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Sandridge Post Acute

255 West Brown Road, Mesa, AZ 85201 · For profit - Corporation · 191 certified beds · (480) 833-3988 Medicare & Medicaid certified

Call the home — (480) 833-3988 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2025
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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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) 2 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
606 N Country Club Dr · (480) 444-7480 · Call to confirm hours
Pharmacy
746 W University Dr · (480) 668-6350 · Call to confirm hours
Grocery
320 W Brown Rd
Park
1000 N Date · (480) 644-3075 · Typically dawn to dusk
Place of worship
805 N Country Club Dr · (480) 833-7312

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 improved from 2 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 increased9.8%10.7%15.4%better
Long-stay residents who lose too much weight8.8%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection0.5%1.2%2.0%better
Long-stay residents with depressive symptoms7.7%3.9%6.5%worse
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 injury0.7%2.1%3.3%better
Long-stay residents whose ability to walk worsened9.0%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.3%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.3%94.6%95.3%typical
Long-stay residents with pressure ulcers2.5%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control24.1%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.8%10.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine99.1%87.3%79.4%better
Short-stay residents rehospitalized after admission27.6%23.7%22.6%worse
Short-stay residents with an outpatient ER visit5.9%10.4%12.0%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

53.5% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.5%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
81.0%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 81.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 58 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.5%CMS range 41.2–62.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.0–17.310.7%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 discharge81.0%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 discharge56.9%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 discharge39.7%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 identified98.3%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 discharge88.1%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 worsened1.7%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 3.5–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

0.41
RN hours/ resident / day
1.03
LPN hours/ resident / day
1.73
Aide hours/ resident / day
3.17
Total nurse hours/ resident / day
0.22
RN hoursweekends
52.6%
Total nursing turnover
52.6%
RN turnover

How full it usually is: this home is certified for 191 beds and averages 148.6 residents a day — about 78% occupied, or roughly 42 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.97 hrs/resident/day on weekends vs 3.25 on weekdays — 9% thinner on weekends. RN hours go from 0.49 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

1
deficiencies at the latest standard inspection (2026-05-01)
3
at the previous standard inspection (2024-03-22)

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

Inspection deficiencies

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

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Dcited before2026-05-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation, staff interviews and policy review, the facility failed to ensure that medications were properly stored and not left at the bedside for 1 of 1 residents sampled (Resident #160). The universe was 156. The deficient practice could result in residents and visitors having unrestricted access to medications. Findings include: Resident #160 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy, unspecified dementia, and other abnormalities of gait and mobility. Review of the care plan first initiated on March 18, 2026, revealed a focus for cognitive loss related to Alzheimer's disease or other dementias with interventions to explain all care before providing and to monitor for changes in cognitive status. Further review of the care plan revealed no evidence of Resident #160 being authorized or able to self-administer medications. Review of the modified admission minimum data set (MDS) dated [DATE] revealed Resident #160 had a brief interview 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of clinical records, and review of facility policies and procedures, the facility failed to ensure that the medical record was complete and accurate for one resident (#10). This deficient practice could lead to inadequate investigation, monitoring, and follow up to ensure the resident's safety and well-being.Findings include: Resident #10 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease of the native coronary artery without angina pectoris, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia following cerebral infarction, dysphagia, paraplegia, essential (primary) hypertension, hyperlipidemia, a personal history of recurrent pneumonia, a history of falling, and gastrostomy status.A review of the intake and five-day report provided by the facility revealed that on December 18, 2025, at approximately 10:30 AM, the Administrator (staff #88) was made aware by Nurse Manager…

