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Chandler Post Acute And Rehabilitation

2121 West Elgin Street, Chandler, AZ 85224 · For profit - Corporation · 120 certified beds · (480) 899-6717 Medicare & Medicaid certified

Call the home — (480) 899-6717 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20251 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2201 W Fairview St Ste 1 · (480) 800-4890 · Call to confirm hours
Pharmacy
2227 W Pecos Rd · (480) 739-6040 · Call to confirm hours
Grocery
Bashas’0.4 mi
2650 W Geronimo Pl · (480) 895-9350 · Call to confirm hours
Park
1500 W Maggio Way · (480) 782-2727 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.3%10.7%15.4%better
Long-stay residents who lose too much weight8.0%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder3.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.5%1.2%2.0%better
Long-stay residents with depressive symptoms1.7%3.9%6.5%better
Long-stay residents who were physically restrained2.7%0.3%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%2.1%3.3%better
Long-stay residents whose ability to walk worsened7.4%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.6%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine96.4%94.6%95.3%typical
Long-stay residents with pressure ulcers1.0%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control17.2%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.6%87.3%79.4%better
Short-stay residents rehospitalized after admission20.0%23.7%22.6%better
Short-stay residents with an outpatient ER visit15.1%10.4%12.0%worse

‡ 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.

67.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.5%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
66.2%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.30
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 66.2% 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 71 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 0.62 therapist hours per resident per day in 2025Q4 — more than 90% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF67.5%CMS range 57.9–77.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.2–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.5–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.79
RN hours/ resident / day
0.97
LPN hours/ resident / day
1.99
Aide hours/ resident / day
3.75
Total nurse hours/ resident / day
0.46
RN hoursweekends
43.7%
Total nursing turnover
47.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 105.9 residents a day — about 88% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 4.14 on weekdays — 19% thinner on weekends. RN hours go from 0.76 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

