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Camelback Post Acute Care And Rehabilitation

4635 North 14th Street, Phoenix, AZ 85014 · For profit - Corporation · 107 certified beds · (602) 264-9039 Medicare & Medicaid certified

Call the home — (602) 264-9039 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20261 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
4751 N 15th St #3 · (602) 277-7526 · Call to confirm hours
Pharmacy
4602 N 16th St Ste 200 · (888) 370-1724 · Call to confirm hours
Grocery
4724 N 20th St · (602) 263-0771 · Call to confirm hours
Park
1718 E Campbell Ave · Typically dawn to dusk
Place of worship
1550 E Meadowbrook Ave · (520) 325-2775

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 increased6.4%10.7%15.4%better
Long-stay residents who lose too much weight4.3%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.2%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%3.9%6.5%check this — see note marked star below the table
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 injury0.0%2.1%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication21.8%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.3%94.6%95.3%typical
Long-stay residents with pressure ulcers6.1%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control27.9%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.3%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine86.5%87.3%79.4%typical
Short-stay residents rehospitalized after admission21.4%23.7%22.6%typical
Short-stay residents with an outpatient ER visit5.7%10.4%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

52.0% 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 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.0%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
73.2%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 73.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 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 18% 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 SNF52.0%CMS range 42.4–60.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.2–15.810.7%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 discharge73.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.3%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 discharge68.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.4–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.83
RN hours/ resident / day
0.76
LPN hours/ resident / day
1.66
Aide hours/ resident / day
3.25
Total nurse hours/ resident / day
0.57
RN hoursweekends
34.4%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 107 beds and averages 84.3 residents a day — about 79% occupied, or roughly 23 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.66 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 2.74 hrs/resident/day on weekends vs 3.46 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.93 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below 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

8
deficiencies at the latest standard inspection (2024-04-24)
0
at the previous standard inspection (2022-12-01)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2023-11-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to coordinate one resident's (#4) care/medications with hospital physician to ensure medications were given according to physician instructions. The deficient practice resulted in significant harm to the resident. Findings included: Resident #4 was admitted to the facility on [DATE] and discharged on 10/22/2023 with diagnoses that included epilepsy and traumatic brain injury (TBI). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. Review of a discharge paperwork from a hospital with a printed date of 10/19/2023 revealed a physician order for Phenytoin (anti-convulsant) 50 mg (milligram) oral tablet, chewable 3 tab(s) oral twice a day; Clobazam (sedative) 10 mg oral tablet 2 tablets oral twice a day. The hospital discharge order also included an order to continue taking Cenobamate…

    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 before2026-06-03 · 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 observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure care and services regarding oxygen therapy were provided to meet the needs of one of four sampled residents (Resident #3). The deficient practice could result in a resident not receiving necessary respiratory care, and could result in a worsening medical condition and physical harm.Findings include:Resident #3 was re-admitted on [DATE] with diagnoses of cognitive communication deficit, schizophrenia, abnormalities of gait and mobility, acquired absence of right leg below the knee, acquired absence of left toe(s), fracture of shaft of left fibula, atrial fibrillation, end stage renal disease, dependence on renal dialysis, and chronic obstructive pulmonary disease, need for assistance with personal care, and personal history of other mental and behavioral disorders.Physician orders dated November 23, 2025, included:- PRN (as needed) oxygen, to titrate between 1-5 liters per minute…

    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 · D2026-01-13 · 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 reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to protect the rights of one resident, resident (#1) to be free from verbal abuse by staff. The deficient practice could result in further abuse. Findings Include: Resident #1 was admitted on [DATE], with a diagnosis that included spinal stenosis, retention of urine, hypertension, fibromyalgia, obesity, muscle weakness, abnormalities of gait and mobility, need for assistance with personal care, and low back pain. The care plan dated November 26, 2025, had a focused care area for risk of impaired cognitive function/dementia or impaired thought process related to the new environment. Interventions included engaging in simple, structured activities that avoid overly demanding tasks, identifying yourself at each interaction, face when speaking, and making eye contact, reducing any distractions-turn off the TV and radio, and closing the door. Use simple, directive sentences. Provide…