    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 before2025-12-02 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 record review, staff interviews, review of facility policies and review of SA database, the facility failed to ensure a through investigation was conducted for abuse and misappropriation of property for two residents (#29 and #33). The deficient practice could result in ongoing abuse of residents.Findings include: -Regarding resident #29Resident #29 was admitted [DATE], and discharged [DATE], with diagnoses that include chronic obstructive pulmonary disease; schizophrenia; bipolar disorder, unspecified; anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; and personal history of transient ischemic attack, and cerebral infarction, without residual deficits. Review of the care plan initiated on March 2, 2022 revealed a focus area for mood, resident is at risk for fluctuating mood symptoms related to sadness, depression, anxiety, fear caused by functional changes. Interventions include observe signs and symptoms for worsening sadness, depression, anxiety, fear, anger, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-02 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure that three medication carts were secured in accordance with professional standards and facility policy when left unattended. The deficient practice could result in residents, visitors, and/or staff members having unrestricted access to medications and medical supplies.Findings include:An observation conducted on December 16, 2025, at 11:13 a.m., revealed that a medication cart on the Beta 2 unit was unattended and unlocked while outside of the direct line of sight of staff. The observation was evidenced by the State Agency (SA) being able to pull open three drawers holding resident medications, over-the-counter (OTC) medications, and diabetic supplies, including lancets.An observation conducted on December 16, 2025, at 11:21 a.m., revealed that the fill-in Director of Nursing and Licensed Practical Nurse Manager (LPN Manager/Staff#13) walked by the unlocked medication cart on the Beta 2 unit and locked it as she walked by. An interview was conducted on December 16, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-02 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that resident-identifiable information and records were kept confidential and not visible to the public. The deficient practice could result in the violation of residents' rights to privacy.Findings include:An observation conducted on December 16, 2025, at 11:27 a.m., revealed that an unattended medication cart on the Beta 1 unit had a laptop on top of it with resident records open on the screen. The nurse was observed in a resident room.An interview was conducted on December 16, 2025, at 11:28 a.m. with a Licensed Practical Nurse (LPN/Staff#202) who stated that it was not her process, or the facility's process, to leave her laptop open with resident records visible and unattended. The LPN stated that the risk of leaving the records open on her laptop was that it was a Health Insurance Portability and Accountability Act (HIPAA) violation. An observation conducted on December 17, 2025, at 8:02 a.m., revealed that a medication cart on the Beta 2 unit was unattended and had a laptop on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-18 · 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 clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident # 16) was free from abuse by another resident (# 22). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident (# 22) Resident (# 22) was admitted to the facility on [DATE] with diagnoses of major depressive disorder, Post Traumatic Stress Disorder, bipolar disorder, and hemiplegia and hemiparesis affecting left non-dominant side. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. It was also noted that the resident is rarely understood. A comprehensive care plan dated December 3, 2024, revealed that Resident (# 22) makes statements of auditory hallucination and delusions. Interventions include, maintaining calm with a slow, understandable approach, and staff to observe for signs and symptoms 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 clinical record review, interviews, and review of facility policies, the facility failed to ensure six of six sampled residents (#2, #3, #4, #5, #6 and #8) were free from sexual or physical abuse from one resident #1. The deficient practice could lead to sexual, physical and psychosocial harm to the residents. Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These…

    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 · Ecited before2025-04-18 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report an allegation of sexual abuse involving five residents (#2, # 3, #4, #5 and #6) to the State Agency. The deficient practice could result in continued resident to resident sexual abuse Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed…

    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 · Ecited before2025-04-18 · tag F0609 — failed to report abuse allegations — pattern
    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 clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of sexual abuse for five residents (#2, # 3, #4, #5 and #6) was reported to the State Agency. Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others and wandering. These assessments occurred 1-3 days of the lookback period. Review of the 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-18 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 reviews, staff interviews, review of facility records, and review of policies and procedures, the facility failed to have evidence that an alleged violation involving sexual abuse regarding five residents (#2, # 3, #4, #5 and #6) was thoroughly investigated. The deficient practice could result in additional alleged violations involving abuse not being investigated Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood, but will self-isolate. Indicators for physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, 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
Show the remaining 19 citations
  • Potential for harm · Dcited before2025-01-14 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to report and investigate an allegation of abuse involving one resident (#1) to the State Agency. The deficient practice could result in further incidents of abuse. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under hospice…

