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Bella Vita Health and Rehabilitation Center

5125 North 58th Avenue, Glendale, AZ 85301 · For profit - Corporation · 176 certified beds · (623) 931-5800 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$8,278 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-11-06)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4524 N Maryvale Pkwy Ste 220 · (623) 535-4582 · Call to confirm hours
Pharmacy
4616 N 51st Ave Ste 108 · (480) 566-6497 · Call to confirm hours
Grocery
5836 W Camelback Rd · (623) 404-0540 · Call to confirm hours
Park
5821 W Bethany Home Rd · (623) 930-2820 · Typically dawn to dusk

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 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased4.5%10.7%15.4%better
Long-stay residents who lose too much weight4.5%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.9%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.5%3.9%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better 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 worsened12.3%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.3%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine75.0%94.6%95.3%worse
Long-stay residents with pressure ulcers1.2%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control16.8%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.2%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine87.0%87.3%79.4%typical
Short-stay residents rehospitalized after admission17.5%23.7%22.6%better
Short-stay residents with an outpatient ER visit11.5%10.4%12.0%typical

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.

52.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
71.1%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 71.1% 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 83 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 45.3–60.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.7–15.110.7%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 discharge71.1%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 discharge62.6%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 discharge65.1%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 setting100.0%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 discharge71.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 hospitalization5.2%CMS range 2.8–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.31
RN hours/ resident / day
1.37
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.88
Total nurse hours/ resident / day
0.24
RN hoursweekends
44.5%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 176 beds and averages 159.5 residents a day — about 91% occupied, or roughly 16 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.44 hrs/resident/day on weekends vs 4.06 on weekdays — 15% thinner on weekends. RN hours go from 0.33 to 0.24 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

5
deficiencies at the latest standard inspection (2024-10-31)
0
at the previous standard inspection (2023-03-10)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2025-11-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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, facility documentation, policy review, and the State Agency complaint tracking system, the facility failed to ensure that one resident (#1) was not neglected by failing to assess and meet their basic needs to prevent the development of a Stage 3 pressure ulcer and Deep Tissue Injury (DTI). The deficient practice could result in the residents' development of pressure ulcers and deep tissue injuries.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included hypertension, Diabetes Mellitus (DM) Type 2, Schizophrenia, Non-Alzheimer's Dementia, and Cerebrovascular Accident (CVA) with a left-sided weakness.On May 9, 2025, a Braden Scale for Predicting Pressure Sore Risk assessment was completed, and the resident's score was 10.0, high risk.A review of a document, Skin Evaluation-PRN/Weekly, dated May 10, 2025, revealed an initial admission skin evaluation by a wound nurse. The skin evaluation revealed the resident's bilateral feet were dry and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-07-02 · 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 staff and residents interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#2) right to be free from verbal abuse from a staff member for one of eleven sampled residents. The deficient practice could result in psychosocial harm to the resident.-Findings include:-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, anxiety disorder, depression, type 2 diabetes mellitus, chronic kidney disease, and epilepsy.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating intact cognition. Additionally, Section C-Cognitive patterns revealed Resident #2 had no inattention, disorganized thinking, or altered level of consciousness. Section E-Behavior revealed the resident had no hallucinations or delusions.…

    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 plan of correction
  • Potential for harm · D2026-06-03 · 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, hospital discharge documentation review, staff interviews, and review of facility policies and procedures, the facility failed to ensure physician-ordered services were provided in accordance with professional standards of practice for one (#16) of three sampled residents by failing to implement and coordinate physician-directed oncology follow-up appointments identified on the hospital discharge plan. The deficient practice had the potential to result in delayed evaluation, diagnosis, monitoring, and treatment of the resident's medical condition.Findings include:Hospital discharge documentation dated May 3, 2026, revealed Resident #16 had a scheduled oncology laboratory appointment on May 5, 2026, at 9:30 a.m. and a scheduled oncology follow-up appointment with his oncologist on May 8, 2026, at 9:00 a.m.Resident #16 was admitted to the facility on [DATE], with diagnoses that included acute on chronic systolic congestive heart failure, chronic obstructive pulmonary disease…

