Payson Care Center
107 East Lone Pine Drive, Payson, AZ 85541 · For profit - Limited Liability company · 163 certified beds · (928) 474-6896 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 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 (30) — 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)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.4% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.4% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.0% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 17.1% | 3.9% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.1% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.0% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.7% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.0% | 23.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.6% | 10.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.94 | 1.47 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.58 | 1.42 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 93.9% 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 49 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.3%CMS range 58.4–75.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.9–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 93.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 85.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 89.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 91.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 3.9–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 163 beds and averages 41.0 residents a day — about 25% occupied, or roughly 122 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.55 hrs/resident/day on weekends vs 4.12 on weekdays — 14% thinner on weekends. RN hours go from 0.90 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · D2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure a resident's (#72) skin was adequately assessed and treated according to professional standards. The deficient practice could lead to missed skin conditions, resulting in wounds, infection, or other physical harm to a resident. -Findings include: Resident #72 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease, obesity, radiculopathy, encounter for orthopedic aftercare, spinal stenosis, and rheumatoid arthritis. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. A care plan dated February 27, 2025, indicated the resident was at risk for skin breakdown, with interventions to include weekly skin checks and treatment as ordered. There was no evidence of a physician's order 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.
- Potential for harm · E2025-03-07 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 clinical record review, staff interviews, and policy and procedures review, the facility failed to ensure that consent was obtained by the resident before psychotropic medications were administered for one of five sampled residents (#23). The deficient practice could result in residents receiving an unnecessary psychotropic medication. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Review of the order summary revealed a physician's order dated April 24, 2024 for Duloxetine hydrochloric acid (HCL) capsule delayed release particles 30 milligrams (MG); give two capsules by mouth at bedtime for depression dated. Review of resident's #23 clinical record revealed a medication informed consent form dated April 24, 2024 that listed the medication Duloxetine. However, the consent form was not signed by the resident or 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.
- Potential for harm · E2025-03-07 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for five of nine sampled staff (#28, #34, #48, #53, and #56). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the certified nursing assistant (CNA/Staff #28) Review of personnel file for the CNA (staff #28) revealed a hire date of March 1, 2010. Physical sign-in sheets and certification of online completion provided by the facility revealed that Staff #28 did not complete required annual training for dementia for the year of 2024 and 2025. - Regarding the occupational therapist (OT/Staff #34) Review of personnel file for the OT (staff #34) revealed a hire date of April 3, 2024. Physical sign-in sheets and certification of online completion provided by the facility revealed that Staff #34 did not complete required training for dementia for the year of 2024 and 2025. - Regarding the licensed practical nurse (LPN/Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-07 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure that five of nine sampled staff sampled staff (#28, #34, #48, #53 and #56) received ongoing education on abuse, neglect, exploitation, and providing care to those with Alzheimer's or other dementia. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the certified nursing assistant (CNA/Staff #28) Review of personnel file for the CNA (staff #28) revealed a hire date of March 1, 2010. Physical sign-in sheets and certification of online completion provided by the facility revealed that Staff #28 did not complete required annual training for dementia for the year of 2024 and 2025. - Regarding the occupational therapist (OT/Staff #34) Review of personnel file for the OT (staff #34) revealed a hire date of April 3, 2024. Physical sign-in sheets and certification of online completion provided by the facility revealed that Staff #34 did not complete required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure that one resident (#35) was issued a written Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) within the required timeframe and one resident (#26) was not given the SNF ABN notification as required. Findings include: Resident (#35) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, abnormalities of gait and mobility, and generalized muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the Occupational Therapy Discharge Summary revealed dates of service December 20, 2024 through January 31, 2025. It also revealed that the resident had reached maximum potential with skilled services. The resident was discharged as per physician or case manager. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
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 one resident (#18) was provided with adequate supervision to prevent falls. The deficient practice could result in residents being harmed physically. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included, pain in thoracic spine, pain in left and right leg, age related osteoporosis, and other abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate cognitive impairment. The assessment also revealed that the facility was unable to determine falls in the last month prior to admission or last 2-6 months of admission, but indicated the resident did not have any falls since admission. Review of the resident's care plan revealed no evidence of a focus or interventions related to falls prior to or after each documented fall. 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.
