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Catalina Post Acute And Rehabilitation

2611 North Warren Avenue, Tucson, AZ 85719 · For profit - Limited Liability company · 102 certified beds · (520) 795-9574 Medicare & Medicaid certified

Call the home — (520) 795-9574 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 21 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1501 S Campbell Ave · (520) 694-8888 · Call to confirm hours
Pharmacy
865 E Grant Rd · (520) 622-4853 · Call to confirm hours
Grocery
2754 N Campbell Ave · (520) 321-0408 · Call to confirm hours
Park
1100 E Mitchell St · (520) 791-4873 · Typically dawn to dusk
Place of worship
2509 N Campbell Ave · (520) 342-7072

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 3 to 4 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 rating4★
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 increased11.9%10.7%15.4%better
Long-stay residents who lose too much weight8.4%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection1.0%1.2%2.0%better
Long-stay residents with depressive symptoms8.9%3.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%2.1%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened14.2%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.3%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine90.9%94.6%95.3%typical
Long-stay residents with pressure ulcers4.4%4.4%4.7%typical
Long-stay residents with worsening bladder/bowel control15.4%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.2%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine88.1%87.3%79.4%better
Short-stay residents rehospitalized after admission19.4%23.7%22.6%better
Short-stay residents with an outpatient ER visit11.3%10.4%12.0%typical

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

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

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

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

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

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

71.7% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

71.7%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
73.5%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 73.5% 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 34 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF71.7%CMS range 59.6–81.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.0–13.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge73.5%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 discharge55.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.1%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 hospitalization6.1%CMS range 3.3–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.92
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.81
RN hoursweekends
41.7%
Total nursing turnover
31.3%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 97.3 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.56 hrs/resident/day on weekends vs 4.14 on weekdays — 14% thinner on weekends. RN hours go from 0.96 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-09-16)
7
at the previous standard inspection (2023-07-07)

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.

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

  • Potential for harm · D2025-10-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident's (#91) assessment was accurate and reflective of the resident's status at the time of the assessment. The deficient practice could result in the resident not receiving appropriate care that is necessary for their wellbeing.Findings include:Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, generalized muscle weakness, tracheostomy status, and dysphagia following cerebral infarction.Resident #91 was discharged from the facility on October 10, 2025.Review of the admission Minimum Data Set (MDS), dated [DATE] indicated Resident #91 completed a Brief Interview for Mental Status (BIMS) and scored a 00 which indicated she had severe cognitive impairment. The same MDS also indicated Resident #91 had no impairments in in the upper (shoulder, elbow, wrist, and hand) extremity.Review of the discharge record from 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Facility The facility failed to ensure that food is labeled and dated in accordance with food safety practices.Based on observations, staff interviews and policy review, the facility failed to ensure that food is labeled and dated in accordance with professional food safety standards.Findings include:An initial kitchen walk-through was conducted on September 14, 2025 at 9:00 AM. The cook, staff #55, was present during the walk-through, as the dietary manager was not on premises at the time. A bag of jalapenos, dated August 27, 2025, was observed in the cooling refrigerator. Staff #55 stated that the jalapenos should not be in the refrigerator more than 2 weeks. She removed the bag and stated that the risk for storing the jalapenos past the 2 week designated time frame could include foodborne illness. A further observation revealed a tomato, not bagged, with no indication of date or how long it had been there. A bag of lettuce was observed dated September 7, 2025 with no noted use-by date. Staff #55 stated that she was unsure how long these could be kept.During the same initial…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, staff interviews, and the facility's policies and procedures, the facility failed to ensure that 1 out of 23 residents (Resident # 7) received pain medication as ordered by the physician.Findings include: Resident # 7 was admitted on [DATE], with diagnosis of morbid obesity, muscle weakness, cognitive communication deficit, bipolar disorder, and major depressive disorder. Review of Resident # 7's care plan dated March 18, 2024, revealed that Resident # 7 was currently on opioids for pain management, with interventions that include administering opioids as prescribed. A review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident # 7 is cognitively intact. Further review of the MDS revealed opioid usage. Review of Orders dated August 16, 2025, for Resident # 7 revealed an order for Oxycodone oral tablet 10 milligrams (mg) to be given by mouth every 4 hours as needed for pain rated as a 6-10.…

    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 · Dcited before2025-09-16 · 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 clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for 1 of 27 sampled residents (#45) in accordance with professional standards of practice. The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation.Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for one resident (#45) out of 21 The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation.Findings include:Resident #45 was initially admitted on [DATE] with diagnosis including type II diabetes mellites with diabetic neuropathy, chronic…

    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 · D2025-06-23 · 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

