Life Care Center Of Sierra Vista
2305 East Wilcox Drive, Sierra Vista, AZ 85635 · For profit - Corporation · 152 certified beds · (520) 458-1050 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $55,881 in federal fines (most recent 2024-10-18)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.1% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.3% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.6% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.1% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 78.1% | 94.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.8% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.6% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.3% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.9% | 87.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 34.4% | 23.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.9% | 10.4% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.5% 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 298 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 86.8% 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 76 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.5%CMS range 56.1–65.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.1–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 86.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 71.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 86.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 93.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 88.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.2%CMS range 6.6–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 152 beds and averages 71.3 residents a day — about 47% occupied, or roughly 81 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 3.08 hrs/resident/day on weekends vs 3.87 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.80 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2024-10-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice resulted in the resident being sexually abused. Findings include: Resident #2 was admitted on [DATE] with diagnoses of cognitive communication deficit, Parkinson's disease, and anxiety disorder. The care plan with revision date of September 9, 2024 revealed the resident had actual and potential psychosocial well-being problem related to cognitive impairment, family discord and past history of physical and sexual abuse. Interventions included supervised visits with a family member and during visits, resident #2 and the family member had to be either in a public area or must be able to be viewed by staff while in her room. A communication note dated September 23, 2024 included that the resident's family member/POA (power of attorney) asked to get a report of a sexual abuse allegations from September 9; 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.
- Actual harm · Gcited before2024-05-31 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, review of facility documentation, facility policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure there was a physician order for a narcotic medication that was administered to one resident (#2). The deficient practice could result in residents receiving unnecessary medication. Findings include: Resident #2 was admitted on [DATE] with diagnoses of paroxysmal atrial fibrillation and Alzheimer's disease. A care plan dated [DATE] included that this resident was at risk for falls related to cognitive impairment and hypotension. A physician's order dated [DATE] included acetaminophen (analgesic) Tablet 325 milligrams, give 2 tablet by mouth every 4 hours as needed for temperature above 101 degrees, not to exceed 3 gram/24 hours. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. A review of the clinical record revealed no evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and facility's policy review, the facility failed to protect the rights of one resident (Resident #10) to be free from abuse by another resident (#25). This deficient practice could place residents at risk for resident-to-resident abuse and potential physical harm.Findings include: -Resident #25 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that include pulmonary embolism, acute respiratory failure, heart failure, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. The care-plan revealed the resident used antidepressant medication related to depression, with a goal of being free from adverse reactions and a noted goal to observe and report adverse reactions, and psyche follow up as indicated. -Resident #10 (Victim) was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-02 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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, facility documentation, staff interviews, and policy review, the facility failed to protect the resident's (#1) rights to be free from misappropriation from staff. This deficient practice could result in further incidents of staff to resident financial abuse. Findings include: -Resident #1 was admitted to the facility on [DATE], with diagnoses that include congestive heart failure, atrial fibrillation, ventricular tachycardia, thyrotoxicosis, and pulmonary embolism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the State Agency (SA) complaint system revealed that on January 8, 2026 at 5:22 p.m. an incident was reported by the facility that a local police department officer arrived to the facility at 3:30 p.m. and informed the receptionist that he needed to speak with the Director of Nursing. The Executive Director and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the resident's (#100) rights