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Life Care Center of Paradise Valley

4065 East Bell Road, Phoenix, AZ 85032 · For profit - Corporation · 210 certified beds · (602) 867-0212 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)
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 (25% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 20% 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.

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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3805 E Bell Rd Ste 2400 · (602) 482-2116 · Call to confirm hours
Pharmacy
3805 E Bell Rd Ste 1100
Grocery
3607 E Bell Rd · (602) 493-5555 · Call to confirm hours
Park
17402 N 40th St · (602) 495-3785 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased1.0%10.7%15.4%better
Long-stay residents who lose too much weight4.0%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.7%0.8%0.9%better
Long-stay residents with a urinary tract infection0.4%1.2%2.0%better
Long-stay residents with depressive symptoms14.4%3.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.4%2.1%3.3%better
Long-stay residents whose ability to walk worsened9.8%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.1%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers1.2%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control19.4%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.9%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.9%87.3%79.4%better
Short-stay residents rehospitalized after admission8.7%23.7%22.6%better
Short-stay residents with an outpatient ER visit2.7%10.4%12.0%better

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

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

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

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

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

71.6% 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 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

71.6%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
93.6%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 93.6% 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 47 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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 SNF71.6%CMS range 62.0–80.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.1–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge93.6%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 discharge87.2%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 discharge85.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.6%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 setting71.1%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 discharge91.3%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 hospitalization6.4%CMS range 3.0–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.61
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.75
Total nurse hours/ resident / day
0.45
RN hoursweekends
25.3%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 210 beds and averages 103.5 residents a day — about 49% occupied, or roughly 106 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.21 hrs/resident/day on weekends vs 3.96 on weekdays — 19% thinner on weekends. RN hours go from 0.67 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%. 1 administrator has left in the past year.

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

2
deficiencies at the latest standard inspection (2026-02-20)
8
at the previous standard inspection (2024-07-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 clinical record, and review of facility policy and procedure, the facility failed to ensure a comprehensive care plan was implemented for one of three sampled residents (#25) to ensure safe mobility during a functional transfer. The deficient practice could result in injury to a resident, or failure to honor a resident's preference.-Findings include:Resident #25 was admitted [DATE], with diagnoses of schizophrenia, anxiety, depression, emotional lability, chronic obstructive pulmonary disease, gangrene and necrosis of lung, and sarcopenia. A care plan focus initiated October 23, 2024, revealed Resident #25 had an activities of daily living (ADL) performance deficit due to weakness.Additionally, a care plan focus initiated September 26, 2025, revealed the resident had episodes of paranoia as evidence by making statements about other residents and staff that were unfounded.A revision to the resident's ADL care plan focus dated March 11, 2026, revealed two additional…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to protect the rights of one resident (#51) to be free from physical abuse from facility staff. The deficient practice could result in appropriate action not taken and further abuse of residents. Findings include:Resident #51 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adjustment disorder with mixed anxiety and depressed mood, hyperlipidemia, morbid (severe) obesity due to excess calories, neuralgia and neuritis, and abnormalities of gait and mobility.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident is cognitively intact. In a progress note dated June 2, 2026 At 5:46 pm the documentation revealed that at approximately 2:15 pm, LPN (Licensed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-02-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility observations, resident and staff interviews, and review of the clinical record and facility policy, the facility failed to ensure that medications were stored securely and were not left unattended at residents' bedsides for two of 28 sampled residents (#53 and #40) or on top of the medication cart. The deficient practice could result in unauthorized access to medications, medication errors, misuse, allergic reactions, adverse drug effects or other harm.Findings Include: -Regarding Resident #53: Resident #53 was admitted to the facility on [DATE], with a diagnosis including: chronic obstructive pulmonary disease with (acute) exacerbation, atrial fibrillation, and pneumonia. A Care Plan initiated on January 12, 2026, revealed a focus for a physician's order for unsupervised self-administration of the following medications: Ventolin HFA 2 puffs every(Q) 4hrs (hours) prn (as needed). The care plan was revised on February 17, 2026, to include a physician's order for Voltaren gel 2 grams TID (three…

    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 before2026-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, the facility failed to ensure appropriate infection control practices were implemented for 1 of 5 sampled residents (#136) regarding following contact precautions. The universe was 28 residents. The deficient practice could result in a spread of preventable illness to residents and staff. Findings include: -Resident #136 was admitted to the facility on [DATE], with diagnoses that included prosthesis, subsequent encounter, aftercare following joint replacement surgery, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction.The physician order dated February 11, 2026 included usage of contact isolation precautions over and above standard precautions, related to ESBL- E. coli hip wound infection every shift.The care plan initiated on February 12, 2026 revealed a focus that the resident was on intravenous medications related to ESBL-E. coli (Escherichia coli producing extended-spectrum beta-lactamase)…