    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 before2025-01-14 · 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 staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#1) was reported to the State Agency. The deficient practice can result in further incidents of abuse not being reported in accordance with professional standards. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under…

    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 before2025-01-14 · 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 and review of the facility policy, the facility failed to investigate and correct alleged violations of abuse for resident #1. The deficient practice could lead to residents suffering from psychosocial harm and further abuse of residents. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of senile degeneration of brain, unspecified dementia and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe impairement. Record revealed resident #1 was admitted to hospice services on January 3, 2025. An interview was conducted on January 13, 2025 at 1:58 pm with a certified nursing assistant (CNA)/Staff #124. Staff #124 identified resident #1 who was observed sitting in a reclining chair with her feet elevated, eyes close, dressed in pants and sweat shirt. Staff #124 stated that resident #1 is newly admitted under hospice services. And while resident is receiving…

    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 before2024-12-19 · 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 Based on clinical record review, interviews, review of Hoyer lift manual and facility policies, the facility failed to use a two-person transfer, as identified by the equipment manual, when transferring a resident. This resulted in resident #3 sustaining a major injury. Findings include: Resident #3 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, closed fracture of the right lower leg with routine healing and stage 1 kidney disease. The activities of daily living (ADLs) care plan dated August 13, 2020 revealed that the resident required assistance with ADLs/mobility secondary to multiple chronic conditions, morbid obesity and history of foot/leg fractures. Intervenations included extensive assistance of 1-2 staff for bed mobility, toileting and dressing; may use Hoyer lift for transfers; and total dependence for bathing. The care plan dated February 6, 2023 included that the resident was at risk for falls related to history of falls, impaired mobility 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 before2024-08-30 · 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 Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure adequate supervision was provided to prevent elopement for one resident (#37). The deficient practice resulted in resident eloping from the facility. Findings include: Resident #37 admitted [DATE] with diagnoses of dementia, diastolic congestive heart failure (CHF), adjustment disorder and anxiety disorders The elopement risk dated January 29, 2024 revealed a score of 10 indicating the resident was at risk for elopement. Another elopement risk dated April 29, 2024 revealed a score of 22 indicating the resident was at risk for elopement. The assessment included that the resident voiced attempt to elope but there was no action made. The initial facility report received on August 26, 2024 revealed that on August 25, 2024 at 7:15 p.m., a certified nurse assistant (CNA) told the on-duty nurse that the resident cannot be located during checks and changes. The documentation included that the resident was…

    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 · D2024-03-22 · 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 resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #16. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #16 was admitted on [DATE] with diagnosis including hypertensive heart disease with heart failure, bipolar disorder, schizophrenia, dementia, mood disturbance, anxiety, type 2 diabetes, depression, atherosclerotic heart disease of native coronary arteries, heart failure, Parkinson's disease, and psychotic disturbance. A review of the quarterly MDS (minimum data set) dated [DATE] revealed a BIMS (Brief interview of mental status) score of 14, suggesting the resident was cognitively intact. A review of the physician orders revealed an order dated [DATE] noting a DNR (do not resuscitate). A subsequent order in the electronic health record dated [DATE]…

    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 before2024-03-22 · 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 clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident, #74 was free from staff abuse. The deficient practice could result in other residents being abused. Findings include: Resident #74 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, hypertension, paraplegia, muscle weakness and idiopathic neuropathy. A review of the quarterly MDS (minimum data set) dated July 20, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. A review of the care plan for resident #74 revealed no significant behaviors and or applicable findings. A review of the progress notes revealed that a skin assessment was conducted on September 15, 2023 revealing no skin injuries or wounds. The progress notes further revealed a change of condition documentation on September 17, 2023. A review of the facility's investigative report revealed that on…