- Potential for harm · D2025-03-07 · tag F0696 — isolatedProvide appropriate care/assistance for a resident with a prosthesis.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure resident # 26 was provided care and assistance, to aid in the preparation of the left prosthetic device readiness. This deficient practice can result in resident deconditioning, adversely impacting prosthetic device use. Findings include: Resident #26 was readmitted to the facility on [DATE], following amputation of the left lower extremity on October 2, 2024. Additional clinical diagnoses include Type 2 Diabetes Mellitus, bilateral amputation of the lower extremities, muscle weakness, and limitation of activities due to disability. A physical therapy consultation report dated October 9, 2024 revealed the resident will need a fitting for the right lower prosthetic. A progress note dated October 11, 2024 revealed the resident was a little sad, but willing to try the prosthetic device. An order dated October 15, 2024 revealed an order for the resident be referred for resizing of the right below the knee amputation. A progress note dated October 21, 2024 revealed the resident was in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0826 — isolatedProvide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
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 facility policy, the facility failed to ensure one sampled resident (#26) received the restorative nursing services necessary to attain the resident's highest level of health and well-being. This deficient practice can result in the impairment of residents' ability to carry out activities of daily living (ADLs). Findings include: Resident # 26 was admitted to the facility on [DATE] for orthopedic aftercare following an amputation of the lower extremity. Further clinical diagnoses include a previous amputation of the lower extremity, muscle weakness, protein-calorie malnutrition, Type 2 Diabetes Mellitus (DM), and Chronic Kidney Disease (CKD). The Occupational Therapy Discharge Summary for the certification period of December 5, 2024 through January 1, 2025 was signed by OT on December 5, 2025, and by the provider on December 16, 2024. The OT discharge summary supported the design and implementation of a restorative nursing program. The discharge summary advised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, facility documentation, and staff interviews, the facility failed to ensure that two residents (Resident #104 and Resident #400) do not abuse each other. The deficient practice could result in further instances of resident to resident altercations, creating an unsafe environment. - In regards to Resident #104 Resident #104 was re-admitted to the facility on [DATE] with the diagnosis of post-traumatic stress disorder, unspecified, anxiety disorder, unspecified, vascular dementia, severe, with other behavioral disturbance, other amnesia, sensorineural hearing loss, bilateral, cognitive communication deficit. A quarterly MDS (minimum data set) dated March 25, 2022 revealed a BIMS (Brief Interview for Mental Status) score of 00, indicating that Resident #104 had the most severe level of cognitive impairment, signifying a person has demonstrated very poor cognitive function on the Brief Interview for Mental Status (BIMS) test, essentially showing a lack of ability to answer basic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that documentation and evidence of an investigation of an alleged incident between two residents (Resident #104 and Resident #400) were retained as evidence of a thorough investigation had been completed. The deficient practice could result in further instances inadequate investigation completion and documentation retention of completed investigations. - In regards to Resident #104 Resident #104 was re-admitted to the facility on [DATE] with the diagnosis of post-traumatic stress disorder, unspecified, anxiety disorder, unspecified, vascular dementia, severe, with other behavioral disturbance, other amnesia, sensorineural hearing loss, bilateral, cognitive communication deficit. A quarterly MDS (minimum data set) dated March 25, 2022 revealed a BIMS (Brief Interview for Mental Status) score of 00, indicating that Resident #104 had the most severe level of cognitive impairment, signifying 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.