to be free from abuse by another resident (#200). This deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #100 (Perpetrator) was admitted to the facility on [DATE], with diagnosis that include Dementia, insomnia, anxiety, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated the resident had severe cognitive impairment. A review of resident's #100 care-plan revealed the resident has impaired cognitive ability related to dementia, and needs simple 1 to 2 step instructions. -Resident #200 (Victim) was admitted to the facility on [DATE], with diagnoses that include Spinal stenosis, diabetes mellitus type 2, weakness, anxiety, and depression. Review of the admission Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-09 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, staff and resident interviews, and facility policy, the facility failed to ensure the resident's personal privacy and confidentiality of their medical records. The deficient practice could result in the exposure of personal/private medical information. Findings Include:An observation was conducted on September 09, 2025, at 4:18 AM, where medication Cart # 2 was left unattended with an unlocked computer displaying Residents' # 8,14,2,10,6,4, and 12 medical information. Licensed Practical Nurse (LPN/Staff #33) went to medication cart # 2 after coming out of a resident room. Resident # 8 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, dementia, and anxiety. Resident # 14 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, muscle weakness, and acute respiratory failure with hypoxia. Resident #2 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, muscle weakness, and heart failure.Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation, interviews, and review of facility policy and procedure, the facility failed to ensure medications including controlled substances were stored according to regulation and facility policy. The deficient practice could lead to residents gaining access to medications.Findings include:An observation was conducted on [DATE], at 4:10 A.M. of the facility hallway between the 100 and 300 hall units. There was an open doorway, with no restriction to walk between the two units. At the corner of the two units was a nurse's station, and behind the nurse's station was a medication cart that was not locked. A bottle labeled as iron tablets was on top of the medication cart. There were no staff observed in proximity to this nurse's station. During the observation, there were staff observed going in and out of resident rooms approximately 100 feet away on the 100 hall unit, and at times there were no staff observed on the 100 hall unit. The cart remained in surveyor observation during the entire period of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, facility documentation, and a review of policies and procedures, the facility failed to ensure that food items in the freezer were properly labeled and dated. This deficient practice had the potential to result in food contamination, which could cause illness or food poisoning among residents.Findings Include:On September 7, 2025, at 10:15 a.m., during an initial walk-through visit with [NAME] #27, who was present on behalf of the kitchen manager (Staff #42), a partially full plastic bag of broccoli without a label or date, was observed sitting on a shelf inside the freezer.An interview was conducted immediately following the observation, on September 7, 2025, at 10:20 a.m., with [NAME] #27. The staff member confirmed the findings and acknowledged that all opened food items should be labeled with the date they were opened and stored in either a sealed container or a zipper bag. The kitchen staff also confirmed the understanding that using food items without proper labeling could place residents at risk for food poisoning and other food-borne…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation, protecting residents from further abuse for one resident (#46), and reporting allegations of abuse. The deficient practice could result in abuse/neglect continuing and not being prevented. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. Review of resident #46's progress note dated March 26, 2025 revealed that the facility contacted another state agency regarding suspicion of financial exploitation involving the resident's frequent visitor (resident friend #666). Review of the SA database did not reveal any documentation that a self-report was submitted by the facility regarding the allegation of exploitation. However, the SA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to report allegations of exploitation for one resident (#46) within the required timeframe. The deficient practice in abuse allegations not being reported and further abuse continuing. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has intact long term and short-term memory. An Alert Note dated March 26, 2025 documented that the facility contacted another state agency for suspicion of financial exploitation involving resident's frequent visitor (resident friend #666). However, further review of the resident's clinical record did not reveal any indication that the allegation of financial exploitation was reported to The State Agency (SA). Furthermore, review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews, and review of policy and procedure the facility failed to ensure an allegation of exploitation (resident #46) was fully investigated. The deficient practice could result in allegations of abuse to include exploitation not being investigated and abuse/exploitation occurring in the facility. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. A report submitted from another state agency was received by the State Agency (SA) on June 19, 2025 regarding an allegation of exploitation pertaining to resident #46. Review of the SA database revealed that the facility failed to submit a self-report regarding the allegation of exploitation. Further review of the SA database indicated that the facility failed to submit a thorough investigation regarding the allegation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-09 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#43) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs.Findings Include:Resident #43 was initially admitted to the facility on [DATE] with diagnoses that included paraplegia, Paranoid Schizophrenia and Schizophrenia Disorder.A review of record dated September 25, 2023 revealed a Level 1 PASRR (Pre-admission Screening and Resident Review) was completed, but no referral for any Level II.The care plan initiated on October 5, 2023 revealed that Resident uses antipsychotic medications related to Schizophrenia as evidence by auditory hallucinations. A review of orders dated February 18, 2025 revealed Resident has an active order for risperidone oral tablet 0.5 MG (milligram) give 0.5 mg by mouth at bedtime for schizoaffective disorder auditory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2025-09-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure medications for one resident (#38) were administered as ordered by the physician. The deficient practice could place residents' safety at risk and could result in resident's not receiving the treatment that they need.Findings Include:Resident #38 was admitted to the facility on [DATE] with an active diagnoses that included Heart Failure, Hypertension, and Orthostatic Hypotension.A review of admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 12.0, moderately impaired.A review of physician's order dated August 22, 2025 revealed an order for Isosorbide Mononitrate ER (Extended Release) oral tablet 30 mg (milligram) give 0.5 tablet by mouth one time a day related to atherosclerotic heart disease. Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60.A review of Resident's blood pressure and pulse rate taken on September…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-09 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, staff interviews, review of facility documents and policy, the facility failed to ensure hand hygiene was performed during medication administration observation and the facility failed to sanitize a glucometer after use. The deficient practice could place residents at risk for infections.Findings Include:Resident #26 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM).A review of orders revealed the following physician orders:- Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Milliliter) inject 10 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus; and- Insulin Lispro Injection Solution 100 UNIT/ML inject 4 unit subcutaneously before meals related to Type 2 Diabetes Mellitus.On September 9, 2025 at 5:25 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN)/Staff #16. The following medications were dispensed: Lispro…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary. Findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that include Sepsis, weakness, chronic obstructive pulmonary disorder, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension. A review of the 5-day MDS (Minimum Data Set) dated January 7, 2025 noted the resident had a BIMS of 15, indicating no cognitive impairment. The care plan dated January 7, 2025 revealed the resident has a stage 1 pressure injury, with interventions including administer medications as ordered. The care plan dated January 7, 2025 also revealed the resident is at-risk for rehospitalization, with a noted intervention of staff to provide timely communication to physician's regarding any change in resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in preventable injuries as a result of elopement. Findings include: -Resident #200 was admitted to the facility on [DATE] with diagnoses that included abdominal aortic aneurism, diabetes mellitus type 2, dementia, and hypertension. A 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A care plan dated March 25, 2025 revealed resident #200 was at risk for elopement, with noted interventions of adding the resident to the elopement book for additional supervision, and encouraging the resident to participate in activities to divert from exit seeking behavior. An elopement assessment risk evaluation dated March 25, 2025 revealed staff had assessed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary. Findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that include Sepsis, weakness, chronic obstructive pulmonary disorder, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension. A review of the 5-day MDS (Minimum Data Set) dated January 7, 2025 noted the resident had a BIMS of 15, indicating no cognitive impairment. The care plan dated January 7, 2025 revealed the resident has a stage 1 pressure injury, with interventions including administer medications as ordered. Review of the physician's orders dated January 3, 2025 showed an order for Ceftriaxone injection solution 2GM (grams) with instructions to give 2 grams intravenously in the evening for infection for a duration of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's Power of Attorney (POA) was notified of the resident's hospitalization. The deficient practice prevented the POA from being informed of the resident's care and change in condition. