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Foothills Rehabilitation Center

2250 North Craycroft Road, Tucson, AZ 85712 · For profit - Limited Liability company · 149 certified beds · (520) 733-8700 Medicare & Medicaid certified

Call the home — (520) 733-8700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 20251 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 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 staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5240 E Knight Ste 112 · (520) 210-8300 · Call to confirm hours
Pharmacy
5310 E Grant Rd · (520) 324-1890 · Call to confirm hours
Grocery
4766 E Grant Rd · (520) 323-4500 · Call to confirm hours
Park
2900 N Craycroft Rd · (520) 749-0201 · Typically dawn to dusk
Place of worship
1926 N Cloverland Ave · (520) 444-8810

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

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 fell from 3 to 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.

Overall rating2★
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 increased5.5%10.7%15.4%better
Long-stay residents who lose too much weight5.1%5.3%5.4%typical
Long-stay residents with a catheter left in their bladder2.0%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%3.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%2.1%3.3%better
Long-stay residents whose ability to walk worsened11.8%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.3%21.0%18.9%typical
Long-stay residents given the seasonal flu vaccine96.2%94.6%95.3%typical
Long-stay residents with pressure ulcers4.3%4.4%4.7%typical
Long-stay residents with worsening bladder/bowel control4.5%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.2%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine91.7%87.3%79.4%better

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

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

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

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

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

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

53.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
0.27U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF53.6%CMS range 40.2–67.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.4–17.610.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.1%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 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

0.71
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.59
Aide hours/ resident / day
4.07
Total nurse hours/ resident / day
0.49
RN hoursweekends
22.8%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 149 beds and averages 124.4 residents a day — about 83% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above 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 3.80 hrs/resident/day on weekends vs 4.18 on weekdays — 9% thinner on weekends. RN hours go from 0.79 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%.

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

Inspection trend

11
deficiencies at the latest standard inspection (2026-03-28)
1
at the previous standard inspection (2025-03-07)

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.

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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2024-11-25 · 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 and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#1) out of 3 sampled is free from preventable falls. This deficient practice could result in resident injury and mortality. Findings include: Resident #1 was admitted on [DATE] with diagnosis including MS (multiple sclerosis) chronic respiratory failure, tracheostomy, hemiplegia and hemiparesis affecting the right dominant side, chronic pain, muscle weakness, wedge compression fractures, fracture of right tibia, and fracture right fibula. A review of the MDS (minimum data set) dated November 13, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. A review of the resident's care plan revealed that a focus area noting that the resident required the use of a mechanical lift device (Hoyer lift) and a 2-person assist was initiated on December 5, 2023. A review of the progress notes revealed that 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
  • Actual harm · Gcited before2023-02-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#62) did not sustain a preventable accident. The sample size was 24. The deficient practice increased the risk for pain, injury and/or hospitalization. Findings include: Resident #62 admitted to the facility on [DATE] with diagnoses including cerebellar stroke syndrome, diverticulosis of the large intestine and a persistent vegetative state. The activities of daily living (ADL) care plan dated 03/11/21 related to bathing, grooming, hygiene, toileting and bed mobility had a goal for the resident not to decline in ADL function. Interventions included 2 staff assistance for bed mobility. Review of the annual Minimum Data Set assessment dated [DATE] revealed the resident's cognition was not assessed and she required total assistance of one to two persons for most ADLs. A nursing progress note dated 01/15/23 at 3:30 a.m. included that the nurse had been called to the resident's room where she 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-03-28 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, interviews, and review of the facility's policy and procedures the facility failed to ensure their policy was implemented and followed related to abuse/neglect and abuse investigation for Residents #19, #56, #139, #144, #149, #167 and #174. The universe was 25. The deficient practice could result in failure to recognize, respond and take appropriate action to prevent residents from continued abuse and neglect and risk for ongoing harm, exploitation and serious adverse outcomes.Findings include:Regarding Resident #167 -Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease. Review of the admission MDS, dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2026-03-28 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy reviews, the facility failed to ensure allegations of abuse for 5 of 25 sampled residents (#19, #174, #149, #139 and #56) were thoroughly investigated. The deficient practice could result in failure to recognize, respond and take appropriate action to prevent residents from continued abuse and neglect and risk for ongoing harm, exploitation and serious adverse outcomes.Findings include: -Resident #174 was admitted on [DATE] and discharged on February 14, 2024 with diagnosis including acute/ chronic respiratory failure with hypoxia and hypercapnia, muscle weakness, Parkinson's disease, chronic obstructive pulmonary disease, obstructive sleep apnea, morbid obesity, transient ischemic attack, hypoventilation syndrome, atrial fibrillation, chronic systolic congestive heart failure, aneurysm of other specified arteries, anemia, sick sinus syndrome, dyspnea, asthma, gastroparesis, osteoarthritis-right knee and shoulder, chronic kidney…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-03-28 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 a baseline care plan was provided to resident/representative for 3 of 25 sampled residents (#168, #171 and #175). The deficient practice could result in residents not receiving the necessary care and services to meet their assessed needs upon admission.Findings include:-Resident #168 was admitted on [DATE] with diagnoses of acute posthemorrhagic anemia, unsteadiness of feet, difficulty of walking, seizures, and COPD (chronic pulmonary obstructive disease). The nursing note dated October 23, 2023 included that resident arrived from the hospital, was alert and oriented x 4 and was able to make needs known. Per the documentation all consents were signed by the resident. The baseline care plan dated October 23, 2023 included that the meeting was attended by the social services and nutrition staff; and did not indicate the resident or resident representative was part of the creation of the baseline care plan.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2026-03-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled and stored in accordance with professional food safety standards. The deficient practices could result in food-borne illnesses.Findings include:An initial kitchen observation was conducted on March 24, 2026 at 8:20 AM with the Dietary Manager (staff #108). There was an open 2-pound package of Hormel deli smoked ham inside a Ziploc bag with no open date on either the original packaging or the Ziploc bag; and, a box of mushrooms labeled with a production date of March 9, 2026 was found in the kitchen refrigerator. The mushrooms in the box were dark brown in color and were 'mushy'. The Dietary Manager stated that the mushrooms were browning and should be going in the trash. A observation of the kitchen freezer was also conducted with the dietary manager (staff #108) on March 24, 2026 at 8:30 AM. In the freezer was an open 64-ounce bag of Frozen Harvest mixed vegetables with no open or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-03-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure infection control practices were followed regarding Enhanced Barrier Precautions (EBP) for 3 residents (#82, #42, and #10) The universe is 25. This deficient practice can result in contamination and spread of infection.Findings include:-Resident #82 was admitted to the facility on [DATE] with diagnoses of MRSA (Methicillin resistant Staphylococcus aureus) infection, rash and other nonspecific skin eruption, Zoster without complications and disorder of skin and subcutaneous tissue. The care plan dated March 2, 2026 included resident was at risk for dehydration related to MRSA bacteremia. The nursing note dated March 21, 2026 revealed admission diagnosis of MRSA infection. The wound note dated March 24, 3036 included that the resident had a wound to the breast related to acute generalized exanthematous pustulosis. The facesheet in the clinical record that resident was on EBP related to…

