Resorts at Beaufort
11 Todd Drive, Beaufort, SC 29901 · For profit - Limited Liability company · 170 certified beds · (843) 524-8911 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — 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 2025-05-16)
- nursing-staff turnover (65%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 improved from 1 to 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.6% | 11.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.1% | 3.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.2% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 5.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.6% | 12.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.5% | 21.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 17.0% | 16.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.7% | 78.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.5% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.8% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.67 | 2.04 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.59 | 1.84 | 1.80 | better |
‡ 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.
38.5% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.7% 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 38 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.5%CMS range 25.3–50.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.4%CMS range 10.8–19.7 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.7% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.0%CMS range 5.8–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 170 beds and averages 126.8 residents a day — about 75% occupied, or roughly 43 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.25 on weekdays — 18% thinner on weekends. RN hours go from 0.67 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2025-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, record review, and facility document and policy review, the facility failed to provide one-to-one (1:1) supervision as needed in accordance with Resident (R)1's fall prevention care plan and failed to recognize and address all potential accident hazards in the resident's environment for 1 (R1) of 3 residents reviewed for falls. Specifically, on 01/25/2025, approximately five to ten minutes after the resident was assisted into bed by staff, who placed a reclined geriatric chair along the side of the resident's bed, R1 was seen coming down the hallway yelling that their eye hurt, and the resident's right eye was noted to be redder and more irritated than their left eye. While in the hallway, the resident became too weak to support their weight and was lowered to the floor by a nurse for an assisted fall. During the early morning hours of 01/26/2025, it was noted that the resident cried out in pain when trying to move their neck, and the resident was sent to the hospital for further evaluation. Hospital records reflected that the resident had a history…
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.
- Potential for harm · E2026-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, interviews, and document review, the facility failed to maintain the facility in good repair for resident areas. Specifically, there were side rails loose, rusty toilet seats, towel bar that was separated off the wall, walls in disrepair, cove molding missing, and spacing around air conditioner (AC) units. The facility's failure to repair the residents' environment has the potential to cause injuries to residents in two of three halls (A and C halls).Findings include:1.Observation and interview with the Maintenance Director (MD) of the C hall on 05/01/26 at 3:06 PM through 3:16 PM revealed the following:Room C01-D, a two-to-three-inch movement in the right side of the side rail. Room C08-W, the wall had three large gouged areas near the bedroom door. The MD stated I don't go in every room. The wall will get fixed when the Certified Nurse Aides (CNAs) tell him. Room A17-P, rusty toilet seat with rusty handles on the toilet riser. The towel bar was lying on the floor. The MD stated, Therapy…
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.
- Potential for harm · D2026-04-02 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and policy review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident (R)13) of three residents reviewed for SNF ABNs. This failed practice had the potential to affect all residents receiving Medicare Part A benefits and continued to reside in the facility to make an informed decision on continuing the services. Findings include:Review of the facility's policy titled, Advanced Beneficiary Notices dated 01/08/26 revealed, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines:1. Social Services is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/representatives of this contact person shall be posted conspicuously in the facility.2. The Social Services will provide Medicare information to residents/representatives upon request. The current CMS-approved version of the forms shall be used at the time 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.
- Potential for harm · Dcited before2026-04-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observation, interview, record review, and facility policy review, the facility failed to ensure a resident's fingernails were kept clean and trimmed for one of one resident (Resident (R) 9) reviewed for activities of daily living of 33 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility.Findings include:Review of the facility's policy titled, Nail Care dated 01/08/26 indicated, The purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health .3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. 5. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes . 6.…
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.
- Potential for harm · D2026-04-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 observations, record review, interviews, and facility policy review, the facility failed to ensure the resident's gastrostomy tube (G-tube) was patent by checking for placement prior to administering medications for one of four residents (Resident (R) 33) observed during medication administration. This failure had the potential to result in the resident not receiving the medication. Findings include:Review of the facility's policy titled Medication Administration via Enteral Tube, reviewed 01/08/26, provided by the facility, revealed Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . 11. Procedure: . h. Enteral tube placement must be verified prior to administering any fluids or medication .Review of R33's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses that included multiple…
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.