    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 · Ecited before2025-06-19 · 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, interviews, facility documentation and policy, the facility failed to ensure that a mechanical lift for resident transfer, was cleaned and disinfected according to professional standards. The deficient practice could result in the spread of infection and resident illness. Findings include: At the conclusion of a mechanical lift observation conducted on June 19, 2025 at 12:45 p.m., the Certified Nursing Assistant (CNA/Staff #20) rolled the mechanical lift to the end of the hallway. Cleaning and disinfection of the lift was not performed after resident use. A second mechanical lift transfer observation was conducted. The mechanical lift was not cleaned or disinfected prior to resident use at approximately 12:50 p.m. At the conclusion of the second mechanical lift observation, CNA/Staff#7 was observed rolling the mechanical lift with the sling to the end of the hall without cleaning or disinfecting the equipment. At approximately June 19, 2025 at 1:10 p.m., CNA # 20 was observed picking up the unwiped sling from the parked mechanical lift with bare hands 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure one resident #77, was free from verbal and/or physical abuse from a family member. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Findings include: Resident #77 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 2 (mild) and rheumatoid arthritis, unspecified. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #77 BIMS (Brief Interview of Mental Status) score was 14 which indicated intact cognition. The care plan revised on January 13, 2024 included resident #77 had limited mobility and pain from severe rheumatoid arthritis, contractures and deformity of the back, neck, bilateral hands, feet and ankles. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0660 — pattern
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, resident/staff interviews the facility documentation and policy review, failed to ensure a discharge planning based on the assessed needs and goals was in place for one resident (#49). The deficient practice could result in the delay of the resident transfer/discharge to the facility of choice. Findings include: Resident #49 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure. The care plan dated December 21, 2023 included a discharge plan that the resident wished to return home. The communication note dated May 23, 2024 included that the social services director (SSD/staff #50) had a conversation with the resident's family related to a request to transfer to an assisted living (AL). Per the documentation, the family wanted the transfer. An email correspondence dated May 23, 2024 between the SSD (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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor. The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect. The facility census was 89, and the resident sample was 18. Findings include: Resident #25 was admitted on [DATE] with diagnoses that included, dementia, type 2 diabetes mellitus with hyperglycemia, hemiplegia/hemiparesis related to cerebral infarction. The care plan, initiated on November 18, 2019 revealed the following areas of focus: -Cognitive deficits related to diagnosis of dementia, and history of CVA -Communication: may have barriers to communication related to expressive aphasia Review the June 2024 Medication Administration Record (MAR) revealed change of condition monitoring for mental well-being from June 12, 2024 through June 15, 2024. The progress note dated June 12, 2024 through June 15, 2024,…

    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 · D2024-07-18 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident's (#3) choice regarding advance directives and orders were accurately reflected in the medical record. The deficient practice could result in resident's choices noted being followed. The resident census was 89 and the sample was 18. Findings include: Resident #3 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including acute kidney failure, pneumonitis, anxiety, and depression. The advance directive statement form dated [DATE] revealed the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest. The care plan dated [DATE] revealed the resident had an Advance Directives of CPR and was a full code. Goal was that the resident's advance directives will be honored. Interventions included that code status will be reviewed quarterly and as needed. Review of the Minimum Data Set (MDS) assessment…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, observations, staff interviews, and policy, the facility failed to ensure that a care plan intervention for monitoring medication side effects related to use of an antianxiety medication was implemented for one resident (#60). The deficient practice could result in the resident not receiving the care and services to meet their needs. Findings include: Resident #60 was admitted on [DATE] with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status. The active physician order summary included an order to monitor for side effects related to anti-anxiety medications. The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness. The physician order dated December 28, 2023 included to monitor behaviors of restlessness every shift for 14 days; and, to code whether behavior improved, worsened or unchanged. The care plan was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-07-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan was revised to include resident-specific nutritional goals for one resident (#76). The deficient practice could result the resident not being involved and not able to make decisions about their care and needs. Findings include: Resident #76 was admitted on [DATE] with diagnoses of acute metabolic acidosis, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, anemia, dysphagia, and chronic kidney disease. The weight on May 03, 2024 was 130 lbs. (pounds) Review of the nutrition care plan initiated on May 03, 2024 revealed the resident had nutritional problems due her medical diagnoses of dysphagia, esophageal stenosis, and cerebrovascular accident; and, had nutritional risks due to suboptimal meal intakes related to decreased appetite, and potential for weight fluctuations/fluid deficit due to fluid shifts due to diuretic medication. Interventions included to report results to…