    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 · D2024-03-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 observations, resident and staff interviews, clinical record review, and policies and procedures, the facility failed ensure that oxygen cylinders are not stored directly on the floor for one resident, # 364. The deficient practice could cause the cylinder to tip over, the valve to break off and or the cylinder to potentially explode. Findings include: Resident #364 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, acquired absence of left leg-below the knee, anxiety, and major depressive disorder-recurrent. A review of the MDS (minimum data set) dated March 19, 2024 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. A review of the physician orders revealed an order on March 8, 2024 for 2 liters per minute of oxygen via nasal cannula as needed, per concentrator/ tank for shortness of breath. An observation was conducted on March 20, 2024 at 11:49 AM in the room 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-01 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 facility policy and procedures, the facility failed to ensure that one resident (#14) was free from abuse by other resident (#21). The deficient practice could result in residents being emotionally and physically harmed. Findings include: -Resident (#14) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, bipolar disorder, anxiety disorder, and post traumatic disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. A physician's progress note dated October 23, 2023 at 4:35 PM included that the patient is in bed and states that pain level is 2/10 to his face and nose. Resident had an altercation last night. Review of a 5-day written investigation revealed a statement dated October 23, 2023 by resident #14. He stated that he and resident #21 were both swinging at each other and resident #21 did not hit him…

    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 before2024-03-01 · 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 Based on observations, documentation, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#1) did not elope. The deficient practice could result in residents getting lost and/or harmed. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, alcohol abuse, and opioid abuse. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. The elopement risk assessment dated [DATE] revealed a score of 18 indicating the resident was a high risk for elopement. Review of the care plan dated December 29, 2023 revealed the resident has a history of leaving against medical advise. Interventions included to administer medications as ordered, to assess for placement in a specifically designed therapeutic unit as indicated, and to assess living concerns and issues causing behavior. A progress note dated December 15, 2023 at 5:15 PM…

    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 · D2022-11-18 · 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 review, the facility failed to ensure one resident (#5) was assessed to self-administer medications. The sample size was 26. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: Resident #5 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, asthma, COPD (Chronic Obstructive Pulmonary Disease), allergic rhinitis and chronic sinusitis. Review of the physician orders included the following medication orders: -Artificial Tear Solution, instill one drop in both eyes every 8 hours as needed for dry eyes order dated March 15, 2021. -Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Microgram/Inhalation) (Umeclidinium Bromide), one puff inhale orally one time a day for COPD order dated August 10, 2021. -Flonase Allergy Relief Suspension 50 MCG/ACT (Actuation) (Fluticasone…

    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 · D2022-11-18 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 policy review, the facility failed to ensure two residents (#122 & #65) and/or the residents' representative were provided written information regarding the facility's policy for bed hold. The sample was 2. The deficient practice could result in residents not being informed of the facility's bed hold policy. Findings include: -Resident #65 was admitted to the facility on [DATE], with diagnoses that included chronic pulmonary disease, type II diabetes mellitus, and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. A progress note dated September 14, 2022 at 12:29 p.m. revealed the resident appeared puffy and cheeks were pink. Vitals were taken and noted. The resident's left hand and arm were also puffier. A rolled pillow case was placed for the resident to grip and elevated the arm. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-18 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for one resident (#3). The sample size was 26. The deficient practice could affect the resident's continuity of care. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included trimalleolar fracture of left lower leg, vascular dementia, type 2 diabetes, hypertension, obstructive pulmonary disease, and depression. Review of the care plan initiated on 6/14/22 revealed it was modified on 6/17/22 to reflect concern that the resident had a decline in cognitive function or impaired related to dementia. The goal was that the resident would be able to make simple decisions by responding yes or no on most days. Interventions included monitoring for decline in Activity of Daily Living (ADL) function and referring to rehabilitation therapy if decline in ADLs is noted.…