10 ↑
deficiencies at the latest standard inspection (2025-12-12)
0
at the previous standard inspection (2023-12-07)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure that a medication was administered following the physician ordered parameters for one resident (#135). The deficient practice resulted in hospitalization due to lowered blood pressure. Findings included:Resident #135 was admitted to the facility on [DATE].Review of the hospital records revealed the resident #135 had a past medical history of urinary tract infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), Hypertension, and Cerebrovascular Disease (CVA).The admission progress note dated November 10, 2025 included the resident arrived at the facility; and that the resident was alert, oriented x 4, awake and able to make needs known. The care plan dated November 10, 2025 included interventions to administer medications/treatments as ordered, to monitor/document for side effects and effectiveness and to report occurrences to the physician.A review of the order…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure hand hygiene was performed and PPE was appropriately applied for one resident (Resident #9) , and infection control measures were implemented for a resident with a urinary catheter (Resident #71) and during a dressing change (Resident #166). This deficient practice can result in contamination and spread of infection. Findings include: Regarding Resident # 71 Resident #71 was admitted to the facility on [DATE], with conditions that included encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, long-term (current) use of anticoagulants, need for assistance with personal care, generalized muscle weakness, and cognitive communication deficit, hypertension, wound infection, and diabetes mellitus. A review of the admission Minimum Data Set (MDS) accepted November 30, 2025, revealed the resident had a Brief Interview Mental Status Score…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-12 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, facility documents, and policy, the facility failed to ensure several residents' rooms were equipped with a working communication system to call for staff assistance. The deficient practice could place residents' safety at risk.Findings include:An observation in the behavioral unit was conducted on December 9, 2025 at 10:50 AM and revealed the call light in one room (#1) was on the floor behind the resident's bed and was out of reach.An observation of another room (#2) in the behavioral unit was conducted on December 9, 2025 at 1:33 PM, and there was no call light available for resident use. In a later observation of room (#1) conducted on December 9, 2025 at 3:20 PM, the same room (#1) continued to have the call light out of the resident's reach. The call light was on the floor behind the resident's bed.During a medication administration observation conducted on December 11, 2025, at 6:22 AM, an interview was conducted with a Licensed Practical Nurse (LPN/Staff #468) who stated that the behavioral unit was staffed with 1 nurse and 3-4…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#9) and/or the resident representative were informed of the risks and benefits of restraints prior to usage of abdominal binder, waist/seat belt restraint and bilateral mitt restraints. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and risks of restraints. The census was 109.Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrostomy, anoxic brain damage, anxiety, and dementia. A behavior progress note dated October 22, 2022 revealed that a binder was placed over the resident's peg tube to prevent him pulling the peg tube out.Review of progress notes dated October 22, 2022 through February 24, 2025 revealed no evidence of a consent for the use of a binder from the resident's representative, or acknowledgement of risks/benefits.A care plan initiated on February 25,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation were conducted for the least restrictive alternatives for the least amount of time and conduct ongoing evaluations of the need for physical restraints for one resident (Resident #9). The deficient practice could result in the resident not able to use a less restrictive alternative. The census was 109. Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrostomy, anoxic brain damage, anxiety, and Dementia.A behavior progress note dated October 22, 2022 revealed that a binder was placed over the resident's peg tube to prevent him pulling the peg tube out.A nursing progress note dated October 23, 2022, revealed the patient tried to pull out a PICC line and tube feeding while he was in a geri-chair and he required 1-2 staff members to be with him just to keep him safe.A physician progress note dated February 10, 2025…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure a thorough investigation of an allegation of neglect was completed for one resident (#9). The census was 109. The deficient practice could result in incomplete investigations of allegations of abuse.Findings included: Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrotomy, anoxic brain damage, anxiety, and dementia. A Comprehensive Data Set Minimal Data Set (MDS) assessment, dated November 04, 2022, revealed no BIMS (Brief Interview of Mental Status) score; however, it did indicate that Resident #9's cognitive skills for daily decision-making were severely impaired. A change in condition note dated November 06, 2022, at 16:59 revealed that Resident #9 made multiple attempts to put himself on the ground from his geri (geriatric) chair. The note further revealed that the resident had mats in his room and a helmet on for his safety. The note also…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that on residents Minimum Data Set (MDS) assessment regarding restraints was accurate. The deficient practice could result in inaccurate documentation of the resident's medical history and needs. The census was 109. Findings include:Resident #9 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included gastrotomy, anoxic brain damage, anxiety, and dementia. A behavioral progress note dated February 13, 2025, indicated that a G-tube was replaced, a new hand mitts and binder placed.A March 4, 2025 behavior note revealed that the resident had been restless and agitated, posey mitts were in place and abdominal binder to protect G-tube site.A Care Plan initiated on May 21, 2025, revealed a focus area for physical restraints documenting the use and the bilateral soft wrist mittens related to traumatic brain injury. This care plan also revealed an intervention…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has 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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the state mental health authority was notified of a resident's change in mental condition for one resident (#37). The deficient practice could result in residents not receiving the proper level of care to meet their needs.Findings Include:Resident #37 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, bipolar disorder, and colostomy status. A Level 1 Pre-admission Screening and Resident Review (PASARR) dated February 25, 2025 was completed with no referral was necessary for PASARR Level 2. Further review of the PASRR revealed that the Bipolar Diagnosis was not included. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident was congenitally intact. Further review of the MDS revealed no psychiatric or mood disorders and special treatment which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 Number of residents sampled:Number of residents cited: 1Based on observations, record review, staff interviews, review of facility documents, policy, [NAME] Nursing Drug Book, and Medlineplus.gov website, the facility failed to ensure medications for one resident (#14) were administered as ordered by the physician and according to accepted standards of clinical practice. The deficient practice could place residents' safety at risk.Findings include:Resident #14 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, hypoglycemia, and Post-Traumatic Stress Disorder.The care plan dated December 7, 2023, revealed the resident had Diabetes Mellitus. The interventions included diabetes medication as ordered.A physician order dated February 6, 2024 revealed an order for Metformin Hydrochloride (HCL) 500 MG tablet give one tablet by mouth with meals for diabetes. And, another physician order with a revision date of July 16, 2024 revealed an order to OK to crush and combine crushable…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and the facility's policy and procedures, the facility failed to ensure that food items were properly stored and dated to meet safety standards. The deficient practice could result in loss of nutritive value and increase the risk of foodborne illness. Findings include:An initial kitchen observation was conducted on December 9, 2025, at 8:20 a.m. with the Dietary Supervisor (Staff/#308). The following were observed in the walk-in refrigerator:Salad bag opened, exposed to air, and labeled with open and use by dates of 12/6-12/121lb ground beef, without an open or use-by date Employee lunch bag on the shelfBoiled eggs container opened, exposed to air9 unlabeled and undated juice cups1lb bag of green beans opened, exposed to air bag of lettuce opened and exposed to air During a follow-up Kitchen Observation conducted on December 11, 2025, at 6:26 a.m., two sheet cake pans were observed uncovered on the prep counter. A tray line temperature check and observation conducted on December 11, 2025, at 11:46 am revealed the following:12/11/2025 11:40 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#10) right to be free from physical abuse from another resident (#8). The deficient practice could result in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. Additionally, the assessment revealed Resident #10 had no hallucinations, no delusions, no inattention, no disorganized thinking, and no altered level of consciousness.Resident #10's care plan was reviewed and revealed no evidence of physical or psychosocial monitoring related to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2025-11-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of physical abuse of a resident (#10) immediately and within 2 hours to mandated entities. The deficient practice could lead to ongoing abuse of a resident resulting in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment.A Behavior Note dated October 31, 2025, revealed Resident #10 went outside with other residents at lunch to eat pizza and sweets. Additionally, the note revealed that Resident #10 went into the main dining area at 2:00 P.M. with other…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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, review of clinical record, and review of facility policy and procedure, the facility failed to immediately assess residents (#8 and #10) after an allegation of physical abuse, and failed to investigate the allegation according to facility policy. The deficient practice could result in physical and psychosocial harm of a resident.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment.Resident #10's care plan was reviewed and revealed no evidence of physical or psychosocial monitoring related to an allegation of physical abuse from another resident.The assessment list of Resident #10's medical record…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of sexual abuse of one resident (#10) to mandated entities within 2 hours. The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. The facility conducted an in-service regarding Abuse Prevention and Reporting Policy (documentation was included at the time of the request), to include immediate separation of residents, safety, assessment of involved parties, timely…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-11-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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, review of clinical record, and review of facility policy and procedure, the facility failed to investigate an allegation of sexual abuse of one resident (#10). The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. The facility conducted an in-service regarding Abuse Prevention and Reporting Policy (documentation was included at the time of the request), to include immediate separation of residents, safety, assessment of involved parties, timely notifications and documentation. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-11-01 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 Base on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to monitor and ensure that resident (#34) was administered pain and psychotropic medications as per the orders and medications were left with the resident unsupervised. The deficient practice could result in the pain and anxiety not being managed. Findings include: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included post traumatic disorder, anxiety, major depression, low back pain, and chronic pain syndrome. The care plan dated May 26, 2023 revealed that the resident is on pain medication therapy related to pain. Interventions included to administer medication as ordered. Review of the care plan dated May 29, 2023 revealed that the resident is on anti-anxiety mediation due to anxiety as evidenced by restlessness. Interventions included to give anti-anxiety medications as ordered by the physician. The minimum data set (MDS) dated [DATE] included…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of documentation, photographs, staff interviews, and the facility policy and procedure, the facility failed to provide services in accordance with professional standards of practice for one resident (#1). The deficient practice could result in appropriate services not being identified and provided to residents. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified fracture of thoracic vertebrae 5 and 6, subsequent encounter for fracture with routine healing , hypertension, and hypotension. The order summary revealed an order for aspirin tablet chewable 81 milligram (mg) one tablet by mouth one time a day for clotting prevention dated January 16, 2024; ticagrelor oral tablet 90 mg one tablet by mouth for clotting prevention dated January 16, 2024, the order discontinued and request for stop date not provided; and ticagrelor oral tablet 90 mg give one…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that changes in resident #491 condition will be communicated to the physician. The deficient practice could result in delayed treatment. Findings include: Resident #491 was admitted on [DATE], with diagnoses of traumatic hemorrhage of cerebrum without loss of consciousness, wedge compression fracture of T11-T12 vertebra, fracture of the lower end of right radius and lower end of right ulna, dementia, essential primary hypertension, and atrial fibrillation. Record review dated September 8, 2023, revealed the following orders: aspirin 81 mg give one tablet by mouth one time a day for CVA prophylaxis, Lisinopril oral tablet 2.5 mg give one tablet by mouth one time a day for hypertension, and Amiodarone HCL oral tablet 200 mg give two tablets by mouth every 12 hours for atrial fibrillation for 7 days then give one tablet by mouth one time a day for atrial fibrillation for 23 days. Record review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure infection control standard precautions was implemented by staff during incontinence care. The deficient practice has the potential of contamination among other residents in the facility. Findings include: An observation of incontinence care was conducted on October 17, 2023 at 9:50 a.m. with two certified nurse assistants (CNAs/staffs #146 and #125). Staff #125 assisted the resident on