    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 before2024-05-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent the spread of infection. The deficient practice could result in the spread of infection to residents. Findings include: On May 28, 2024 at approximately 8:01 a.m., a yellow round bin and one gray square bin full of soiled sheets and other laundry items were observed to be overflowing in the hallway on Hall 200 by the laundry room. There was also a smaller silver container full of dirty towels and the lid was not completely covering the bin. The hallway smelled of urine. On May 28, 2024 at approximately 8:05 a.m. a female staff was observed pushing the yellow round bin and gray square bin full of soiled laundry through the exit door near the laundry room and left them outside. The smaller silver container with dirty towels was left in the hallway. On May 28, 2024 at the Housekeeping Supervisor (staff #76) was observed entering the Hall 200 through the exit door when the soiled sheets…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-29 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent odor and ensure a comfortable environment. The deficient practice could impact the residents' safe, sanitary, and homelike environment. Findings include: On May 28, 2024 at approximately 8:01 a.m., a yellow round bin and one gray square bin full of soiled sheets and other laundry items were observed to be overflowing in the hallway on Hall 200 by the laundry room. There was also a smaller silver container full of dirty towels and the lid was not completely covering the bin. The hallway smelled of urine. On May 28, 2024 at approximately 8:05 a.m. a female staff was observed pushing the yellow round bin and gray square bin full of soiled laundry through the exit door near the laundry room and left them outside. The smaller silver container with dirty towels was left in the hallway. On May 28, 2024 at the Housekeeping Supervisor (staff #76) was observed entering the Hall 200 through 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-29 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 assess one resident (#35) for pain and take vitals when admitted to the facility in a timely manner, and failed to administer pain medication with pain parameters for one resident (#27). The deficient practice could result in residents' pain not being identified and addressed, residents' being overmedicated or under-medicated. Findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of left tibial tuberosity, subsequent encounter for closed fracture with routine healing, Epilepsy, and type II diabetes. Review of the order summary revealed: -April 27, 2024, monitor level of pain for every shift/using the following scale: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain. -April 27, 2024, Tylenol tablet 325 mg give two tablets by mouth every six hours as needed for pain 1-3. -April 27, 2024, Celecoxib capsule 200 mg give one capsule by…

    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 · E2024-04-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, food items were not expired, temperature logs were maintained, equipment was sanitized, and food was served under sanitary conditions. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding food labeling and dating: During the initial kitchen observation conducted on April 21, 2024 at 7:17 a.m., two items wrapped in foil was found in the walk-in freezer which was unmarked/not labeled and not dated. Additionally, cereal dispenser for what appears to be [NAME] Krispies, Raisin Bran, Corn Flakes, and Cheerios did not have an expiration date. A bin containing oatmeal was marked 2/16 but it is unknown if that is the filled date or the expiration date. A bin containing lentil was marked 2/1 and did not specify if it was the fill date or expiration date. A container marked bread crumbs was labeled 2/1 but the same container was also marked Panko with 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that dirty dishes were not left in a common areas where residents have access, and that common areas were cleaned and disinfected. The deficient practice could result in residents becoming ill or infected. Findings include: On April 21, 2024 at 8:27 a.m. brown liquid in a gray cup with a straw was observed on a mobile tray in the 200 hall just outside a resident's room and it was unattended. Also, a tray was observed in the Northeast dining room with toast, leftover cereal in a bowl that resembled heart shaped Cheerios, one bowl of leftover oatmeal and milk, leftover scrambled eggs on the plate, and orange liquid in a Styrofoam cup with a straw. The tray was unattended and there were three residents sitting in the dining area watching TV. On April 21, 2024 at 8:49 a.m. feces, approximately 1.5 inches, was observed in the middle of the hallway in front of room [ROOM NUMBER]. Staff were observed walking by…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 facility policies and procedures, the facility failed to ensure one resident's (#81) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #81 was admitted on [DATE] with diagnosis including an unspecified fracture of the right femur, end stage renal disease, osteomyelitis, encounter for orthopedic aftercare following surgical amputation, complete amputation of left foot, dependence on renal dialysis, type II diabetes mellites with diabetic polyneuropathy, chronic systolic heart failure and aneurysm of iliac artery. It was further noted in the electronic health record that the resident left the facility against medical advice on August 20, 2023. A review of the MDS (minimum data set) revealed no noted score for the BIMS (brief interview of mental status). A review of the electronic 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · 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 and resident interviews and policy review, the facility failed to ensure one resident's (#44) representative was able to participate in the care planning process. The deficient practice could result in residents and representatives not participating in and understanding their plan of care. Findings include: Resident #44 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, atrial fibrillation, aphasia, and cognitive communication deficit. Review of the cognition care plan initiated on November 20, 2023 indicated that the resident is at risk for impaired cognitive function/dementia or impaired thought process. Interventions include to communicate with family/caregivers regarding resident's capabilities and needs, and social services to provide psychosocial support as needed. The resident's admission record indicated that the resident has two emergency contacts. The first emergency contact (primary) is…