Show the remaining 20 citations
- Potential for harm · Dcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
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 ensure one resident (#5) was provided with adequate supervision to prevent a fall. The deficient practice could result in residents being harmed physically and psychologically. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, chronic kidney disease, polyneuropathy, and history of falling. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section J revealed the resident had a fall within the last month and within the last 2-6 months. A care plan dated January 13, 2025, revealed the resident is at risk for falls. A goal indicated that the resident will not sustain serious injury requiring hospitalization through the review date. Interventions included to assist with activities of daily living (ADLs) as needed 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.
- Potential for harm · Dcited before2025-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, the facility failed to ensure respiratory services were provided according to professional standards for one resident (#5). The deficient practice could result in residents receiving unmonitored doses of supplemental oxygen, and the provider not being aware of the resident's status. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, chronic kidney disease, polyneuropathy, and history of falling. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the care plan revealed no evidence of a care plan for oxygen use. A physician order dated January 6, 2025, indicated for Oxygen continuously per nasal cannula. Document, with no further instructions or information. Review of the O2 Sats Summary log revealed that from January 6, 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.
- Potential for harm · Dcited before2025-01-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that the medical record was complete and accurate for one resident (#5). The deficient practice could lead to interdisciplinary team members not being aware of the resident's status and could lead to a gap in care. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, chronic kidney disease, polyneuropathy, and history of falling. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A Behavior Note dated January 19, 2025, at 5:41 AM, indicated that the resident was anxious and restless, climbing out of bed, and taking off his nasal cannula. The resident was difficult to redirect. The note indicated that the resident is resting in bed, and the nurse will continue to monitor for behaviors. There was no evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-14 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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, record review, interviews, and review of facility documentation and policy, the facility failed to ensure residents were not abused by other residents, for 4 of 5 sampled residents (#1, #2, #3, and #4) and one resident (#5) was not abused by a staff member for 1 of 5 sampled residents. The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident. -Regarding Resident #1 and Resident #2: Resident #1 was admitted to the facility on [DATE], with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that written policies and procedures were developed and implemented to prohibit and prevent abuse for one resident (#1). The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident. Resident #1 was admitted to the facility on [DATE], with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that an allegation of abuse was reported immediately but not later than two hours to the State Agency and mandated entities for one resident (#1). The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident. Resident #1 was admitted to the facility on [DATE], with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that an allegation of abuse was thoroughly investigated, and that further potential abuse was prevented during an investigation of abuse for one resident (#1). The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident. Resident #1 was admitted to the facility on [DATE], with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that the medical record was complete and accurately documented for one resident (#1). The deficient practice could lead to an insufficient record of a resident's status resulting in a decreased quality of care provided. Resident #1 was admitted to the facility on [DATE], with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-06 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, staff interview and facility policy and procedure, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in activities program for residents are not directed by a qualified professional. Findings include: Review of the employee file for staff #25 revealed a hire date of September 7, 2021. The personnel file revealed staff #25 did not have evidence of the required qualifications as an activities director. An interview was conducted on April 5, 2023 with staff #25 who stated that she did not have any required certification or qualifications as an activities director. Staff #25 stated that she works five days a week from Tuesday through Saturday, 8 hours a day. She stated that the receptionist (staff #52) covers the activities for Monday. During the interview, a review of the activity calendar was conducted with staff #25 who stated that there was no facility guided activities after 4:00 p.m. because she leaves the facility at 3:00 p.m. Staff #25 also stated that there was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, clinical record review and facility policy and procedure, the facility failed to ensure one resident was provided with privacy in his room. The deficient practice could result resident's personal privacy being breached. Findings include: Resident #22 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia and type 2 diabetes mellitus. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (brief Interview for mental status) score of 12 indicating the resident had moderately impaired cognition. During an observation conducted on April 3, 2023 at 11:03 a.m., resident #22 was inside his room and had a roommate. However, there was no privacy curtains between resident #22 and his roommate. Resident #22 stated he had no privacy and did not like to change his clothing in front of roommate. In another interview conducted on April 4, 2023 at 10:17 a.m., resident #22 stated the privacy curtain had always been down; and that, his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to ensure PASRR (Pre-admission Screening and Resident Review) level I screening was completed for one resident (#22). The sample size was 1. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings Include: Resident #22 was admitted on [DATE] with diagnoses of unspecified psychosis, depression and Alzheimer's disease. A physician order dated February 17, 2023 revealed an order for Seroquel (antipsychotic) 100 mg (milligrams) 1 tablet by mouth at bedtime for diagnosis of psychosis with target behavior of yelling out. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The section on the MDS for the PASSR evaluation was not marked. A physician order dated March 13, 2023 included the following orders:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#23) and/or the resident representative were informed of the risk and benefits of psychotropic medications prior to the administration of the medications. The sample size was 5. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychotropic drugs. Findings include: Resident #23 was admitted on [DATE] with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, and cognitive communication deficit. Review of the physician's orders revealed an order dated September 12, 2021 for Bupropion extended release 300 milligrams (mg) by mouth daily for major depression disorder and an order dated September 13, 2021 for Sertraline 100 mg by mouth at bedtime for depression. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 08 indicating the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0623 — isolatedProvide 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 reviews, staff interviews, and review of policies and procedures, the facility failed to notify one resident (#358) and the resident's representative in writing of a discharge containing the required information, failed to notify one resident (#56) and the resident's representative in writing of a transfer, and failed to send a copy of the transfer/discharge notices to the Office of the State Long Term Care Ombudsman. The deficient practice could result in residents/representatives not being provide written notice of transfers/discharges and the Ombudsman not receiving a copy of the notices. Findings include: -Resident #358 was admitted to the facility on [DATE] with diagnoses that included artificial openings of the digestive tract, protein- calorie malnutrition, Barrett's esophagus, dysphagia, and esophageal varices without bleeding. Review of the discharge/transfer order form dated February 28, 2020 at 3:00 PM revealed resident #358 was discharged home on March 5, 2020 because the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a Minimum Data Set (MDS) assessment was accurate for one resident (#31). The sample size was 15. The deficient practice could result in MDS assessments not being accurate and in data that is not accurate for quality monitoring. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses of alcoholic cirrhosis of the liver without ascites, hepatic failure, and COVID-19. A physician order dated July 6, 2021 included for a regular diet, regular texture, thin consistency. A quarterly MDS assessment dated [DATE] included this resident required supervision for eating and setup help only. This MDS assessment also included in Section K, question K0510, column 2 that this resident was on parenteral/intravenous (IV) feeding and had a feeding tube. However, review of the clinical record, including the physician orders, progress notes, and care plan did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0660 — isolatedPlan 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 interviews, and facility policy, the facility failed to ensure a discharge care plan was developed and implemented that addressed all of the needs for one resident (#358) being discharged home, by failing to ensure the resident had durable medical equipment (DME) in place prior to discharge. The sample size was 2. The deficient practice could result in a delay of DME for residents who are discharged . Findings include: Resident #358 was admitted to the facility on [DATE] with diagnoses that included artificial openings of the digestive tract, protein-calorie malnutrition, Barrett's esophagus, dysphagia, and esophageal varices without bleeding. A physician order dated February 2, 2020 included an enteral feed order of Osmolite 1.2 at 40 milliliters (mL) per hour for 24 hours per day via pump. Review of the Care Plan Conference Record dated February 4, 2020 revealed social services discussed discharge of the resident returning home. None of the boxes for reviewing the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure that one of three sampled residents (#6) received consistent showers. Failure to consistently bath or shower residents could result in unhealthy hygiene practices. Findings include: Resident #6 was admitted to the facility on [DATE], with diagnoses that included a urinary tract infection, acute kidney failure and diabetes type II. Review of an Activity of Daily Living (ADL) care plan dated 9/12/2021 revealed the resident is to be bathed or showered 2 times weekly and that the resident is totally dependent on two staff to provide. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS assessment also included the resident required total dependence on staff for bathing. According to a Certified Nursing Assistant (CNA) 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.