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included Dementia, malnutrition, and age-related cataract. Review of the quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) assessment was completed on February 16, 2024. The BIMS assessment revealed resident #1 scored a 06 which indicated the resident was severely cognitively impaired. The MDS also indicated resident #1 had no behavioral symptoms or falls since the prior quarterly assessment. A complaint was received, on February 14, 2025, via the SA complaint portal which indicated the resident was taken to the hospital due to a fall. The complaint indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's electronic health record (EHR) contained accurate information about the resident's condition including changes in their condition. The deficient practice could prevent the resident from obtaining accurate services based on their medical condition. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included Dementia, malnutrition, and age-related cataract. Review of the quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) assessment was completed on February 16, 2024. The BIMS assessment revealed resident #1 scored a 06 which indicated the resident was severely cognitively impaired. The MDS also indicated resident #1 had no behavioral symptoms or falls since the prior quarterly assessment. A complaint was received, on February 14, 2025, via the SA complaint portal which indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure abuse policies and procedures were implemented to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice could result in appropriate action not taken and further abuse of the resident. Findings include: Resident #2 was admitted on [DATE] with diagnoses of cognitive communication deficit, Parkinson's disease, and anxiety disorder. The care plan with revision date of September 9, 2024 revealed the resident had actual and potential psychosocial well-being problem related to cognitive impairment, family discord and past history of physical and sexual abuse. Interventions included supervised visits with a family member and during visits, resident #2 and the family member had to be either in a public area or must be able to be viewed by staff while in her room. A communication note dated September 23, 2024 included that the resident's family member/POA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure medications were administered as ordered for one resident (#1). The deficient practice could result in resident not receiving treatment for their assessed needs. Findings include: Resident #1 was admitted on [DATE] with diagnoses of encephalopathy, muscle weakness, and a cognitive communication deficit. A review of the admission minimum Data Set (MDS) assessment, dated October 8, 2024, revealed the resident was not able to complete a Brief Interview for Mental Status (BIMS); and that, staff assessment revealed the resident had a severely impaired cognitive skills for daily decision making. The hospital discharge instructions dated October 8, 2024 included an order for Droxidopa (anti-Parkinson agent) 300 mg (milligrams) capsules every 8 hours for 30 days. Problem lists included brain disorder, chronic stroke and coagulopathy. The physician order dated October 4, 2024 included for Droxia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-31 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect 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 record review, staff interviews, facility records and facility policy, the facility failed to ensure medications were not misappropriated for 3 residents (#5, #31, #64). This deficient practice resulted in the administration of unprescribed medications. Findings include: Regarding Resident #5 Review of the Medication Administration Record (MAR) revealed that Alprazolam (Xanax) oral tablet 0.5 milligrams (mg) was ordered for resident #5 for anxiety on the following dates 2/11/2024, 2/16/2024, and 2/22/2024. The documentation also included that the medication was discontinued on the following dates, 2/16/2024, 2/22/2024 and 2/27/2024. Review of the Controlled Substance Inventory Form dated 3/19/2024 revealed that resident #5 was listed twice with the same prescription number for Alprazolam 0.5 mg tablets. The document revealed a dispense quantity of 60 with a quantity of 10 destroyed. Further review of the document revealed another dispense quantity of 60 and a quantity of 30 destroyed. The document 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.
- Potential for harm · Ecited before2023-12-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 -resident #119 was admitted on [DATE] through 10/5/23 with diagnoses of cognitive communication deficit, and generalized muscle weakness. A care plan dated 9/20/23 included ADL assistance and therapy services to maintain or attain highest level of function and included interventions of assisting with mobility and ADL's as needed. Review of the task documentation survey report for September, 2023 included that the resident was to receive bathing on Tuesdays and Friday evening shift. However, this report included that the resident was not provided showers on 3 of 4 opportunities. An interview was conducted on 12/21/23 at 1:50 PM with a Certified Nursing Assistant (CNA/staff #10) who said that when she first gets here in the morning the computer will show a list of showers, and they will say what shift they are for. She said that CNA's only document in the computer. She said that they are occasionally shorthanded but that they are usually pretty good about getting showers done and if they cannot get it done 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.
