Elite Nursing And Rehabilitation Care Center
300 Royal Tower Drive, Birmingham, AL 35209 · For profit - Limited Liability company · 143 certified beds · (205) 870-5666 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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 $6,682 in federal fines (most recent 2024-08-13)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 | 18.5% | 12.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.7% | 12.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.7% | 24.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.5% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.2% | 12.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.7% | 21.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 40.4% | 80.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.0% | 24.8% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.7% | 11.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.30 | 1.96 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.84 | 1.70 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
37.2% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 37.2%CMS range 25.3–48.5 | 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 | 10.5%CMS range 7.1–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.8% | 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 | 62.5% | 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 | 75.0% | 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 | 96.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 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 | 13.5% | 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 | 10.3%CMS range 6.5–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 143 beds and averages 120.6 residents a day — about 84% occupied, or roughly 22 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below 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 2.98 hrs/resident/day on weekends vs 3.40 on weekdays — 12% thinner on weekends. RN hours go from 0.54 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · D2024-10-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 interviews, resident record review, review of the facility investigative file, review of a Facility Reported Incident (FRI), and review of a facility policy titled Abuse, Neglect and Exploitation, the facility failed to conduct a thorough investigation of an allegation of physical abuse on 09/13/2024 to include determining the time the alleged incident occurred. This citation resulted from the investigation of complaint/report number AL00048805 and had the potential to affect Resident Identifier (RI) #1, one of six residents sampled for abuse. Findings include: A facility policy titled Abuse, Neglect and Exploitation, reviewed 01/2024, documented: . Definitions: Abuse means the willful infliction of injury . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. V. Investigation of Alleged Abuse, Neglect and Exploitation . 6. Providing complete and thorough documentation of the investigation. RI #1 was re-admitted to the facility on [DATE] and had diagnoses 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 · F2024-08-13 · tag F0580 — failed to tell family and doctor about changes — widespreadImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, interview, facility's policies titled Notification of Changes, and Information and Communication the facility failed to ensure residents' families were notified when the facility was unable to maintain the first floor's residents' right to a safe and homelike environment when the facility's air conditioning system failed to maintain temperatures less than 81 °F (degrees Fahrenheit) in the residents' common areas and residents' rooms on the first floor. Due to the elevated temperatures, the facility initiated an enhanced hydration round program. The facility did not notify residents' families or representatives of the elevated temperatures or the enhanced hydration round program. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. This deficient practice was cited as a result of the investigation of complaint/report numbers AL00048537 and AL00048538. Findings Include: Cross-Reference F 584. The facility's policy titled Information and Communication with a revised date of 12/23 revealed: Policy: 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.
- Potential for harm · Fcited before2024-08-13 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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
Based on observations, interviews, record reviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to maintain safe and comfortable temperatures in residents' common areas and residents' rooms on the first floor. The facility failed to ensure temperatures in residents' common areas and residents' rooms were not above 81 degrees from 08/09/2024 through 08/13/2024. The temperatures on the first floor were recorded above 81 °F (degrees Fahrenheit) during all five days of the survey. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. The deficiency was cited as a result of the investigation of complaint/report number AL00047537 and AL00047538. Findings Include: On 08/07/2024, the State Survey Agency received an anonymous complaint alleging the facility had no air conditioning. On 08/08/2024, the State Survey Agency received a complaint alleging the facility had no air conditioning for four days, and it was 83 °F in the complainant's family member's room. A review of a facility policy…
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 · Fcited before2024-03-29 · 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 — an excerpt from the official record, may be distressing
Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility's policy titled Sanitation Inspection, the facility failed to ensure the stove top, knobs, handles, and drip pans were free of a heavy grease build up. This had the potential to affect 129 of 130 residents who received meals from the facility's kitchen. Findings Include: A review of 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, documented: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . A review of policy titled Sanitation Inspection dated 12/23 documented: .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary .1. All food service areas shall be kept clean, sanitary . On 03/26/2024 at 2:31 PM, the initial kitchen tour was conducted by the Surveyor with the Dietary Manager. During the tour, it was observed that there was a significant accumulation of grease on the stove top, knobs, and handles.…
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 · Fcited before2024-03-29 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 policies titled Hand Hygiene, Standard Precautions Infection Control, Handling Clean Linen, and Water Management Program the facility failed to ensure: 1) Laundry Staff (LS) #7 washed her hands after leaving Resident Identifier (RI) #54 and RI #10's room with contaminated laundry hangers and touching clean clothing for RI #74. 2) LS #9 kept clean sheets off the floor and off her clothing while folding clean laundry on 03/28/24. 3) Clean blankets for the residents were stored in a clean dust free area and ensured the blankets were not touching the wall. 4) Certified Nursing Assistant (CNA) #10 washed or sanitized her hands after leaving RI #115's room and before picking up RI #23's meal tray while delivering meals on 3/28/24. 5) Maintenance Director (MD) implemented a water management program to prevent and identify Legionella This affected five of 26 sampled residents and had the potential to affect all residents residing in the facility. Findings Include: 1)…