- Potential for harm · D2022-01-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure treatments were provided consistently for one sampled resident (#30) with a pressure ulcer. The deficient practice could result in worsening of pressure ulcers. Findings include: Resident #30 was admitted on [DATE], with diagnoses that included pressure ulcer of the sacral region, end stage renal disease, heart failure and spinal stenosis. A physician order dated 12/23/2021 included to clean the coccyx/buttocks wound with wound cleanser, dry, apply Triad Paste to the wound bed and cover daily every day shift. The admission Minimum Data Set assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 15 which indicated the resident had no cognitive impairment. The assessment included the resident had one stage 3 pressure ulcer that was present on admission but did not included the resident was receiving pressure ulcer care. Review of the care plan initiated on 12/31/21, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure an order for oxygen was in place for one sampled resident (#30) receiving oxygen. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #30 was admitted on [DATE], with diagnoses that included end stage renal disease, heart failure and spinal stenosis. Review of the admission Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status indicating the resident had no cognitive impairment. During an observation conducted of the resident on 01/24/22 at 02:01 PM, the resident was observed receiving oxygen via nasal cannula at 3 liters. An interview was conducted with resident #30 on 01/24/22 at 02:08 PM. The resident stated that he wears oxygen on and off when he needs it and has been doing so for 2 to 3 weeks. However, review of the clinical record revealed no order for oxygen use or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-27 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and policy review, the facility failed to ensure that the temperature of one out of two nourishment refrigerators was consistently checked and documented on the temperature log. The deficient practice could result in food spoilage and foodborne illness. Findings include: A kitchen observation was conducted with the Kitchen Manger (staff #60) on 01/26/22 at 09:56 AM. The nourishment refrigerator temperature log dated January 2022 was observed to not have documentation of temperatures on January 1, 5, 6, 7, 8, 13, 14, 15, 19, 20, 21, 22, 23, and 24, 2022 for station 2. An interview was conducted with the Kitchen Manager (staff #60) on 01/26/22 at 01:09 PM. Staff #60 stated that the nourishment refrigerator temperature should be checked and documented every day however, this has not been done. Staff #60 stated that there is no specific person designated to check the nourishment refrigerators daily. Staff #60 stated it is her responsibility to ensure that this has been done. The Kitchen Manager stated that not checking and documenting the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-01-27 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result residents and visitors not being made aware of the current staffing information. Findings include: An observation was conducted on January 24, 2022 at 10:46 am of the posted nurse staffing information located in the front lobby. The posted nurse staffing information was dated December 31, 2021. An interview was conducted on January 27, 2022 at 9:23 am with the Staffing Coordinator (staff #23), who stated that she usually posts the daily nurse staffing information. Staff #23 acknowledged the nurse staffing information that was posted on Monday, January 24, 2022 at 10:46 am was not current. An interview was conducted on January 27, 2022 at 9:26 am with the Director of Nursing (DON/staff#43). When the DON was informed of the observation conducted on Monday, January 24, 2022 at 10:46 am of the nurse staffing information posted that was dated December 31, 2021, the DON stated ok. A review of 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; 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 / manager | Type | Role | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2006 |
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/08/1989 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| KEENOM, STEPHANIE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 03/16/2025 |
| WILLIAMS, JERMAINE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/22/2025 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 04/21/1994 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| LAY, LISA | Individual | CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE OFFICER | since 04/01/2011 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2025 |
| EGBO, OBINNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2026 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| PAYSON UNITED MEDICAL INVESTORS LLC | Organization | ADP OF THE SNF | since 12/19/2007 |
CMS files one row per role, so the 24 rows in the source record cover these 16 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.
3 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.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
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.
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 035117. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-07, 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.