- Potential for harm · Dcited before2025-08-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on interview, record review, and facility policy review, the facility failed to ensure staff implemented the care plan for 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/2025, a staff member attempted a bed-to-chair transfer for R5 with a mechanical lift, with only one staff member present. The mechanical lift malfunctioned, and the resident fell to the floor. Findings include: Review of a facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of an admission Record revealed the facility admitted R5 on 09/26/24. According to the admission Record, the resident had a medical history that included, but was not limited to, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other specified disorders of bone, morbid (severe) obesity due to excess…
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.
- Potential for harm · Dcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview, record review, and review of the owner's manual for Model: F600B Bariatric Full Body Patient Lift, the facility failed to ensure staff safely transferred 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/25, a staff member failed to follow the resident's care plan and ignored the noises emitted from the mechanical lift when she assisted the resident with a transfer from their bed to their wheelchair. During the transfer, the mechanical lift malfunctioned, and R5 fell to the floor. Findings include: Review of a document titled Competency Assessment Lifting Machine, Using a Mechanical, revised on 07/2017, revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The Steps in the Procedure section revealed, 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.An Owner's Manual for the Model: F600B Bariatric Full Body Patient…
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.
- Potential for harm · D2025-05-16 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility document and policy review, the facility failed to ensure staff did not utilize a geriatric chair without assessing whether the use of the geriatric chair was considered a restraint for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, despite a known history of climbing out of the side of their geriatric chair and a history of climbing from their bed over their geriatric chair when staff positioned it by the resident's bed, staff placed R1 in a geriatric chair in a reclined position and also utilized the geriatric chair positioned along the side of the resident's bed while the resident was in bed to prevent the resident from getting up without staff's knowledge. Findings included: A facility policy titled, Use of Restraints, revised 04/2017, indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff…
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.
- Potential for harm · D2025-05-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected falls and resulting injuries for 1 (Resident (R)1) of 3 sampled residents. Findings included: A facility policy titled, MDS 3.0 Completion, reviewed/revised on 09/30/2024, revealed, According to federal regulations, the facility conducts initially a periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. The section of the policy titled, Care Plan Team Responsibility for Assessment Completion, 1. Interdisciplinary Responsibility for Completion of MDS Sections specified, c. Persons completing part of the assessment must attest to the accuracy of the section they completed. R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina,…
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.
- Potential for harm · Dcited before2025-05-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on interview, record review, and facility policy review, the facility failed to ensure staff checked for incontinence and/or provided incontinence care during routine rounds for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, on the evening 01/25/2025, after the resident experienced an assisted fall to the floor, staff placed the resident in a geriatric chair and did not check to see if the resident required incontinence care until sometime between 5:00 AM to 6:00 AM the following morning. Findings included: R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina, the bundle of nerves at the base of the spinal cord, become compressed); other mechanical complication of internal fixation device of vertebrae; history of falling; lack of coordination; muscle weakness; dementia; bipolar disorder, current episode manic severe with psychotic features; unspecified mood…
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.
- Potential for harm · D2025-01-08 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880. Findings include: Review of the policy titled, Resident Rights, revised on 10/01/24, states: Employees shall treat all residents with kindness, respect and dignity. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of CDC Infection Control Summary of Recommendations with a revised date of 03/25/24 states, III.B.2. Keep the collecting bag below the bladder. Do not rest the bag on the floor. Review of R33's face sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited 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.
Show the remaining 11 citations
- Potential for harm · D2025-01-08 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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, and facility policy, the facility failed to identify and complete a Significant Change in Status Assessment (SCSA) for 2 of 2 residents reviewed for significant change in condition. Specifically Resident (R)42's comprehensive assessment was not updated after the election of hospice services, or a major decline within the fourteen-day status change requirement. Findings include: Review of the facility policy titled, Policy-MDS 3.0 Completion, revised 09/30/24, states: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 2c. Significant Change Assessment- completed within fourteen (14) days of the identification of a status change that meets the requirements outlined in Chapter 2 of the 3.0 Version RAI Manual. i. A significant change is defined, according to the RAI Manual, MDS version 3.0, as a decline or improvement 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.