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 · F2024-03-29 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility's policy titled Infection Prevention and Control Program the facility failed to ensure the facility employed a certified infection preventionist from 1/5/2022 until 3/29/2024. This deficient practice affected 130 residents in the facility. Findings Include: A review of a facility policy titled Infection Prevention and Control Program with an implemented date of 12/22, and a reviewed date of 12/2023 revealed: . Policy Explanation and Compliance Guidelines. 1. The designated Infection Preventionist is responsible for oversight of the program and serves a consultant to our staff on infectious diseases. A review of the facility's employment record for the previous certified infection preventionist revealed a hire date of 03/27/2020 and last day of employment as 01/05/2022. A review of TRAIN TRAINING PLAN PROOF OF COMPLETION for ADM/IC revealed: . (ADM/IC) has successfully completed Nursing Home Infection Preventionist Training Course as of 03/29/2024 On 03/29/2024 at 10:52 AM an interview was conducted with Administrator/Infection Control…
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 · F2024-03-29 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and a review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1) Two ovens in the kitchen had exposed electrical wiring and were in working condition 2) The walk-in freezer was free from excessive ice buildup on two fans, the floor, ceiling, and boxes containing food products. This was observed on the initial tour of the kitchen on 03/26/2024. This had the potential to affect 129 of 130 residents receiving meals from the facility kitchen. Findings Include: The 2022 U.S. Food and Drug Administration documents the following: . Maintenance and Operation 4-501.11 Good Repair and Proper Adjustment A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements . On 03/26/2024 at 2:31 PM during the initial kitchen tour, two ovens were observed with exposed wiring at the base of both ovens. The Dietary Manager (DM) was interviewed and asked why the ovens had exposed wiring. The DM stated that the ovens were not working. When asked how long the ovens had not been…
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 · Ecited before2024-03-29 · 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, review of a facility policy titled Safe and Homelike Environment, the facility document titled Plan of correction for torn floors and complaint/report number AL00046076, the facility failed to ensure Resident Identifier (RI) #128's room's floor covering was not torn, ceiling tiles were not stained in RI #128's room, and that RI #128's room did not have a urine odor. This affected RI #128. The torn floors had the potential to affect residents in 47 rooms. Findings Include: Review of a facility policy Safe and Homelike Environment with a revised date of 12/2023 documented Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, . A review of a facility document titled Plan of correction for torn floors dated 03/28/2024 documented the floor replacements started on 02/14/2024 and would be completed by 05/01/2024. The plan indicated 52 rooms floors were to be replaced. The plan indicated five of the 52 rooms had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, the facility failed to ensure Section N, Medications, of Resident Identifier (RI) #124's quarterly Minimum Data Set (MDS) was accurately coded for anticoagulant and antiplatelet medication. This deficient practice affected RI #124 one of twenty-six sampled residents whose MDS was reviewed during the survey. Findings Include: The Centers for Medicare &Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 Section N documented: . N0415: High-Risk Drug Classes: Use and Indication .E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . or clopidogrel as N0415E, Anticoagulant. N04151I Check if an antiplatelet medication (e.g., aspirin . clopidogrel) was taken by the resident at any…
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 · D2024-03-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, interview and review of the facility policy Resident Assessment - Coordination with PASARR Program, the facility failed to submit for a new Level I for Resident Identifier (RI) #14 when a new diagnosis for Psychotic Disorder was given on 07/07/2021. This affected RI #14 one of two residents reviewed for PASARR (Pre-admission Screening Annual Resident Review). Findings Include: Review of a facility policy Resident Assessment - Coordination with PASARR Program with a revised date of 12/2023 documented . Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions . a. PASARR Level I i. Negative Level I Screening - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder arises later. 9. any resident who exhibits a newly evident or possible serious mental disorder, . or related condition will be referred promptly to the state mental…
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 12 citations
- Potential for harm · Dcited before2024-03-29 · 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 interview ,record review and a facility policies titled Comprehensive Care Plans and Oxygen Administration, the facility failed to ensure a care plan was developed for Resident Identifier (RI) #13's use of oxygen therapy. This affected RI #13, one of 26 sampled residents whose plans of care were reviewed. Findings Include: A facility policy titled Comprehensive Care Plans revised 01/2023 indicated: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . A facility policy titled Oxygen Administration…
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 · D2024-03-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 interview the facility failed to ensure Resident Identifier (RI) #483 had a physician's order for a urinary catheter when he/she was admitted to the facility with a Catheter on 08/20/2022. This affected one of three residents sampled for urinary catheter use. Findings Include: RI #483 was admitted to the facility on [DATE]. A review of RI #483's Physician Orders for August 2022 revealed no order for the use of a catheter. A review of RI #483's progress notes from 08/28/2022 documented that RI #483's catheter was removed. A telephone interview with the Medical Director revealed that he gave a verbal order to remove the catheter on 08/28/2022. On 03/28/2024 at 10:54 AM an interview was conducted with the Admissions Nurse (AN). The AN stated that RI #483 was admitted to the facility on [DATE] with a foley catheter. On 03/29/2024 at 11:43AM an interview was conducted with the Director of Nurse (DON). The DON said that if a resident was admitted with a catheter a physician's order for 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.