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

    Infection Control Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-03-28 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident's (#120) advance directive was accurately documented and implemented in accordance with the resident's expressed preference. The universe was 25. The deficient practice could result in the resident's wishes and preferences related to life-sustaining treatment not followed and honored. Findings include:Resident #120 was admitted to the facility on [DATE], discharged on [DATE], and returned to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Morbidity, and Acute Kidney failure, unspecified.Review of the Change in Condition (CIC) Minimum Data Set (MDS), dated [DATE], revealed Resident #120 completed a Brief Interview for Mental Status (BIMS) and scored a 13 which indicated he was cognitively intact.Review of Resident #120's Care Plan revealed it was last reviewed/revised on [DATE]. The Care Plan identified 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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-03-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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, resident interviews, staff interviews, and a review of policies and procedures, the facility failed to ensure a safe homelike environment for residents. This deficient practice had the potential for resident injury and psychosocial harm. Findings include:Resident #39 was admitted on [DATE] with diagnosis including anemia, hypertension, diabetes mellitis, and depressionThe 5-day MDS (minimum data set) with an assessment reference date of December 29, 2025 revealed that the resident had a BIMS score of 15, indicating that the resident was cognitively intact.A review of the facilities work-orders from January 2026 through March 26, 2026 revealed a total of 16 work orders for the entire time span. There was no evidence of a work-order for either the baseboards or the hole in the wall for the 200-hall.An observation was conducted on March 24, 2026 at 9:27 AM past the entrance doors of the 200-hall secured unit. To both sides of the hall, missing sections of baseboards were observed. On 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 plan of correction
  • Potential for harm · Dcited before2026-03-28 · 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 clinical record review, interviews, facility policy review and the Resident Assessment Instrument, the facility failed to ensure the assessment for one sampled Resident #45. The universe was 25. The deficient practice could result in residents not meeting their needs according to the comprehensive assessment. Findings include:Resident #45 was admitted to the facility on [DATE] with diagnoses that included presence of cardiac pacemaker, morbid (severe) obesity, type 2 diabetes mellitus with other skin complications, type 2 diabetes mellitus with diabetic polyneuropathy and chronic respiratory failure with hypoxia.The face sheet in the electronic medical records revealed Resident #45 was identified as a white female.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included Resident #45 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated resident was cognitively intact. Section A101 included Resident #45 was white.However, the Prehospital Medical Care Directive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-03-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, the facility documentation and policy review, the facility failed to ensure the care plan was revised to reflect the assessed need for a two-person assist with bathing for one resident's (#167). The universe was 25. The deficient practice led to staff providing care with only one person assist which resulted in the resident sustaining an injury and being hospitalized .Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease.Review of the admission Minimum Data Set (MDS), dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist.The care plan indicated dated December 6, 2022 revealed the resident required total assist for all Activities of Daily Living…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-03-28 · 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, interviews, review of the facility's policy and procedures, the facility failed to ensure one resident (#167) was free from unavoidable accidents. The universe was 25. The deficient practice resulted in a resident sustaining a major injury.-Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease.Review of the admission Minimum Data Set (MDS), dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist.The care plan indicated dated December 6, 2022 revealed the resident required total assist for all Activities of Daily Living (ADLs) which included bathing; and, was at risk for falling related to weakness. The goal was that the resident will remain free from injury.…