    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 · D2024-04-24 · 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 observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a potentially dangerous item was not left in a public area on one resident's (#1) mobile tray where other residents could access it. The deficient practice could result in residents injuring themselves. Findings include: On April 21, 2024 at 8:27 a.m., a mobile tray was observed in the hallway by room [ROOM NUMBER]. There was a blue razor with a clear plastic cover over the blade on the tray and the tray was left unattended. An interview was conducted on April 21, 2024 at 8:37 a.m. with a certified nursing assistant (CNA/staff #88), who stated that they put the mobile tray outside of the resident's room because there is no room for his wheelchair. She stated that the razor is supposed to be thrown away once it has been used and there is a risk of residents cutting themselves on the razor. After the interview, staff #88 began walking away and the surveyor had to intervene and ask her to remove 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-04-24 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#1) was assessed for the risk of entrapment when using full size bedrails on both sides of the bed and to assess and document the ongoing need for bed rails. The deficient practice could result in residents being physically injured. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, muscle spasm of the back, disorder of the autonomic nervous system and depression. Review of the Assistive Device Consent form dated September 18, 2019 did not reveal a consent for the use of two full size bed rails. The care plan dated September 24, 2019 included that the resident has quadriplegia related to a spinal injury status post a motor vehicle accident in 1991. Interventions included two full side rails up when in bed for unsafe jerky movements related to muscle spasms. The resident's care plan dated September 24, 2019 states 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) provided eight hours of coverage in a 24 hour period. Findings include: Review of the daily staff posting dated December 24, 2023 revealed that the census was 82. There were four licensed practical nurses (LPNs) from 6:00 a.m. to 6:00 p.m. and seven certified nursing assistants (CNAs) from 6:00 am. to 2:00 p.m. for the day shift. There were six CNAs from 2:00 p.m. to 10:00 p.m. There were four LPNs from 6:00 p.m. to 6:00 a.m. and four CNAs from 10:00 p.m. to 6:00 a.m. During an interview conducted on April 23, 2024 at 9:16 a.m. with the Staffing Coordinator (staff #75), the daily staff posting dated December 24, 2023 was reviewed and Staff #75. She stated that the census was 82 and that there were four (LPNs) from 6:00 a.m to 6:00 p.m. and four LPNs from 6:00 p.m. to 6:00 a.m. She stated that the facility is required to for 8 hours daily and she could not find one for December 24, 2023. She stated that she called the Director of Nursing (DON)…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0732 — isolated
    Post 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 the facility policy and procedures, the facility failed to ensure that the daily staff posting reflected the correct information. Findings include: An observation of the daily staff posting was conducted on April 21, 2024 at 7:15 a.m. The daily staff posting was posted on the wall behind the receptionist's desk. The date on the posting was April 19, 2024 with a census of 76. The census for April 21, 2024 was 75. An interview was conducted on April 21, 2024 at 7:15 a.m. with a licensed practical nurse (LPN/staff #6, who stated that she thought the charge nurse updates the daily staff posting when she comes in to work at 10:00 a.m. An interview was conducted on April 21, 2023 at 8:57 a.m. with the receptionist (staff #109), who stated that the Staffing Coordinator (staff #75) usually posts the daily staff posting and is usually here by 8:00 a.m. During the interview, it was observed that there was not a daily staff posting on the wall and staff #109 stated that she usually looks at the posting to ensure that the date is correct and didn't…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-08-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Regarding staff not wearing appropriate Personal Protective Equipment (PPE): -Observations were conducted of the DON (staff #53) on August 17, 2021 at 1:45 pm and 3:05 pm, and on August 18, 2021 at 7:45 am. The DON was observed on these occasions to be wearing a cloth face mask with no other face mask or covering. The cloth face mask was not well fitting and slid down when the DON was talking, exposing his nose. -An observation of a housekeeping staff was conducted on August 18, 2021 at 7:47 am. The housekeeping staff member was cleaning a room in the COVID-19 unknown unit. The staff member was wearing an N95 face mask, with only one strap secured behind her head. The other strap was hanging down below her chin. The staff member was not wearing any other face mask or covering. -An observation was conducted of an LPN (staff #50) on August 18, 2021 at 2:45 pm. The LPN was standing near the nurses' station talking with a resident. The LPN had a surgical mask on, but he was holding the front of the mask under his chin, exposing the LPN's nose and mouth while he was talking to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-20 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one of two sampled residents (#22) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included status post fall and left patella displaced fracture. A care plan initiated on January 30, 2020 revealed the resident used psychotropic medications related to mood disorder as evidenced by verbal aggression. The goals included the resident would have fewer episodes of verbal aggression. Interventions included to administer medications as ordered and to monitor/document for side effects. A Pre-admission Screening and Resident Review (PASRR) Level I screening completed on February 21, 2020 included that…