    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 · D2024-07-18 · 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 review of clinical records and policy, observations, and staff interviews the facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use. The deficient practice could result in scaling down of services, provided by the facility, that do not align with the highest practicability of care. Findings include: Resident #49 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure. The care-plan initiated on January 11, 2024 revealed that the resident had oxygen therapy related to COPD. Interventions included O2 (oxygen) via nasal cannula continuous per medical doctor orders. A physician order dated July 18, 2024 revealed an order for oxygen at 2 liters per minute continuously via nasal cannula; may titrate to 4 liters to maintain 88% saturation. An observation conducted on July 18, 2024 at 2:03 p.m.…

    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 · D2024-07-18 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review, staff interviews, facility policy review and Center for Medicare and Medicaid Services (CMS) guideline, the facility failed to ensure that the occupational therapist (OT/staff #88) had a valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. The deficient practice could result in staff not being knowledgeable of how to prvide emergency care to residents. Findings include: Review of the personnel file for an occupational therapist (OT/staff #88) revealed a hire date of [DATE]. Continued review of the personnel file included that the CPR or First Aid certification had an expiration date of February 28, 2012. During an interview conducted on [DATE] at 11:00 a.m, a review of the personnel file of the OT was conducted with the Payroll Coordinator (staff #55) who stated that there was no evidence found of any valid CPR or First Aid certifications for the OT (staff #88). The payroll coordinator stated that she thought that CPR or First Aid certifications were only…

    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 · D2024-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure there was adequate monitoring for side effects related to the use of a psychotropic medication for one resident (#60). The census was 89. The deficient practice could result in residents being at risk for unidentified adverse reactions related to the use of the medication. Findings include: Resident #60 was admitted on [DATE] with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status. The active physician order summary included an order to monitor for side effects related to anti-anxiety medications. The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness. The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication every shift…

    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 before2024-06-14 · 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, facility and hospital documentation, staff interviews and policy review, the facility failed to ensure that two residents (#17, 10) was free from verbal abuse. Findings include: -Resident #10 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Adjustment Disorder with disturbance of conduct. Review of a care plan initiated 12/19/2023 included that this resident displays comments towards other residents and visitors at times as noted aggressive like behaviors. This care plan included 2 incidents: Family visiting and resident verbalized you need to control your kids and stated fat people are ugly, continued comments related to residents' appearances and body size. 12/19/2023 interaction with another resident and 3/27/24 confrontational language. This care plan included an intervention of observe interaction around others and intervene if noted concerns. However, an abusive incident was noted on 3/27/2024. A progress note dated 3/27/2024 included that at…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (# 8) was free from verbal abuse. The deficient practice may result in psychosocial harm as a result of un-averting or intervening communication that may lead to verbal abuse. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, and recurrent severe major depressive disorder with psychotic symptoms. The Annual MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact. A review of medical record documentation revealed that on August 17, 2023 at 10:30 a.m. Resident #8 reported to the facility's administrator that she had felt threatened a day prior by a night shift staff. Resident # 8 disclosed the interaction which made her feel threated involved Certified…

    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 before2024-02-14 · 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 review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions, signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility. Findings include: Resident #408 was admitted on [DATE] with diagnoses of surgical aftercare following surgery on the skin, sepsis (unspecified organism), and encounter for attention to gastrostomy. The most recent admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Review of medical records for Resident #408 revealed the presence of a feeding tube, wound, and a catheter. However, during an observation of care for Resident #408 February 13, 2024 at 10:05 AM, in room [ROOM NUMBER] revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#369) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family when the resident had a change of condition. This failure has the potential for confusion between resident's family and the facility. Findings: Resident (#369) was admitted to the facility on [DATE] with diagnosis that included, cardiac arrhythmia, unspecified; Parkinson's disease; bradycardia, unspecified; unspecified dementia with behavioral disturbance; anorexia; major depressive disorder, single episode unspecified. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) record revealed resident score was 03, indicating severe cognitive impairment. Further review of the MDS revealed resident was dependent or required extensive assist with activities of daily living. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#520) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: 1.) Resident #520 (alleged victim) was admitted on [DATE] with diagnoses that included Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was not conducted, however the resident was assessed as being severely cognitively impaired. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms, or wandering during the assessment period. A cognition care plan initiated on October 4, 2022 revealed that the resident has impaired cognitive ability and impaired thought process related to Alzheimer's disease and dementia. Interventions included to allow extra time for resident to respond to question and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to ensure that two resident's (#525, #535) care plans were updated and revised as needed. Findings include: 1.) Regarding resident #525 Resident #525 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering. A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said I fucking him up because he pissed on the floor again. The note indicated that skin assessments were completed on both residents.…