    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 · D2025-12-29 · 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 closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that one resident's (#911) injury of unknown origin was reported to the state agency. The deficient practice could result in injury of unknown origin not being reviewed for potential abuse.Findings include: Resident #911 (alleged victim) was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, borderline personality disorder, anxiety disorder, age-related cognitive decline, and depression. Review of a care plan initiated on October 26, 2024 revealed that the resident is on anticoagulant therapy. Interventions indicated to monitor/document/report to MD (Medical Doctor) PRN (Pro Re Nata = as needed) signs/symptoms of anticoagulant complications such as bruising, and to monitor/document location, size and treatment of skin injury. A care plan pertaining to resident's impaired thought process/dementia, and cognitive-loss initiated October 26,…

    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 · D2025-12-29 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 closed record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure that the receiving facility was provided the required documentation pertaining to one resident's (#911) transfer/discharge. The deficient practice could lead to the receiving facility not having the appropriate information regarding the resident's medical status and cause a delay in treatment/care.Findings include: Resident #911 (alleged victim) was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, borderline personality disorder, anxiety disorder, age-related cognitive decline, and depression. Review of a care plan initiated on October 26, 2024 revealed that the resident is on anticoagulant therapy. Interventions indicated to monitor/document/report to MD (Medical Doctor) PRN (Pro Re Nata = as needed) signs/symptoms of anticoagulant complications such as bruising, and to monitor/document location, size and treatment of skin injury. A care plan…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-19 · tag F0660 — pattern
    Plan the resident's discharge to meet the resident's goals and needs.
    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 and resident/resident representative interviews, the facility failed to ensure that the resident and resident ' s representatives were a part of the discharge/transfer process for 4 of 5 sampled residents (#21, #32, #16 and #14). Findings include: -Regarding Resident #21 Resident #21 was originally admitted on [DATE] with diagnoses that included cerebral palsy, functional quadriplegia, tourettes and dysphagia. Review of the resident ' s care plan dated February 19, 2017 indicated that the resident did not have an active discharge plan and wished to remain in the facility for long term care (LTC). There were no additions or corrections made to the care plan until the cancellation due to the resident ' s discharge date d March 3, 2025. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 28, 2025 indicating that the resident ' s niece/representative was notified. There were no prior indications of discharge planning. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-19 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident/resident representative interviews, the facility failed to ensure that residents and/or the resident's representative (RR) were notified in writing of transfer to another facility for 2 of 5 sampled residents (#21, and #14). Failure of notification had the potential to affect the resident and their RR by not having clear knowledge of where and why the resident was transferred. Findings include: -Regarding Resident #21 Resident #21 was originally admitted on [DATE] with diagnoses that included cerebral palsy, functional quadriplegia, tourettes and dysphagia. Review of the clinical record revealed a notice of proposed transfer/discharge document dated February 28, 2025 indicating that the resident ' s niece/representative was notified. There were no prior indications of discharge planning. Review of the resident ' s care plan dated February 19, 2017 indicated that the resident did not have an active discharge plan and wished to remain in the facility for long…

    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 before2024-10-31 · 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 observations, staff and resident/resident representative interviews, clinical record and policy review the facility failed to ensure that two resident 's (#214 and #525) were free from abuse. The deficient practice may result in physical and/or psychosocial harm to the residents. Findings include: Resident #214 was admitted on [DATE] and discharged on January 21, 2024 with diagnosis including unilateral primary osteoarthritis of left hip, other intervertebral disc disorders of lumbar region, pain in left hip, and muscle weakness. Review of the incident report dated January 15, 2024 revealed Resident #214 had a Brief Interview for Mental Status (BIMS) summary score of 14 indicating no cognitive impairment. The care-plan initiated on January 18, 2024 revealed that Resident #214 was at risk for impaired thought process related to new environment. The goal was that resident will maintain current level of cognitive function through the review date. Interventions included - monitor/observe resident for…