    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 · D2021-08-20 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASRR) was completed prior to or upon admission and a PASRR Level I screening was updated when required for one of two sampled residents (#22). The deficient practice increases the risk that individuals who have a mental disorder or intellectual disability may be inappropriately placed in nursing homes and/or they may not receive appropriate treatment or services. Findings include: -Regarding the initial PASRR Level I screening: Resident #22 was admitted to the facility on [DATE]. However, admitting diagnoses were not included on the resident's face sheet or medical diagnosis list. Review of the clinical record revealed a PASRR Level I screening completed on October 16, 2018. However, further review of the clinical record did not reveal that a PASRR Level I screening had been completed prior to or upon the resident's admission to the facility…

    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 · D2021-08-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#267) received the necessary services to maintain good grooming and hygiene. The deficient practice could result in grooming and hygiene needs of residents not being met. Findings include: Resident #267 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, difficulty walking, and unspecified dementia without behavioral disturbance. Resident #267's care plan was reviewed and included a care plan focus that was initiated on December 16, 2020 which stated the resident had an Activity of Daily Living (ADL) self-care performance deficit and required staff participation with personal hygiene and oral care. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 11 on the Brief Interview for Mental Status (BIMS)…

    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 · D2021-08-20 · 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 observations, clinical record reviews, resident and staff interviews, and review of policy and procedure, the facility failed to ensure two residents received treatment and care in accordance with professional standards of practice related to a peripheral intravenous (IV) catheter for one resident (#267) and related to treatment orders for a knee immobilizer for one resident (#59). The sample size was 19. The deficient practice could lead to residents not receiving appropriate care and treatment. Findings include: -Resident #267 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, difficulty walking, and unspecified dementia without behavioral disturbance. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate impaired cognition.…

    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 before2021-08-20 · 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, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one sampled resident (#317) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #317 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, obesity, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of the Initial admission Record dated August 14, 2021 revealed the resident was receiving oxygen via nasal cannula at 4 liters per minute. Review of the vital sign documentation revealed the resident's oxygen saturation was obtained on August 14, 16, 17, and 18, 2021 while receiving oxygen via nasal cannula. During an observation conducted of the resident on August 16, 2021 at 1:10 PM, the resident was observed receiving oxygen via nasal cannula at 2.5 liters per minute. Multiple observations were conducted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-20 · 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 observation, staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#39) clinical record accurately reflected a medication administration. The sample size was 7. The deficient practice increases the risk for medication error. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism, unspecified, hyperlipidemia, unspecified, and primary hypertension. An altered cardiovascular status related to angina and hypertension care plan dated July 29, 2021 had a goal the resident would be free from signs and symptoms of complications of cardiac problems. Interventions included vital signs as ordered, and to notify the physician of any abnormal readings. The physician's orders dated August 6, 2021 included: - amlodipine besylate (antihypertensive) 5 milligrams (mg) give 2 tablets one time a day for hypertension. - lisinopril (antihypertensive) 20 mg give 1 tablet one time a day for hypertension. -…

    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 THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
BURNAM, SOONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2006
ZOBELL, GAVINIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2026
JONES, CHRISTINEIndividualCORPORATE DIRECTORsince 01/02/2022
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
CLARK, RANDOLPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/2023
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/03/2025
CARETRUST GP LLCOrganizationADP OF THE SNFsince 06/01/2000
CARETRUST REIT INCOrganizationADP OF THE SNFsince 06/01/2000
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 06/01/2000
THE ENSIGN GROUP INCOrganizationADP OF THE SNFsince 06/01/2000

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

$13.9M
Net patient revenuemost recent cost report
+16.3%
Operating marginrevenue minus expenses
$1.5M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 8%Other / private 32%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$389per resident / day
operating cost
$11,813per month
≈ monthly operating cost
$464per 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 035088. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-24, 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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