    Based on resident interview, policy review, and staff interview, the facility failed to ensure a Registered Nurse (RN/Registry Staff # 467), who was from a staffing agency and not employed by the facility directly, had the specific competencies and skill sets necessary to care for residents' needs. This failure had the potential to affect all residents assigned to the RN's care during her shift. Findings include: Review of the facility 5-day report revealed alleged perpetrator RN (Registry/ Staff # 467) had been contracted through a nursing registry. Facility eMAR documents revealed that the RN (alleged perpetrator) worked at the facility as a registered nurse starting August 26, 2022 and no additional documentation for scheduled shifts worked in August 2022. Further review revealed the registry RN was scheduled to work the following days; September 2,3,4,9,10.11.16.17, 18, 23,24,25, and 30 for the 6PM-6AM shift. The facility became aware of the alleged perpetrator on September 19, 2022 when the Dietary Supervisor (Staff/#56) alerted the Director of Nursing (DON/Staff #147) 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-08 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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, resident and staff interviews and facility documents, the facility failed to ensure that two residents (#21, #52) received activities of daily living (ADL) care per facility policy. Failure to do so could result in psychosocial harm. Findings include: -Resident #52 was admitted [DATE] with diagnoses of sepsis and metabolic encephalopathy. A care plan dated July 2, 2024 included a self-care performance deficit related to weakness, and impaired mobility which included to encourage to participate to the fullest extent with each interaction. A Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired and that showering was not attempted due to a medical condition or safety concern. A document titled West Showers included that resident #52's room was to be provided showers 2 times a week by the 2 PM to 10 PM shift and that any missed showers were to be caught up on Sundays. This document included that shower sheets need to be filled out and signed by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure room temperatures were within the safe temperature range. The deficient practice put the residents at increased risks for harm such as lack of sleep and heat stroke. Findings include: A TELS (Facility maintenance reporting) report for 6/1/2024 through 7/8/2024 did not include any requests for action regarding temperature. However, interviews with 8 residents included that they had been informing staff of the problems with temperatures. A document dated 6/26/2024 an order was placed for a new HVAC (Heating, Ventilation and Air Conditioning) unit on the south hallway, on 6/28/2024, 3 rental air condition units, 3 swamp coolers, and 5 portable fans were placed on the south hallway. A temperature logbook included that temperatures had been taken in 2 rooms in each hallway 2 times since the breakdown of the air conditioning unit, however documentation 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-27 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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, staff interviews, and facility policy, the facility failed to ensure a resident's code status was honored. Findings include: Resident #5 was admitted on [DATE] with pneumonia, and acute respiratory failure with hypoxia. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was severely impaired for daily decision making and had a long and short term memory problem. A Prehospital Medical Care Directive dated [DATE] included that In the event of cardiac or respiratory arrest, I refuse any resuscitation measures Including cardiac compression, endotracheal Intubation and other advanced airway management, artificial ventilation,defibrlllation, administration of advanced cardiac Iife support drugs and related emergency medical procedures. A physician's order dated [DATE] included Do Not Attempt Resuscitation (DNR). However, a progress note dated [DATE] included Please note, this writer was informed that patient was found unconscious without a pulse/respirations, at 1657…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. The deficient practice could result in a potential for food borne illness. Findings include: A freezer observation on June 28, 2023 at 7:15 a.m. revealed vegetable patties and raw chicken not covered, labeled or dated. A refrigerator observation on June 28, 2023 at 7:20 a.m. revealed potatoes, lemons and oranges not labeled or dated. Additionally, 2 oranges were observed to exhibit a fuzzy, grayish substance on the outside of the orange. The discolored oranges were present in a box of oranges. The kitchen manager removed the two oranges and stated that she generally reviews refrigerator contents once a week after deliveries. A box of shredded carrots was observed to be stored in the refrigerator with a use-by date of June 24, 2023. The kitchen manager stated that these should have been removed but had been missed. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated that she reviewed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-07 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: An observation on June 29, 2023, revealed trash strewn in front and to the side of both outside dumpsters. Meatballs and what appeared to be mashed noodles were observed directly in front of the first dumpster, as well as to the side of the first dumpster. Small milk cartons and sausages were observed to the immediate left of the second dumpster. Staff # 65 identified the milk cartons as facility milk cartons utilized for residents. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated she inspects the outside garbage containers at least daily and also relies on kitchen staff to report any adverse refuse conditions. An interview with the administrator, staff # 115 was conducted on June 6, 2023 at 12:29 p.m. He stated that the expectation was that the outside…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2023-07-07 · 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 facility policy review, the facility failed to ensure that medication was administered as ordered for one resident ( #140) and that a physician was notified. Findings include: Resident #140 was admitted on [DATE] with diagnoses of sepsis and Clostridium difficile. A physician order dated June 16, 2023 included the following: -Levofloxacin (antibiotic), 500 mg (milligrams) intravenous one time a day for sepsis until June 20, 2023; -Meropenem (antibiotic), use 1 gram intravenous every 8 hours for sepsis until June 26, 2023; and, -Vancomycin HCl Oral Capsule (antibiotic), give 125 mg by mouth one time a day for C-diff prophylaxis until July 11, 2023. A care plan dated June 20, 2023 included that the resident was on antibiotic therapy including intravenous Meropenem and Levaquin and oral Vancomycin related to severe sepsis and Clostridium difficile prophylaxis. Interventions included to administer medication as ordered. A list of medications available in 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 before2023-07-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy, the facility failed to ensure one resident (#140) receive care and services to prevent/heal pressure ulcers. Findings include: Resident #140 was admitted on [DATE] with diagnoses of a stage 4 pressure ulcer of right buttock, abdominal surgical dehiscence. A physician's order dated June 17, 2023 included cleanse sacral wound with normal saline and pat dry, pack with gauze soaked in Dakins Quarter strength 0.125% and cover with dressing every day shift. A wound assessment details report dated June 19, 2023 included that the sacrum wound was a stage 4 pressure ulcer measuring 2.5cm long x 4.00cm wide x 3cm deep. A wound assessment details report dated June 19, 2023 included that the right buttocks/ischium wound was a stage 4 pressure ulcer measuring 19 cm long x 17.00cm wide x 3cm deep. A physician's order dated June 19, 2023 included cleanse wound to right buttock and ischium with normal saline, pat dry, apply medihoney with alginate, secure…