    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 before2024-10-31 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to notify the Ombudsman of transfer/discharge for one resident (#163). Failure to notify Ombudsman of transfers/discharges may result in residents being discharged against their will. Findings include: Resident # 163 was admitted on [DATE] with a diagnoses including acute kidney failure, Gastro-Esophageal reflex, and multiple fractures of the ribs. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. admission transfer/discharge reports dated July 2024 revealed no evidence that resident (#163) had been listed as discharged . A Care plan dated July 29, 2024 revealed a focus that the resident is to return or be discharged to an alternative placement. A progress note dated July 30, 2024 revealed that the resident was transferred to a rehabilitation facility via stretcher. A physician's order dated July 30, 204 revealed an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#320) was provided assistance with showering and dressing. This deficient practice could result in residents not being provided appropriate hygiene care and services. Findings include: Resident #320 was admitted to the facility on [DATE] with diagnoses that included muscle weakness (generalized), hemiplegia and hemiparesis, and type 2 diabetes mellitus. Review of the care plan dated October 24, 2024 revealed the resident had activities of daily living (ADL) performance deficit related to general weakness, impaired mobility, history of multiple strokes, hypertension, and atrial fibrillation with pacemaker. Review of the Certified Nursing Assistant (CNA) bathing task log revealed no evidence that the resident had received a shower from admission on [DATE] to October 30, 2024. The task log revealed one entry of a refusal of a shower on October 28, 2024. Review of the shower…

    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 · D2024-10-31 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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, interviews, and policy review, the facility failed to ensure that a blood pressure medication was administered within ordered parameters for one resident (# 60). Findings Include: Resident # 60 was re-admitted to the facility on [DATE] with diagnoses that included dependence on hemodialysis, hypotension, hypothyroidism, muscle weakness, and unspecified issues of the musculoskeletal system. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The care plan for hypotension-initiated January 3, 2024, revealed for staff to monitor, and record vital signs, and to report any significant abnormalities to the physician (MD). A medication order for Midodrine HCL 5 mg was initiated on January 30, 2024 for three tablets to be administered with meals for hypotension (low blood pressure), but to hold the dose if the systolic blood pressure was greater than 130.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-10-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, clinical record and policy review the facility failed to ensure enhanced barrier precaution orders were implemented for two residents (#157 and #60); proper infection control practices were implemented during the laundry process; and that, infection prevention and personal protective equipment were utilized as ordered for one resident during medication administration. The deficient practice could result in a spread of preventable illness to residents and staff. Findings Include: -Regarding Resident #157 Resident #157 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left side, morbid obesity, and dysphagia. Review of the Nurse Practitioner (NP) progress noted dated October 11, 2024 revealed that the NP was aware that the resident had a gastrojejunostomy (GJ tube), and therefore instructed the staff to provide GJ tube site care. Review of the physician order dated October 11,…

    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 · Dcited before2024-09-16 · 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 record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#11) was free from abuse from a staff member. This deficient practice could result in the physical and/or mental harm of a resident. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included Bipolar disorder, Anxiety disorder, and Schizophrenia. A 5-day MDS (Minimum Data Set) dated September 10, 2024 was reviewed. A BIMS (Brief Interview for Mental Status) assessment was completed and indicated BIMS score was 13 which indicated Resident #11 was cognitively intact; and that, the resident had experienced hallucinations, and physical and verbal behaviors directed at others. Moreover, this assessment revealed that this resident was independent for bathing. A care plan dated September 10, 2024 revealed that this resident had potential for a psychosocial well-being problem related to a staff to resident altercation. A Psychiatric Note dated September…

    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 before2024-09-10 · 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 documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#107) to be free from abuse by a resident. The deficient practice could result in residents subjected to further abuse. Findings include: Regarding residents #107 and #15: -Resident #107 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, depression and anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS)score of 3 indicating the resident had a severe cognitive impairment. The care plan dated September 5, 2024 revealed the resident had the potential for a psychosocial well-being problem related to resident to resident on September 5, 2024. Interventions included to monitor for mood behavior patterns, aggressive behaviors towards other residents and/or staff, fear of other residents and/or staff and notify provider if present; and that, when conflict arises, remove residents to a calm…