- Potential for harm · Fcited before2019-11-20 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility's policy titled Three Compartment Sink Sanitization, the facility failed to ensure a kitchen aide did not sanitize a knife in the three compartment sink containing food particles in the sanitizing compartment. Further, the kitchen aide removed the knife from the sink using bare hands and placed it on the wall with other clean knives for future use. This had the potential to affect 122 residents receiving meals from the facility's kitchen. Findings include: A review of the facility policy titled Three Compartment Sink Sanitization, dated 5/2018, revealed: .It is the policy of this facility to use the three-compartment sink to clean and sanitize pots, pans and serving utensils as part of the infection control program and eliminate the possibility of spreading harmful microorganisms in the ware washing process. Purpose: To prevent the spread of bacteria that may cause food borne illnesses .Procedure .: 1. First Sink-Wash Dishes . b. Scrape pots/pans as needed, wash pots, pans & utensils thoroughly removing all debris .3. Third…
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 · D2019-11-20 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to ensure Resident Identifier (RI) #14 was provided privacy during medication administration by a licensed nurse. This affected RI #14, one of three residents observed during medication administration, and one of three licensed nurses observed during medication administration. Findings Include: RI #14 was admitted to the facility on [DATE] with diagnoses to include Dry Eye Syndrome of Bilateral Lacrimal Glands. On 11/19/19 at 08:22 a.m., Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed during a medication administration for RI #14. After EI #3 entered RI #14's room, she left the door and privacy curtain open for public view, and visible for RI #14's roommate. The Surveyor observed one unknown person walking down the hallway and RI #14's roommate, RI #46, sitting in a recliner across the room in front of RI #14's bed. EI #3 began administering RI #14's oral and eye drop medications with the door and privacy…
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 before2019-11-20 · 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 observation, interviews, record review, and review of a facility policy titled Infection Control- Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), washed her hands after she placed a topical medication patch to Resident Identifier (RI) #120's right upper back, removed her gloves, and prior to placing RI #120's nasal medication in the medication cart drawer. This affected RI #120, one of three residents observed during the medication administration pass, and EI #1, one of three nurses observed during medication pass. Findings Include: A review of a facility policy titled, Infection Control - Hand Hygiene, dated 11/17/2017, revealed . It is the policy of the facility to perform hand hygiene with national standards . PROCEDURE: . 2.hand hygiene is to be performed: . d. after caring for a resident including after removing gloves . 3.hand hygiene should be performed: . o. After removing gloves . p. After completing duty . RI #120 was admitted to 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.
- Potential for harm · E2018-11-08 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews and a review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual and review of CMS (Centers for Medicare and Medicaid Services) Submission Report MDS (Minimum Data Set) 3.0 NH (Nursing Home) Final Validation, the facility failed to ensure Resident Identifier (RI) #s 14, 16, 76, 9, 15, 13, 19, 1, 6, 8, 12, 10, 11, 7, 5, and 17 MDS assessments were transmitted in a timely manner. This affected 16 of 26 sampled residents for whom MDS assessments were reviewed. Findings Include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Chapter 5: Submission and Correction of the MDS Assessments, page 5-3, revealed the following: . Transmitting Data: . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . All other MDS assessments must be submitted within 14 days of the MDS Completion Date . A review of the CMS Submission Report MDS 3.0 NH Final Validation for 11/7/18 revealed: 1) RI #14's quarterly MDS with an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-11-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of a facility policies titled, Pharmacy Services and Stability of Medications After Opened, the facility failed to ensure expired medications were not stored on medication carts and in the medication storage room. This deficient practice affected three of the four medication carts and one of two medication rooms viewed for expired medications. Findings Include: Review of a facility policy titled, Pharmacy Services, revised 11/17/17, revealed the following: . 14. Expired/discontinued medication that is uncontrolled/controlled shall be removed from the Medication carts and destroyed . On 11/06/2018 at 2:54 PM, the surveyor conducted a medication cart review on the second floor. Employee Identifier (EI) #3, LPN/Licensed Practical Nurse was also present. The surveyor observed the following expired medication still on the medication cart: 1. one bubble pack of MAPAP 325 mg (Acetaminophen) with an expiration date of 8/31/18; and 2. one bubble pack of MAPAP 325 mg (Acetaminophen) with an expiration date of 10/31/18. On 11/06/2018 at 03:36 PM, 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.