    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 · D2024-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and review of facility policy and procedure, the facility failed to ensure that one resident (#333) was provided with floor mat for fall prevention and implementation of the care plan. The deficient practice could result in preventable accidents such as falls. Findings include: Resident #333 was admitted with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease with late onset hypothyroidism, unspecified, muscle weakness (generalized), difficulty in walking, not elsewhere classified, unspecified lack of delirium due to known physiological condition coordination, cognitive communication deficit, repeated falls, pain in left knee A quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief interview for Mental Status (BIMS) score of 03 indicating the resident was cognitively impaired the assessment also included that the resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and review of facility documentation, policy, and procedures, the state regulation on record retention, and the State Agency (SA) complaint tracking system, the facility failed to ensure that medical record for one resident (#1) was retained as required by State law. The deficient pratice could result in pertinent clinical information not accessible. Findings include: Review of the SA complaint tracking system revealed that a complaint was submitted by resident #1 on September 30, 2018 at 5:50 p.m. The federal regulation stated that medical records must be retained for the period of time required by State law. The State law in section 36-401 on record retention stated that patient records must be retained for six years after the date of the patient's discharge. The facility letter dated January 18, 2024 and signed by the administrator revealed that the facility was using an offsite storage for medical records. It also included that according to State law, any records older than 6 years are then destroyed; and that, the oldest facility documentation retained…

    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 · E2023-11-08 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 facility policies and practices, the facility failed to ensure that physician ordered medications were not misappropriated for 10 residents (#7, #43, #44, #49, #65, #74, #75, #87, #93 and #94). The deficient practice could result in residents not having adequate supplies of medications to meet their medical needs. The sample size was 14. Findings include: -Resident #7 was admitted on [DATE] with diagnoses of sepsis and rheumatoid arthritis. A physician order dated September 21, 2021 included for oxycodone hydrochloride (narcotic opioid) 5 mg (milligram) by mouth every 4 hours for pain levels of 5-10. A review of the Individual Resident's Control Substance Record dated October 6 through 25, 2021 revealed documentation that 1 pill was dispensed on each of the following days: -October 11, 13, 15, 16, 20, 21, and 24, 2021. However, review of the Medication Administration Record (MAR) for October 2021 revealed oxycodone was not documented as…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility investigative documentation, and a review of the facility's policies and procedures, the facility failed to protect one resident (#91) from staff verbal abuse. The deficient practice could result in an unsafe resident environment. Findings include: Resident #91 was admitted on [DATE] with diagnoses that included bipolar disorder, schizophrenia, major depressive disorder, diabetes mellitus, and chronic kidney disease. A care plan dated November 12, 2019 revealed the resident required extensive of 1-2 staff with bed mobility, dressing, and personal hygiene; and that, the resident was incontinent of both bowel and bladder. Facility documentation included that on March 12, 2020, a staff witnessed and reported to the facility an incident involving a certified nursing assistant (CNA/staff #91) and resident #91. Per the documentation, the CNA who was with a male staff was providing incontinent care to resident #91; and that, a case manager and a social services 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-08 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of facility policy's, the facility failed to implement their policies on abuse for one resident (#91) and on misappropriation of property for 10 residents (#7, #43, #44, #49, #65, #74, #75, #87, #93 and #94). Failure of development and implementation of these policies could cause continued verbal abuse towards all residents of the facility and cause residents to not have adequate supplies of medications to meet their medical needs. Findings include: -Regarding abuse: Facility documentation included that on March 12, 2020, a staff witnessed and reported to the facility an incident involving a certified nursing assistant (CNA/staff #91) and resident #91. Per the documentation, the CNA who was with a male staff was providing incontinent care to resident #91; and that, a case manager and a social services staff overheard the CNA call the resident a derogatory name. Review of the facility's investigative documentation revealed an interview dated March 12, 202020 with the alleged CNA (staff #91) who admitted that while providing care to resident #91, she admitted to…

    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

“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 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 →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

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 / managerTypeRoleSince
WILKOFF, ROSSIndividualW-2 MANAGING EMPLOYEEsince 07/23/2021
FLETCHER, TODDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2021
LAY, LISAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/08/2018
PRESTON, FORRESTIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/06/1976
SWANKER, RICHARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2022
ZIEGLER, JAMESIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 08/16/1999
CROSS, CINDYIndividualCORPORATE OFFICERsince 04/21/1994
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/21/2000
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/1994

CMS files one row per role, so the 15 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.

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

Follow the money — this home’s finances

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

$9.3M
Net patient revenuemost recent cost report
-17.9%
Operating marginrevenue minus expenses
$2.2M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 5%Other / private 31%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$398per resident / day
operating cost
$12,084per month
≈ monthly operating cost
$337per 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 035146. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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