- Potential for harm · D2022-09-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 resident and staff interviews, observations, review of the clinical record, and policy and procedure, the facility failed to ensure one resident (#24) was provided an appropriately sized wheelchair and bed to accommodate the resident's needs. The deficient practice may result in lack of accommodation for residents' needs. Findings include: Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, affecting left non-dominant side, morbid obesity due to excess calories, and a stage 2 pressure ulcer of the right buttock. An activity care plan dated 06/22/22 related to 1:1's and self-directed activities had a goal to maintain involvement in cognitive stimulation and social activities. Interventions included assisting/escorting the resident to activity functions. The 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status, indicating intact cognition. The resident required extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one sampled resident (#28) received a Level II Pre-admission Screening and Resident Review (PASRR) after remaining in the facility for longer than 40 days. The deficient practice increases the risk for residents being inappropriately placed into nursing facilities and/or not receiving the services they need. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included atrioventricular block, second degree, paranoid schizophrenia, and major depressive disorder, single episode. Review of the Level I PASRR dated 05/21/20 revealed the physician had certified that the resident required 30 days or less of nursing facility services. A PASRR care plan dated 05/22/20 related to [psychiatric] conditions had a goal for no changes to the resident's PASRR status. Interventions included repeating a PASRR as indicated. However, the resident's clinical record did not reflect that a PASRR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 provide consistent restorative nursing services according to the physician order for one resident (#218). The sample size was 4. The deficient practice could decrease residents' ability to carry out the activities of daily living. Findings include: Resident #218 was admitted on [DATE] with diagnoses that included urinary tract infection, abnormalities of gait and mobility, and muscle weakness. A physician's order dated September 11, 2022 included physical therapy (PT) services 5 times a week for 8 weeks. The order stated the POC (plan of care) included TE (training and exercises) to both lower extremities, transfer training, progressive gait training with FWW (front wheel walker), and RNA (Restorative Nursing Assistant) program. A separate order for the RNA for upper extremities, and lower extremities AROM (Active Range of Motion) was written on the same date. A baseline care plan initiated on September 12, 2022 for ADL…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure that one resident (#28) who was unable to carry out activities of daily living (ADLs) was provided services to maintain good hygiene. The sample size was 6. The deficient practice could result in residents with unmet hygiene needs. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included atrioventricular block, second degree, paranoid schizophrenia, and major depressive disorder, single episode. An ADL deficits care plan revised 05/18/22 related to impaired mobility, potential communication deficits, and psychiatric-related diagnoses had a goal to be receptive to assistance needed to complete ADLs. Interventions included assisting with bathing/showers at level required (up to total). Review of the Point of Care Certified Nursing Assistant (POC CNA) documentation from August 2022 to September 2022 revealed the resident had received 5 bathing opportunities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and review of policy and procedures, the facility failed to ensure one sampled resident (#46) received treatment and care, consistent with professional standards of practice. The deficient practice increases the risk for rehospitalizations. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified systolic (congestive) heart failure (CHF), and hypo-osmolality and hyponatremia. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 10 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. The resident required supervision and set up for most Activities of Daily Living (ADLs). Review of the physician orders dated 09/10/22 included Furosemide (diuretic) 40 milligrams (MG); give 1 tablet one time a day for CHF management and spironolactone (potassium sparing diuretic) 25 mg; give 0.5 tablet one time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to review, assess and implement interventions after falls occurred for two residents (#266 and #116). The sample size was 4. The deficient practice could result in an increased number of falls and injuries. Findings include: -Resident #266 was admitted to the facility on [DATE] with diagnoses that included unspecified sequelae of cerebral infarction, abnormalities of gait and mobility, and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 11 indicating the resident had a moderate cognitive impairment. The assessment also included that the resident required a two-person extensive assist with transfers. A progress note dated February 15, 2022 revealed that the nurse walked into the resident's room after constantly yelling out in Spanish, miss come here miss. The resident was found on the floor with his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$55,881 in federal fines across 2 penalties.
- $17,934 — penalty dated 2024-10-18
- $37,947 — penalty dated 2024-05-31
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.4 | -2.4 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SIERRA VISTA MEDICAL INVESTORS INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST | since 12/31/2020 |
| PRESTON, FORREST | Individual | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | since 01/11/1985 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| HUMMEL, RACHEL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2025 |
| KING, LACY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/02/2024 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 04/21/1994 |
| FLETCHER, TODD | Individual | CORPORATE OFFICER | since 11/02/2020 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| LAY, LISA | Individual | CORPORATE OFFICER | since 02/19/2018 |
| SWANKER, RICHARD | Individual | CORPORATE OFFICER | since 04/01/2011 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| ZIEGLER, JAMES | Individual | CORPORATE OFFICER | since 08/16/1999 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2025 |
| PATEL, PARAG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/27/2025 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/27/2024 |
| SIERRA VISTA MEDICAL INVESTORS, LP | Organization | ADP OF THE SNF | since 05/19/1986 |
CMS files one row per role, so the 28 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $992K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035136. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-09, 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.