    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 · E2023-08-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility documentation and policy review, the facility failed to ensure there was a physician order for the use of oxygen for one resident (#2). The deficient practice could result in resident receiving oxygen not administered appropriately and as recommended by the physician. Findings include: Resident #2 was admitted on [DATE] with diagnoses of chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), and dependence on supplemental oxygen. A physician order dated July 13, 2023 revealed to document temperature and oxygen saturation and monitor for symptoms such as shortness of breath or difficulty breathing. A nurse practitioner (NP) note dated July 14, 2023 included the resident had COPD and respiratory failure with hypoxia and was oxygen dependent. It also included the resident had even and labored respiration while resting in bed. Assessments included COPD and oxygen dependence. Plan was to monitor respiratory…

    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 · E2022-02-10 · tag F0552 — pattern
    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 reviews, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of psychotropic medications were explained to 3 residents (#111, #37, and #548) and/or their representatives prior to receiving the medications. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of psychotropic medications. Findings include: -Resident #111 was admitted to the facility on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), muscle weakness, and diabetes mellitus type 2. The resident's mood care plan, dated January 16, 2022, revealed that the resident had potential for a mood problem related to PTSD, anxiety, and depression. Interventions included to provide medications as ordered including an antidepressant medication, and to educate the resident, family, and caregivers about the risk, benefits, and side effects of the antidepressant medication.…

    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 · E2022-02-10 · tag F0645 — pattern
    PASARR 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 clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) documentation was complete, accurate, and available for three residents (#12, #100, and #3). The sample size was 4 residents. The deficient practice could result in residents not receiving specialized services that they require. Findings include: -Resident #12 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder, bipolar disorder, and anxiety disorder. Review of PASRR documentation revealed that a level 1 PASRR was completed prior to admission on [DATE] at an acute care hospital. The document revealed that the resident did have a serious mental disorder, bipolar disorder, and had exhibited hallucinations and delusions. The document further revealed that the resident had experienced an inpatient psychiatric hospitalization within the prior 2 years and the resident required assistance with tasks for 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 · Ecited before2022-02-10 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, observations, staff interviews, and facility policies, the facility failed to ensure 2 residents (#24 and #19) received consistent showers and failed to ensure one resident (#548) received meal assistance. The sample size was 7 residents. The deficient practice could result in resident's needs not being met. Findings include: -Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, type 2 diabetes mellitus, obesity, and muscle weakness. A care plan was initiated on January 14, 2021 that included the resident had an Activities of Daily Living (ADL) self care performance deficit related to diagnoses of Alzheimer's dementia, diabetes mellitus, and obesity. An intervention included to encourage the resident to participate to the fullest extent possible with each interaction. Review of the Certified Nursing Assistant (CNA) documentation for bathing from January through June, 2021 revealed the following: -In January…

    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 · D2022-02-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#548) was treated with respect and dignity. The census was 166. The deficient practice could negatively impact the psychosocial well-being of the residents. Findings Include: Resident #548 was admitted on [DATE] with diagnoses that included COVID-19, unspecified psychosis, need for assistance with personal care, unspecified dementia without behavioral disturbance and abnormal weight loss. The baseline care plan dated January 27, 2022 indicated the resident had a potential nutritional problem related to COVID, anxiety, depression, coronary artery disease, lung cancer, psychosis, and weakness. The dietary orders revealed an order dated January 28, 2022 for a regular diet, mechanical soft texture, with thin liquids consistency. Review of the comprehensive care plan dated January 28, 2022 indicated the resident was at risk for malnutrition due to decreased appetite and intake and was at…

