admitting nurse was responsible for adding high risk medications such as anticoagulants to the care plan upon admission. In an…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-22 · 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 record review and staff interviews the facility failed to revise the comprehensive care plan to accurately reflect the code status for 1 of 3 residents reviewed for advanced directives (Resident #108).Findings included:Resident #108 was admitted to the facility on [DATE] with a diagnosis of dementia.Resident #108's active comprehensive care plan revealed a focus area for advanced directives. The goal was for Resident #108's advanced directives to be honored per the established documentation through the next review. An intervention was Cardio-Pulmonary Resuscitation (CPR is a lifesaving procedure performed when someone's heartbeat or breathing has stopped) Full Code.A physician's order for Resident #108 dated [DATE] entered into Resident #108's electronic medical record by the Assistant Director of Nursing (ADON) was Do Not Resuscitate (DNR is the refusal of CPR).On [DATE] at 4:03 PM an interview with the ADON indicated she entered the DNR order into Resident #108's electronic medical record on [DATE].…

  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 · D2025-08-22 · tag F0773 — isolated
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  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 Medical Director interviews, the facility failed to notify the physician or Nurse Practitioner (NP) of abnormal laboratory test results. This deficient practice affected 1 of 6 sampled residents (Resident #130).Resident #130 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, chronic kidney disease, chronic atrial fibrillation (a condition where the heart beats irregularly and often too fast), and congestive heart failure. Resident #130 had a telephone order called in from the NP from the Cardiology office on 10/11/24 for a BMP (basic metabolic panel, which was a common blood test that measures glucose, calcium, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen and creatinine), draw to be done at the facility. The order was signed off by a nurse on 10/14/2024. Several unsuccessful attempts were made to reach the NP that ordered the lab.Review of the lab results report showed the blood specimen was collected 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-07-26 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, the facility failed to incorporate residents and/or resident representatives in the care planning process for 2 of 2 residents reviewed for care plans (Resident #9 and #24). Findings included: 1. Resident #9 was admitted to facility on 1/24/2019 with diagnoses that included heart disease and Alzheimer's dementia. A review of Resident #9's annual Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. A review of Resident #9's Social Service progress notes revealed the last documented Interdisciplinary (IDT) care plan meeting was held on 11/23/22. An interview with the Social Worker on 7/26/24 at 8:59 AM revealed she did not know why the resident hadn't had a care plan meeting since 11/23/22 as they should be held quarterly. In an interview with the Director of Nursing (DON) on 7/26/24 she stated care plan meetings should have been held quarterly. She was unaware Resident #9 had not had a care plan meeting since 11/23/22. In an…

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

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

“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

$32,991 in federal fines across 2 penalties.

• $17,345 — penalty dated 2025-07-18
• $15,646 — penalty dated 2024-06-21

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

Part of a chain

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

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

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in NC