    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 · D2022-11-18 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 reviews, the facility failed to ensure that a baseline care plan included resident-specific health and safety concerns related to injury for one resident (#176). The sample size was 26. The deficient practice could result in baseline care plans not addressing resident's needs and interventions not being in place to address those needs. Findings include: Resident #176 was admitted on [DATE] with diagnoses that included unspecified fracture of the shaft of the right tibia, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, anxiety disorder, major depressive disorder, and cognitive communication deficit. Review of the Daily/Skilled Note dated January 2, 2022 revealed the reason for skilled care/stay/documentation as teaching and training wound care fracture post fall. The note also indicated the resident was alert and oriented. Review of the 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 revise the comprehensive care plan for one resident (#235). The sample was 26. The deficient practice could result in care not being provided. Findings include: Resident #235 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage with loss of consciousness of an unspecified duration, fall from non-moving wheelchair, and hemiplegia and hemiparesis affecting left non-dominant side. The quarterly Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment also included the resident using a wheelchair as a mobility device. The care plan initiated on June 23, 2021 and revised on November 10, 2021 revealed the resident required assistance/was dependent for activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, bed…

    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 · D2022-11-18 · 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 policy review, the facility failed to administer insulin per physician orders, monitor the behaviors for use of an antipsychotic medication, and ensure a PRN pain medication had pain scale parameters for one resident (#40). The sample size was 5. The deficient practice could result in residents experiencing adverse effects. Findings include: Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified Osteoarthritis, Type II Diabetes Mellitus (DM), peripheral vascular disease. Review of the Order Summary revealed orders for: -Humalog Solution 100 UNIT/ML (Insulin Lispro (Human)) inject as per sliding scale: if 0 - 150 = 0 units (If blood glucose is less than 70, call MD); 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351+ = 10 units and (if blood glucose is greater than 400, call MD immediately for further instruction), subcutaneously before meals and at bedtime…

    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 · D2022-11-18 · 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, resident and staff interviews, and policy review, the facility failed to ensure one resident (#49) was provided wound care and treatment per physician's orders. The sample size was three residents. The deficient practice could result in delayed wound healing and residents not receiving treatment as ordered. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, heart failure, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, major depressive disorder and dependence on wheelchair. Review of the resident's care plan initiated on July 25, 2022 revealed the resident was at risk for skin breakdown related to decreased activity, incontinence, obesity, and decline to accept wound care for the LE (Left Extremity) cellulitis. The interventions stated to encourage the resident to let the nurse do wound treatments and provide wound treatment as ordered. A…

    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 · D2022-11-18 · 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 clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#338) was consistently provided meals to maintain nutritional status. The sample size was 2. The deficient practice could result in nutritional needs of residents not being met. Findings include: Resident #338 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur, dysphagia, metabolic encephalopathy, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, and major depressive disorder. A physician's order dated January 27, 2022 stated regular diet, dysphagia advanced texture, thick liquids-honey consistency. Review of the January 2022 task charting log titled Meal revealed no information regarding resident #338's eating self-performance, eating support provided, and amount eaten on the following dates and meal times: January 27 - lunch January 28 - dinner January 29 - dinner January 31 -…

    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 before2022-11-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#83) clinical record was accurate and complete regarding advance directive. The sample size was 3. The deficient practice could result in residents' clinical records not being complete. Findings include: Resident #83 was admitted to the facility on [DATE] with diagnoses that included chronic osteomyelitis, right ankle and foot open wound, muscle weakness, difficulty in walking, hepatic failure, and alcoholic cirrhosis. Review of resident #83's Advance Directive revealed a file titled DNR Advance Directive. However, upon opening the file, it indicated that the resident signed for a full code. The form was signed by the resident and the facility's representative October 10, 2022. Further review of resident #83's clinical record did not reveal any physician's order regarding the resident's code status. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview 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

“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 PACS GROUP — 274 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 52.9+0.1 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; 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
KARKOUTLY, AHMADIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2024
LINCOLN, ERINIndividualW-2 MANAGING EMPLOYEEsince 09/01/2023
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
HANCOCK, MARKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$9.3M
Net patient revenuemost recent cost report
+16.3%
Operating marginrevenue minus expenses
$203K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 1%Other / private 18%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $203K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$280per resident / day
operating cost
$8,519per month
≈ monthly operating cost
$335per 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 035196. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, 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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