    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 before2022-02-10 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation, policy and procedures, the facility failed to ensure the Ombudsman was notified regarding a transfer for one resident (#75). The deficient practice could result in residents not protected from inappropriate discharge. Findings include: Resident #75 was readmitted [DATE] with diagnoses to include obstructive and reflux uropathy, stage 3 chronic kidney disease and personal history of urinary tract infections (UTIs). The comprehensive care plan (initiation date of January 14, 2019) included the resident had right and left nephrostomy tube for hydronephrosis and a suprapubic catheter for a diagnosis of neurogenic bladder with obstructive uropathy. Interventions included catheter/nephrostomy care as ordered and wearing of abdominal (ABD) binder while in bed to help prevent nephrostomy tube from being pulled out. Per the care plan, the resident had history of refusing to wear the ABD binder and had been to the hospital related to nephrostomy…

    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 · D2022-02-10 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review, staff interviews, facility policy and procedure, the facility failed to ensure two temporary nurse aides (#151 & #47) were fully trained to provide care to residents. The deficient standard could lead to care provided to residents does not meet their needs safely and in a manner that promotes residents' rights, physical, mental and psychosocial well-being. Findings include: A Temporary Nurse Aide (TNA) Skills Competency Checklist was used for facility's new employees who complete the program. It included that Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff's ability to use and integrate the knowledge and skills that were the subject of the training, lecture or video must be assessed and evaluated by staff already determined to be competent in these skill areas. -Regarding staff #151 Personnel file review revealed that staff #151 was hired as a nursing assistant on [DATE]. The TNA Skills…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 and facility policy and procedure review and the National Institute of Mental Health and the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders - 5th Edition), the facility failed to ensure there were adequate indications for the use of an antipsychotic medication for one resident (#148). The deficient practice could result in residents receiving an unnecessary psychotropic medication. Findings include: Resident #148 was admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance and cognitive communication deficit. A physician order dated January 26, 2021 included for Quetiapine Fumarate (antipsychotic) give 50 mg (milligrams) by mouth at bedtime for psychosis as evidenced by yelling out. The verbal consent for psychotropic medications form dated January 26, 2021 included the use of Seroquel (brand name for Quetiapine Fumarate) for psychosis. The care plan on antipsychotic medication use dated January 27,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, staff interviews, and policy and procedures, the facility failed to ensure proper infection control measures related to use of Personal Protective Equipment (PPE) were followed by one staff member (staff #151). The deficient practice could result in the spread of infection. Findings include: Resident #548 was admitted on [DATE] with a primary diagnosis of COVID-19. A physician order dated January 27, 2022 included contact/droplet precautions every shift for 14 days and isolations precautions every shift. The care plan with initiation date of January 28, 2022 included the resident was at risk for psychosocial well-being related to visitation restrictions and remaining mainly in the room due to isolation/droplet precautions. Interventions included adhering to transmission-based precautions; educating staff/resident and any visitors of COVID-19 signs and symptoms and precautions; observing strict isolation and droplet precautions and monitoring compliance at all times. The admission Minimum…

    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

“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

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-11-06

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

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 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 3 of 53.2-0.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 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 - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, 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 5Northgate PlazaIrving, 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 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 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

Showing 40 of 341; 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
HANEY, DOUGIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2002
SRIVASTAVA, VINEEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2012
JONES, CHRISTINEIndividualCORPORATE DIRECTORsince 09/09/2024
BURNAM, SOONIndividualCORPORATE OFFICERsince 10/11/2006
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/09/2026
CARETRUST GP LLCOrganizationADP OF THE SNFsince 04/01/2002
CARETRUST REIT INCOrganizationADP OF THE SNFsince 04/01/2002
CTR PARTNERSHIP LPOrganizationADP OF THE SNFsince 04/01/2002
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 08/01/2002
SKY HOLDINGS AZ LLCOrganizationADP OF THE SNFsince 04/01/2002

CMS files one row per role, so the 14 rows in the source record cover these 10 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.

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

Follow the money — this home’s finances

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

$23.4M
Net patient revenuemost recent cost report
+17.0%
Operating marginrevenue minus expenses
$2.3M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 5%Other / private 25%

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$347per resident / day
operating cost
$10,564per month
≈ monthly operating cost
$418per 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 2026-08-01 — CMS provider number 035092. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-31, 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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