    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 · D2023-07-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, staff interviews, and policies, the facility failed to ensure one sampled resident (#19) who had an enteral feeding tube received the appropriate treatment and services to prevent complications. The deficient practice could result in potential enteral feeding tube complications. Findings include: Resident #19 was admitted on [DATE] with diagnoses that included malignant neoplasm of the larynx, oropharyngeal phase dysphagia, and chronic respiratory failure with hypoxia. A nutrition/hydration care plan initiated on March 24, 2023 indicated resident was NPO and enteral feeding dependent. The interventions included to administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the physician's orders revealed the following: -3/23/2023: May crush/combine medications for administration if not contraindicated and mix with 4 0z (ounces) of water. May use slow push to facilitate consumption. -3/23/2023: Check tube placement and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-07 · 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 clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure one resident (#11) did not receive unnecessary oxygen therapy. The deficient practice could result in high carbon dioxide content in the resident 's blood that can lead to respiratory acidosis and death. Findings include: Resident #11 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart failure and chronic respiratory failure with hypoxia. A care plan initiated on April 6, 2020 revealed that the resident was receiving oxygen therapy related to the diagnosis of COPD. The interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD (medical doctor) pulse oximetry. Review of the physician order dated February 21, 2022 included an order to check pulse ox (oxygen) level on room air and document for oxygen weaning purposes every shift. A physician order dated March 10, 2022 ordered to check pulse ox every…

    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 · D2023-07-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure multi-dose vials that had been opened and accessed were dated and discarded within the required time frame. Findings include: A medication and storage and labeling inspection was conducted on June 29, 2023 at 8:10 a.m. in [NAME] Unit with a registered nurse (staff #6). During the inspection of the medication cart, a box labeled Admelog injection 100 units/ml (milliliter) for resident #295 was open and contained approximately 5 ml of insulin. However, the medication box contained two different insulin vials: the first was marked Admelog (insulin Lispro 100 units/ml); the second was marked Insulin Glargine 100 units/ml. The medication vials revealed no open dates and the second vial has no resident name. The medication cart also had a box labeled Insulin Aspart multi vial use for resident #292 that was open and contained approximately 5 ml of insulin. Another box of Insulin labeled Insulin Lispro with resident #66 had an open vial which contained…

    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 · E2022-07-21 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure 3 residents (#87, #36, #33, and #34) were not administered unnecessary medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: -Resident #87 was readmitted to the facility on [DATE] with diagnoses that included hypoglycemia, atrial fibrillation, and hypotension. Review of the clinical record revealed a physician order dated 05/07/2022 for Diltiazem 30 milligrams (mg) by mouth every 6 hours for AFIB (atrial fibrillation), and hold for heart rate less than 60. Review of the Medication Administration Record (MAR) for May 2022 revealed Diltiazem was scheduled at 1:00 a.m., 7:00 a.m., 1:00 p.m., and 7:00 p.m. The MAR also revealed Diltiazem (antiarrhythmic) was administered on 05/07/2022 at 7:00 p.m., and on 05/08/2022 at 1:00 a.m., 7:00 a.m. and 1:00 p.m. The MAR included what the resident's blood pressure was but did not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and policy reviews, the facility failed to ensure infection control practices were followed. The deficient practice could result in the spread of infection. Findings include: Regarding Glucometer Cleaning/Disinfection During a medication administration observation conducted on July 19, 2022 with an LPN (Licensed Practical Nurse/staff #99), the LPN was observed to obtain several blood sugar levels. At 7:35 a.m., staff #99 was observed exiting a resident room with a glucometer in his gloved right hand with a glucose strip that contained a blood sample. Staff #99 placed the glucometer on top of the medication cart, documented the result on the paper, removed the used glucose strip and discarded it in the sharps container, doffed gloves, and performed hand hygiene. The LPN then prepared the equipment for the next resident (alcohol pad, glucose strip, lancet, glucometer). The LPN was not observed to sanitize or disinfect the glucometer. At 7:38 a.m., staff #99 was observed to obtain a blood sample from another resident using the same glucometer.…