- Potential for harm · D2025-01-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interview, the facility failed to ensure it is free of medication error rate of 5 % (percent) or greater. The error rate was 7.14 % based on 1 of 5 residents observed during med pass. There were two observed errors related to Resident (R)46, who was admitted to the facility on [DATE] with diagnoses including, but not limited to vitamin deficiency and essential (primary) hypertension. Findings: The facility policy entitled Medication Administration - General Policies and Procedures revised 11/1/2015 states Medications are administered as prescribed in accordance with good nursing principle and practices Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. On 01/07/25 at approximately 09:58 AM, LPN (Licensed practical Nurse)1 administered the following medications to R46: -Vitamin D3 125 mg (milligram) (5,000 IU (International Units) ) x 1 -Metoprolol Tartrate 25 mg x 1 On 1/7/25 at approximately 11:10 AM,…
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.
- Potential for harm · Dcited before2025-01-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, interviews and manufacturer package inserts, the facility failed to ensure that 1 of 3 medication room refrigerators, containing refrigerated medications, were operative. Findings include: Review of the facility policy entitled Storage of Medications revised 11/1/2015 states Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Manufacturer package inserts for insulin recommend storage for not in-use (unopened) insulin be stored in a refrigerator at approximately 36-46 degrees F. On 1/07/25 at approximately 10:49 AM, inspection of the Hall A Medication Room revealed the refrigerator thermometer reading was 48 degrees F (Fahrenheit) and plastic bags of insulin for approximately three residents were lying on shelves in standing water with thawed ice packs in the freezer compartment. The temperature log affixed to the refrigerator door had a recorded temperature on 1/6/25 of 38 degrees with numerous prior entries reading 38 degrees. On 1/07/25 at approximately…
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.
- Potential for harm · Dcited before2025-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880. Findings include: Review of the policy titled, Resident Rights, revised on 10/01/24, states: Employees shall treat all residents with kindness, respect and dignity. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of R33's face sheet revealed she was admitted to the facility on [DATE] with diagnosis including, but not limited to, Cerebral Palsy, neuromuscular dysfunction of bladder, retention of urine, and lack of coordination. Review of R33's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference…
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.
- Potential for harm · F2023-02-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 a review of facility policy, observation, and interview, the facility failed to ensure the removal of expired foods from the cooler in 1 of 1 kitchen. Findings include: Review of the facility's policy and procedure titled, Food Receiving and Storage revised on July 2014, revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: Policy interpretation and Implementation to be followed: 8.) All foods Stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). During the initial kitchen tour on 02/07/23 at 10:33 AM, an observation of Cooler 1 revealed, a clear plastic bag containing six heads of lettuce, each containing pink and brown spots on each. The bag had no opening date or expiration date. Interview with the CDM (Certified Dietary Manager) on 02/09/23 at 9:00 AM confirmed the findings.
- Potential for harm · Dcited before2023-02-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, review of the facility policy, and interviews, the facility failed to implement a Care Plan established for Resident (R)41, 1 of 1 resident reviewed for Care Plans, to assist with meals, presenting challenging efforts of using fine motor skills, resulting in decreased will to eat. Findings Include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022 states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: g. receive the services and/or items included in the plan of care. 7. The comprehensive, person-centered care plan: b. describes the services that are 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.
- Potential for harm · D2023-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 review of the facility policy, observations, interviews, and record review, the facility failed to label the oxygen tubing for 1 of 1 Resident (R)43 reviewed for respiratory care. Findings include: Review of the facility's policy titled,Departmental (Respiratory Therapy)-Prevention of Infection dated (revised) November 2011, revealed,It is policy's general guidelines distilled water used in respiratory therapy must be dated and initiated when opened and discarded after twenty-four hours. Under Steps in the Procedure- Infection Control Consideration related to Oxygen Administration lists: (3) [NAME] bottle with date and initials upon opening and discard after twenty four (24) hours. (4) Change the reservoir every forty-eight hours and disinfect with 2% alkaline glutaraldehyde or sterilize. R43 was admitted to the facility on [DATE] with diagnoses including but not limited; dementia, absence of right leg below knee, cerebral infarction due to stenosis, and adult failure to thrive. Review of R43'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.