- Potential for harm · D2018-11-08 · 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 record review, interview and review of a policy titled Resident Assessment Instrument (RAI), the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed when Resident Identifier (RI) #s 75, 94 and 82 elected to receive hospice benefits. This affected three of seven sampled residents reviewed for hospice, and three of 26 sampled residents for whom MDS assessments were reviewed. Findings Include: A facility policy tilted Resident Assessment Instrument (RAI), dated 11/17/17, documented: .PROCEDURE: . 4. Assessments are also completed for residents who have experienced a Significant Change. Within 14 days after the facility determines, or should have determined, that there has been a significant change .A significant change in status MDS is required when a resident elects . the hospice benefit . 1) RI # 75 was readmitted to the facility on [DATE] with a diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery. A physician…
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 before2018-11-08 · 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 record review, interview and review of a policy titled Resident Care Planning, the facility failed ensure a care plan was developed when Resident Identifier (RI) #s 82 and 92 elected to receive hospice benefits. This affected two of seven sampled residents reviewed for hospice. Findings Include: A review of a policy titled Resident Care Planing, dated 5/1/2002, revealed: .It is the policy of this facility that a written plan is developed to meet the individual needs of the resident. The services provided or arranged by the facility must meet professional standards of quality and be provided with each resident's written plan of care . 1) RI #82 was readmitted to the facility on [DATE] with a diagnosis of Chronic Pulmonary Disease. A review of a physician order for RI # 82 documented: .ADMIT TO HOSPICE SERVICES FOR DX (diagnosis) OF COPD (Chronic Obstructive Pulmonary Disease) ON 8/10/18 . A review of RI # 82's medical record revealed no care plan for hospice. An interview was completed with Employee…
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 · D2018-11-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse followed the physician orders for catheter care provided to Resident Indentifier (RI) #94 on 11/7/18. This affected one of one observation of catheter care. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, copyright date of 2017, page 311, revealed: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI # 94 was readmitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. RI # 94's November 2018 Medication Administration Record (MAR) documented the following order for catheter care: .Clean supra-pubic catheter site with hydrogen peroxide and pat dry apply Vaseline/TAO (triple antibiotic ointment) to site twice daily and leave open to air . start :…
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 before2018-11-08 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 and interview, the facility failed to ensure expired nutritional supplements were not stored in the medication room. This was observed in one of two medication rooms. Findings include: On [DATE] at 8:41 a.m. the surveyor observed the medication storage room with Employee Identifier (EI) # 7, Registered Nurse/Administrator. The surveyor observed the following expired items: 1. one bottle of boost (8 ounces) with an expiration date of [DATE], 2. three 8 ounce boxes of Very Vanilla with an expiration date of [DATE]; and 3. one container of thick and easy apple (4 ounces) with an expiration date of [DATE]. On [DATE] at 8:33 a.m. an interview was conducted with EI # 7. EI # 7 stated she observed the expired items in the medication room on [DATE]. EI # 7 stated it was the policy of the facility to discard expired items. EI # 7 stated they should not have been in the medication room. EI # 7 was asked what was the potential harm of having expired items in the medication room. EI # 7 stated it could…
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 · D2018-11-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure licensed staff documented in Resident Identifier (RI) #94's medical record that catheter care had been provided twice a day from November 1, 2018 until November 6, 2018. This affected one of 26 sampled residents for whom medical records were reviewed. Findings Include: RI # 94 was readmitted to the facility on [DATE] with a diagnosis to include Neuromuscular Dysfunction of Bladder. RI # 94's November 2018 Medication Administration Record (MAR) documented the following order for catheter care: .Clean supra-pubic catheter site with hydrogen peroxide and pat dry apply Vaseline/TAO (triple antibiotic ointment) to site twice daily and leave open to air . start : 01/25/2017 . There was no documentation of the completion of the catheter care from November 1, 2018 - November 6, 2018. An interview was completed with Employee Identifier (EI) # 5, Licensed Practical Nurse (LPN), on 11/7/18 at 4:26 p.m EI # 5 was asked why the November 2018 MAR for catheter…
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
$6,682 in federal fines across 1 penalty.
- $6,682 — penalty dated 2024-08-13
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| KAPLAN, YISROEL | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2023 |
| ASCHENDORF, JONATHAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| BELL, TISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/19/2021 |
| PAISLEY, PEYTON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/03/2023 |
CMS files one row per role, so the 9 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.
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 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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 AL
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 Alabama 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 015455. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-29, 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.