    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 · D2022-07-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure one sampled resident (#87) received treatment and care in accordance with professional standards of practice. The deficient practice could result in delayed treatment for abnormal blood sugar levels and vital signs not being monitored during a change in condition. Findings include: Resident #87 readmitted to the facility on [DATE] with diagnoses which included hypoglycemia, atrial fibrillation, hypotension, end stage renal disease, dependence on renal dialysis, unspecified cirrhosis of the liver, and systemic lupus erythematosus. Physician orders dated [DATE] revealed cardiopulmonary resuscitation (CPR)/Full Code, regular diet thin liquids, and that admission orders, medication orders were verified with the physician and no clinically significant medication issues were identified. Review of a nursing note dated [DATE] at 7:28 a.m. revealed the resident was admitted to the facility at 8:31 p.m. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy reviews, the facility failed to ensure two residents (#33 and #45) consistently received the necessary treatment and services to promote the healing of pressure ulcers. The sample size was 4. The deficient practice could delay healing of pressure ulcers. Findings include: -Resident #45 was admitted to the facility on [DATE] with diagnoses that included an unspecified open abdominal wound, pressure ulcer, diabetes type 2, and quadriplegia. Review of the current care plan revealed the resident has a potential for pressure ulcer development related to decreased mobility, episodes of incontinence, and scar tissue related to history of pressure ulcer: August 9, 2021 a coccyx pressure ulcer related to the sacrum stage 4 that was resolved on January 14, 2021. Interventions included weekly skin assessment and PRN (as needed), and monitoring/documenting the location, size and treatment of the skin injury, and reporting abnormalities, failure to heal, signs…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 observations, clinical record review, staff interviews, and policy review, the facility failed to provide evidence that one resident (#238) with limited mobility consistently received appropriate services regarding an orthopedic boot, and that one resident (#33) with limited mobility was provided restorative services as ordered. The sample size was 5 residents. The deficient practice could result in orthopedic boots not being applied for residents, and residents not being provided with restorative services as ordered. Findings include: -Resident #238 was admitted to the facility on [DATE] with diagnoses that included non-displaced fracture of the left calcaneus, and difficulty walking. Review of a physician note dated July 9, 2022 at 10:04 p.m. stated CT (Cat Scan) demonstrates calcaneus fracture and that it is possible that the resident has aggravated this potential delayed or nonunion while in the hospital, and may be the cause of the resident's increased pain about the foot. The note stated the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-21 · 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 interview, and policy review, the facility failed to ensure one resident (#4) known to have repeated falls was consistently assessed after falls. The sample size was 3 residents. The deficient practice could result in residents not being assessed after a fall. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of the care plan initiated on March 29, 2022 revealed the resident was at risk for falls. The interventions included ¼ enable bars to enable bed mobility, sitting up, and transfers, leg rest on the wheelchair, and for staff to make frequent checks on the resident for positioning in bed. The care plan also included the following: Actual fall on April 8 and April 29, 2022 Actual fall on May 26, 2022 Actual fall on June 9 and June 29, 2022 Actual fall on July 5 and July 9, 2022 The quarterly 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
CARETRUST REIT INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/2022
BURNAM, SOONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2006
EAGAR, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2009
SINGH, JASPREETIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
PETERSON, FORRESTIndividualCORPORATE OFFICERsince 01/01/2019
PORT, BARRYIndividualCORPORATE OFFICERsince 07/26/2018
CONCENTRIC HEALTHCARE SOLUTIONS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2003
FAVORITE HEALTHCARE STAFFING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2003
P20 PARENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2003
SOUTHERN ARIZONA HEALTH SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/25/2026
CARETRUST GP LLCOrganizationADP OF THE SNFsince 05/16/2003
CTR PARTNERSHIP LPOrganizationADP OF THE SNFsince 01/01/2022
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 05/16/2013
RILLITO HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 25 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$17.7M
Net patient revenuemost recent cost report
+9.8%
Operating marginrevenue minus expenses
$2.0M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 7%Other / private 33%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$503per resident / day
operating cost
$15,302per month
≈ monthly operating cost
$558per 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 035190. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-16, 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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