- Potential for harm · Dcited before2023-02-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy titled, Storage of Medications, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use by residents in 2 of 4 medication carts and 1 of 2 medication rooms. Findings include: Review of the facility policy titled, Storage of Medications, states, The facility stores all drugs and biological's in a safe, secure and orderly manner. The Policy Interpretation and Implementation, states under number five, Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. An observation on 02/07/23 at 10:45 AM of the A Wing, Hall 1 medication cart 1 for Rooms 1 through 12 revealed 29.75 milliliters of Morphine Sulfate 100 milligrams per 5 milliliters with Lot #AB3265C expired, December 2022. During an interview on 02/07/23 at 10:47 AM with Licensed Practical Nurse (LPN)1 confirmed the expired medication that was locked on the medication cart with narcotics in use for residents. She then called the Director of Nursing (DON)…
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.
- Potential for harm · Dcited before2023-02-09 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interviews, and review of the facility policy titled, Handwashing/Hand Hygiene, Personal Protective Equipment (PPE)-Using Gloves, and Laundry and Bedding, Soiled, the facility failed to ensure gloves were worn to administer Resident (R)54 eye drops during medication administration by Registered Nurse (RN)1. The facility also failed to ensure hand hygiene/washing was completed after administering eye drops on D Wing. Additionally the facility failed to remove the PPE inside the soiled utility room after collecting soiled linen and wash hands. The PPE was removed at the nurse's desk on A Wing, without the completion of handwashing. The deficient practice was observed on 1 of 2 units where soiled linen was picked up by a laundry worker and 1 of 2 units where eye drops were administered during med pass. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, states, This facility considers hand hygiene the primary means to prevent the spread of infections. The Policy Interpretation and Implementation, number 2 states, All personnel shall…
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.
- Potential for harm · D2023-02-09 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and review of the facility policy titled, Fire Safety and Prevention, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers and from the backs of the clothes dryers in the vicinity of the gas flame. Findings include: Review of the facility policy titled, Fire Safety and Prevention, states, All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. The Policy Interpretation and Implementation, states, number 2, Whoever identifies a fire hazard, or other conditions that could develop into a fire hazard, must report the situation to the department director of Maintenance Director as soon as practical. An observation on 02/09/23 at 7:30 AM of the two clothes dryers revealed an excessive amount of lint on the floor, in and on the lint basket around wiring and on the upper 3 sides, inside the dryers. Further observation revealed an excessive amount of lint was noted on the backs of the clothes dryers, on wiring and exhausts pipes and in 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.
- No harm found · B2026-04-02 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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
Based on observations, interviews and facility policy review, the facility failed for one of one meal observation to substitute a lunch meal alternate meal item (tortellini) with another meal item (kielbasa sausage) that has the same comparable nutritive value. The failure had the potential to affects residents at risk of nutritional problems.Findings include:Review of the facility's undated policy titled provided by the DM indicated, Policy Statement: The Dietary Department may make substitutions to the posted menu when necessary; however, all substitutions must be equivalent in nutritional value, appropriate for the resident's diet order, and documented according to facility guidelines. Substitutions must never compromise resident choice, safety, or quality of care.Review of the lunch menu provided by Dietary Manager (DM) revealed, beef stew, rice, and green beans and the alternate was cheese tortellini with alfredo sauce.During an interview on 03/31/26 at 12:44 PM, the DM stated the lunch meal was beef cubes, mashed potatoes, and spinach. The alternate meal was smoked…
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.
“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.
- 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.
Fines & penalties
$10,868 in federal fines across 1 penalty.
- $10,868 — penalty dated 2025-05-16
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 THE ROSENBERG FAMILY — 16 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.2 | +0.8 vs chain |
| Staffing | 3 of 5 | 3.9 | -0.9 vs chain |
| Quality measures | 3 of 5 | 4.0 | -1.0 vs chain |
The other 15 homes this chain runs (chain average 2.7★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RESORTS AT BEAUFORT 2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 04/01/2023 |
| ROSENBERG, AVRAHAM | Individual | INDIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 04/01/2023 |
| ROSENBERG, ZVI | Individual | INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2023 |
| 11 TODD LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 04/01/2023 |
| ROSENBERG, JONATHAN | Individual | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 04/01/2023 |
| ROSENBERG, MOSHE | Individual | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 04/01/2023 |
| CASTOR, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2025 |
| FERGUSON, SANDRA L | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2025 |
| AZ 22 TR | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 04/01/2023 |
| ZA 22 | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 04/01/2023 |
CMS files one row per role, so the 28 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
About 76% 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 $300K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SC
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 South Carolina Medicaid page.
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 425067. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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.