    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 plan of correction
Show the remaining 10 citations
  • Potential for harm · D2026-03-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of clinical record, and facility policy and procedure review, the facility failed to ensure medications were not left at bedside for one of 26 sampled residents (#102). The universe was 124. The deficient practice could result in resident taking the medication outside of the physician ordered parameters resulting in complications such as overdose, negative medication interactions and other residents having unrestricted access to medications.Findings include: Resident #102 was admitted on [DATE] with diagnoses disorganized schizophrenia, age-related osteoporosis, dependence on supplemental oxygen, peripheral vascular disease, obstructive sleep apnea, chronic bronchitis, hereditary and idiopathic neuropathy, and depression. The quarterly MDS (minimum data set) dated March 4, 2026 revealed a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The review of the MDS further revealed no potential indicators of psychosis or…

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

    Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2025-08-01 · 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 The facility failed to ensure resident #1 was free from avoidable accidents when transferring a resident using a Hoyer lift. This deficient practice placed the resident at risk for serious injury, pain, and further decline.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that include obesity, chronic pain syndrome, and long-term use of anticoagulants. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status score of 14, which indicates she was cognitively intact. A review of the care plan, dated March 19, 2025, indicated that a Hoyer lift with 2 staff will be used to safely transfer the resident, and an identified goal was that the resident would not have an injury related to transfers. A review of the physician's orders, dated March 23, 2025, revealed Resident #1 was to be transferred using a 2-person Hoyer lift. A review of the progress notes in the resident's Electronic Health Record (EHR) revealed a note,…

    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 · D2025-07-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, staff and resident interviews, and facility policies and procedures, the facility failed to protect the resident (#8) rights to be free from physical abuse by another resident (#7). The deficient practice could result in bodily injury and emotional or mental trauma.Findings include:-Regarding Resident # 7:Resident #7 was admitted to the facility on [DATE], with diagnoses that included diffuse traumatic brain injury with loss of consciousness, essential hypertension, hereditary and idiopathic neuropathy, unspecified, intrapartum hemorrhage, unspecified, anxiety disorder, unspecified. The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed that the resident had no potential indicators of psychosis but exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing or abusing others sexually), verbal behavioral…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, facility documents and the facility policy and procedures, the facility failed to complete a thorough investigation. The deficient practice could result in allegations not being substantiated. Based on staff interviews, facility documents and the facility policy and procedures, the facility failed to complete a thorough investigation. The deficient practice could result in allegations not being substantiated. Findings include: Review of the 5 day investigation dated June 13, 2025 revealed that (Resident #3) reported to (staff #11) that another nurse (staff #42) has verbally abused her and attempted to hit her awhile back. This document included that 3 residents had been interviewed, however, interviews with staff were not included. An interview was conducted on June 25, 2025 at 2:53 P.M. with the Director of Nursing (DON/staff #18) who said when an allegation is made, the facility has to make sure the resident is safe, separate them, suspend the alleged perpetrator, and do a skin check. She said that she would interview staff, interview the resident and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · 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 clinical record review, interviews, facility documentation and policy review, the facility failed to ensure a colostomy care order was in place for one resident (#1) in accordance with professional standards of care. The deficient practice could result in residents not receiving the needed services for colostomy care. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, acute respiratory failure, use of a gastrostomy tube, and tracheostomy tube. On April 30, 2025, a review of Resident #1's orders revealed no orders for colostomy care. Review of Resident #1's care plan did not identify him having a colostomy bag or that colostomy care was needed. A review of Resident #1's progress notes revealed a note, Respiratory Vent Note, dated February 16, 2025 at 8:05 PM indicating that Resident #1 had a distended abdomen that was hard to the touch. Review of progress note, dated February 17, 2025 at 2:02 PM, revealed Resident #1 was sent out to an…

    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 before2025-03-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 interviews and review of policies and procedures, the facility failed to ensure that staff followed sanitary guidelines during tray-line and when preparing pureed foods; and failed to ensure that foods within the refrigerator were appropriately labeled and dated. The deficient practices could result in food-borne illnesses. