Mill Creek Center for Nursing and Rehabilitation

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.

34.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 50 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 66 beds and averages 61.3 residents a day — about 93% occupied, or roughly 5 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 3.07 hrs/resident/day on weekends vs 3.50 on weekdays — 12% thinner on weekends. RN hours go from 0.54 to 0.42 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%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · J2024-05-29 · 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

  Based on observations, record review, and staff, Medical Director and Transportation Agent staff (Driver #1, Supervisor #1, Supervisor #2) interviews, the facility failed to have Resident #1 assessed by a medical professional before repositioning the resident after he was thrown forward out of his wheelchair while inside a contracted transportation van. On 03/20/24 Driver #1 for the Transportation Agent applied the van brakes suddenly to avoid a collision and Resident #1 slid out of his wheelchair onto the floor of the contracted transportation van. Driver #1 repositioned Resident #1 back into his wheelchair before the Resident was assessed by an emergency professional. Resident #1 complained of left knee pain 6 out of 10 (with 10 being the highest pain scale) and right foot pain, 10 out of 10 and was transferred to the hospital where he was diagnosed with an acute impacted oblique left femoral fracture (a break in the thighbone that occurs at an angle caused by direct trauma when the ends of the thighbone are jammed together) with edema (swelling) and bleeding around the left knee.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-29 · 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

  Based on observations, record review, and staff, Medical Director, Regional Nurse Consultant and Transportation Agent (Driver #1, Supervisor #1 and Supervisor #2) interviews, the facility failed to utilize an occupant restraint system, complete with a shoulder restraint and lap belt, per manufacturer's instructions for Resident #1 who slid out of his wheelchair during transport in a contracted transportation van. Driver #1 applied a shoulder restraint under the armrest of the wheelchair and across the lap of Resident #1 for transport, but did not apply a lap restraint. When Driver #1 applied brakes to avoid hitting a car, Resident #1's buttocks slid out of his wheelchair with his left leg bent forward, and his right leg extended straight out in front. Resident #1 expressed pain to Driver #1. Driver #1 called 911 and when paramedics arrived, Resident #1 complained of left knee pain 6 out of 10 (with 10 being the highest pain scale) and right foot pain, 10 out of 10. Resident #1 was transferred to the hospital where he was diagnosed with an acute impacted oblique left femoral fracture…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-11-16 · 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, staff and Medical Director interviews, and record reviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 2 of 6 residents whose blood glucose levels were checked (Residents #168 and #58). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA) approved disinfectant in accordance with the manufacturer of the glucometer creates a high likelihood of exposing residents to the spread of blood borne infections. Immediate Jeopardy began on 11/14/2023 when Nurse #1 was observed during blood glucose testing for three residents on her assigned hall using a shared glucometer between the three residents but did not follow the manufacturer's instructions to allow for the wet contact time as specified for the disinfectant to be effective. Immediate Jeopardy was removed on 11/15/2023…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-14 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide information to residents regarding the residents' right to accept or refuse medical/surgical treatment when formulating an advanced directive for 4 of 6 sampled residents reviewed for advanced directives (Residents #15, #25, #29, #39). Findings included: 1. Resident #15 was admitted to the facility on [DATE] and re-admitted on [DATE]. The most recent Minimum Data Set assessment dated [DATE] indicated Resident #15 was cognitively intact. Review of the physician's order dated 2/4/25 documented Resident #15's Advance Directive status as Full Code. There was no documentation in Resident #15's medical record indicating the resident was provided information about his right to accept or decline medical or surgical treatment prior to making a Advance Directive decision. During an interview on 4/2/25 at 8:40 a.m., the Social Worker acknowledged the facility did not inform or have any documentation indicating Resident #15 had the right to accept or…

  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 · E2025-04-14 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  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 staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Prevnar 20 (pneumococcal conjugate vaccine (PCV20) in accordance with nationally recognized standards for 4 of 5 residents reviewed for pneumococcal immunizations (Resident #16, #10, #15, and #36). Findings include: The Center for Disease Control and the Advisory Committee on Immunization Practices (ACIP), last reviewed on 10/26/24, now recommends routine vaccination against pneumococcal infection for all adults aged 65 years or older and 19-64 with certain underlying medical conditions. Beginning June 8, 2021, for persons aged 65 years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown, they should receive 1 dose of PCV15 or 1 dose of PCV20. Review of the facility's immunization policy last revised in 2019 stated that all residents would be offered a pneumococcal vaccine upon admission; brand unspecified. A. Record review…