her left side while staff #146 performed pericare to the resident. Staff #146 washed her hands with soap and water, dried her hands and donned disposable gloves on, cleaned the resident's perineal area, removed soiled brief and placed them in the trash bin. Using and without removing the same pair of gloves on, staff #146 then applied new and clean brief on the resident, placed the white flat sheet and blanket on the resident. Staff #146 then walked to the restroom, removed the gloves and washed and dried her hands. During an interview with the director of nursing…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#192) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered. Findings include: Resident #192 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, generalized muscle weakness, and unspecified dementia. Review of the physician order summary revealed an order dated October 6, 2022 for polyethylene glycol 17 grams by mouth one time a day for bowel care. There was no physician order for the resident to self-administer medications. Review of clinical records revealed no indication that the resident was a candidate to self-administer medications. An observation for medication administration was conducted on October 19, 2022 at 7:51 a.m. with a registered nurse (RN/staff #116). During the medication pass, the RN gathered…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedure, the facility failed to implement their policy to ensure one sample resident's (#190) advance directive was implemented. The deficient practice could result in other residents' wishes not being honored. Findings include: Resident #190 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, right femur fracture and protein-calorie malnutrition. A do not resuscitate (DNR) code status advance directive had been completed and signed by the resident's representative on [DATE]. Review of the physician's order revealed an order dated [DATE] that the resident was a DNR. However, a review of the computer dashboard display for this resident revealed the resident was a full code. Review of the 5-day Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 which indicated the resident had severe cognitive impairment. Review of the resident's care plan revealed no evidence…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2022-10-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of change in vital signs for one resident (#48). The sample size was 2. The deficient practice could result in delayed treatment for residents. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential primary hypertension, seizures and unspecified psychosis not due to a substance or known physiological condition. Review of the annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of six, which indicated the resident had severely impaired cognition. Review of physician orders revealed the following orders with corresponding start dates and discontinued date, if applicable: -Abilify (Aripiprazole): give 10 milligram (mg) via gastrostomy-tube (g-tube) at bedtime for psychosis as evidenced by auditory…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure administration of medications met professional standards of quality for one resident (#76). The deficient practice could result in delayed treatment and adverse effects for residents. Findings include: Resident #76 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, urinary tract infection (UTI), sepsis and retention of urine. A physician order dated September 26, 2022 included Cefuroxime Axetil tablet (antibiotic) 250 mg (milligrams) 2 tablets by mouth every 12 hours for UTI/sepsis for 6 days. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 4 on the Brief Interview of Mental Status (BIMS) which indicated severe cognitive impairment. The MDS assessment also revealed the resident received antibiotic medication during the 7 days lookback period. Review of the Medication Administration Record (MAR) for September 2022 revealed the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident #33 was admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, schizoaffective disorder (bipolar type) and borderline personality disorder. During initial observation and interview with resident #33 on October 17, 2022 at 9:57 a.m., resident #33 was observed sitting in the wheelchair. The resident inquired about the purpose of the survey and held out an item that appeared to be a sewing needle (two inches long, sharp on one end, and silver in color) and uttered, I have this and I know you like to look at this. One male resident was observed wandering in the hallway. The resident showed a device (threaded in between two rods with beads threaded in) which the needle was being used for and proceeded to thread the needle through his garment. Review of the care plan initiated on October 9, 2020 revealed the resident had potential for behaviors secondary to a diagnosis of schizoaffective disorder further complicated by traumatic brain injury with behaviors…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#24) was evaluated timely after a significant weight loss. The sample size was 3. The deficient practice could result in delayed interventions for residents experiencing weight loss. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included dementia, vascular dementia, abnormalities of gait and mobility, schizophrenia, and anxiety disorder. Physician orders dated 8/13/22 included regular diet, thin liquids consistency, SNP cereal every AM, and fortified ice cream twice a day. Review of the care plan initiated on 8/13/222 revealed the resident had potential for nutrition risk related to being underweight, diagnoses, and MNA (Mini Nutritional Assessment) score 6.0 indicating malnourished. The goal was that the resident would consume greater than 67% of meals. Interventions stated diet as ordered by the physician, serve supplements as ordered,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 344 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.2-1.2 vs chain
Health inspection 1 of 52.9-1.9 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 343 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - WaxahaWaxahachie, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5River Bend HealthcareSeguin, TX 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA 1 of 5The Chateau WacoWaco, TX 1 of 5The Eden of Las ColinasIrving, TX

Showing 40 of 343; lowest-rated first.

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 / managerTypeRoleSince
JONES, BRETTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/22/2025
PORT, BARRYIndividualMANAGING CONTROL - GOVERNING BODYsince 07/26/2018
UY, MARIETTAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/09/2016
PETERSON, FORRESTIndividualCORPORATE DIRECTORsince 01/01/2019
BURNAM, SOONIndividualCORPORATE OFFICERsince 12/15/2014
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
MONKS, CHANDLERIndividualCORPORATE OFFICERsince 03/01/2024
SATO, AMIIndividualCORPORATE OFFICERsince 09/09/2024
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 11/01/2015

CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$17.9M
Net patient revenuemost recent cost report
+18.6%
Operating marginrevenue minus expenses
$1.8M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 7%Other / private 32%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$403per resident / day
operating cost
$12,255per month
≈ monthly operating cost
$495per day
avg. revenue, all payers

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

What families pay in AZ

Paying with Medicaid

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

Typical monthly cost in Arizona
$8,365/mo
Nursing home (semi-private)
$11,437/mo
Nursing home (private)
$6,250/mo
Assisted living

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 035101. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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