  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 · D2025-04-14 · 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, record reviews, and resident and staff interviews, the facility failed to respect a resident's right to dignity when Resident #212 requested incontinence care and it was not provided until after all the meals trays were passed on the hall for 1 of 1 resident reviewed for dignity (Resident #212). The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses including bowel and bladder incontinence due to impaired mobility, and osteomyelitis. Resident #212's self-care deficit care plan dated 3/13/25 indicated staff were to aid with bowel and bladder incontinence related to immobility. The admission Minimum Data Set (MDS) dated [DATE] specified that Resident #212 was cognitively intact and dependent on toileting, dressing, bathing, transfers, and mobility care. The MDS also determined that the Resident required a mechanical lift for transfers. There were no indications of behaviors exhibited. The MDS indicated Resident #212 was frequently incontinent of bowel 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-14 · 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 record review, observations, and resident and staff interviews, the facility failed to assess and document the ability of a resident to self-administer medications for 1 of 2 residents (Resident #38) reviewed for medication self-administration. Findings included: Resident #38 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #38 was cognitively intact. On 4/1/25 at 9:53 am, an observation was made of fluticasone propionate nasal spray (a steroid nasal spray to treat allergic rhinitis) sitting on Resident #38's bedside table. During an interview with Resident #38 on 4/1/25 at 10:35 am he stated that he used the nasal spray a couple times a day when he needed to for his stuffy nose. Resident #38 reported he couldn't remember who gave the nasal spray to him but he had been using it for a month or two. A care plan last revised on 2/18/25 revealed Resident #38 did not have a care plan to address self-administration of medications. A review of…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-14 · 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 ensure the accessibility of a wheelchair for 1 of 1 resident (Resident #1) reviewed for reasonable accommodations of needs. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: osteomyelitis, cerebral infarction, and diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact; and was totally dependent on staff and a mechanical lift for transfers. During an observation and interview on 3/31/25 at 1:20 p.m., Resident #1 revealed he had not attended the out of room group activities because he had not seen his wheelchair since his return from the hospital (2/18/25). The resident stated that prior to his hospitalization he would use the wheelchair to propel himself to the group activities. An observation of the resident's room and bathroom revealed there was no wheelchair in Resident #1'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-14 · 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

  Based on observation and staff interviews, the facility failed to protect the private health information for 3 of 3 sampled residents by posting confidential medical information in an area accessible to the public (Resident #11, Resident #22, and Resident #158). Findings included: During observations on the 100 and 200 halls on 4/1/25 at 9:51 a.m. and 9:52 a.m., one 8.5 inch x 11-inch white sheet of paper with the updated date of 3/12/25 was posted on the wall with tape located behind and next to 2 of 2 nurses' stations. The signs were documented with Resident #11, Resident #22, and Resident #158's names and medical information concerning the residents' dialysis treatments. The documentation on the signs was in large print, typed and had additional handwritten notes about each dialysis resident. The signs included the residents' names, days of the week each resident was scheduled for dialysis treatment, departure times from the facility, and dialysis procedure times. The posted signs on the walls were visible and readable to residents and visitors from the front of each of the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews, the facility failed to ensure an electrical outlet was securely covered in room [ROOM NUMBER] and failed to ensure resident's clothing was clean and stored neatly in sufficient storage spaces for two residents on the 200 hall. The deficient practice occurred on 1 of 2 halls observed for a clean and homelike environment (200 hall). Findings included: 1. An observation in room [ROOM NUMBER] and interview of Resident #1 was conducted on 3/31/25 at 1:23 p.m. An electrical outlet cover located behind and to the left side of the head of Resident #1's bed was observed partially separated from the wall. There were two electrical cords inserted in the electrical outlet (attached to the bed and the air mattress on the bed) and both attached devices were functioning. The resident revealed he had not been out of his room since his return from the hospital (2/18/25). He indicated he was not aware of the condition of the electrical outlet. During a follow-up observation in room…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-14 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 2 sampled residents (Resident #39) reviewed for hospice services. Findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses which included: dementia and chronic obstructive pulmonary disorder. Resident #39 was admitted to Hospice Services on 2/22/25 with the diagnosis of Alzheimer's disease with late onset. A review of the MDS assessments revealed a Significant Change in Status MDS Assessment was not completed after Resident #39 was admitted to hospice services. During an interview on 4/4/25 at 9:54 a.m., the facility's Administrator revealed the MDS Coordinator was not available. The Administrator acknowledged that a Significant Change MDS should have been completed within fourteen days of Resident #39's admission to Hospice Services.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-14 · 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 observations, record review, and resident and staff interviews, the facility failed to provide incontinence care to a resident upon request for 1 of 1 dependent resident reviewed for activities of daily living (ADL) (Resident #212). The findings included: Resident #212 was admitted to the facility on [DATE] with a diagnosis that included osteomyelitis (bone infection) and bowel and bladder incontinence due to impaired mobility. The admission Minimum Data Set, dated [DATE] specified that Resident # 212 was cognitively intact and dependent for toileting, dressing, bathing, transfers, and mobility care. The MDS also determined that the Resident required a mechanical lift for transfers. There were no indications of behaviors exhibited. The MDS indicated Resident #212 was frequently incontinent of bowel and bladder. Resident #212's self-care deficit care plan dated 3/13/25 indicated staff were to provide assistance with bowel and bladder incontinence related to immobility. An observation was conducted in…

  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 before2025-04-14 · 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

  Based on observations, record review and staff interviews, facility failed to secure a spray cleaner and spray deodorizer inside a housekeeping cart with a working lock for 1 of 2 housekeeping carts (the 2nd floor housekeeping cart) observed for accidents hazards. The findings included: An observation of the housekeeping cart occurred on 3/31/25 at 1:17 PM on the second floor of the facility outside of a resident's room. The side door of the cart was partially ajar. The cart did not have a lock. There were three residents seen nearby the cart. There were no staff members near the cart at the time of observation. During an observation and interview with Housekeeper #1 on 3/31/25 at 1:25 PM, she stated she had a spray cleaner, and a spray deodorizer inside the cart. Houskeeper #1 reported the cart used to have a lock but it broke sometime over the weekend (3/28/25-3/30/25). She explained she reported it to the Environmental Manager but it had not been fixed yet. Housekeeper #1 stated she was aware the cart should have a working lock, but it was the only cart on the floor. Housekeeper…

  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

“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

$29,876 in federal fines across 2 penalties.

• $16,452 — penalty dated 2024-05-29
• $13,424 — penalty dated 2023-09-28

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 ALLIANCE HEALTH GROUP — 12 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 7 rows in the source record cover these 4 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.

This home reported $1.7M 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

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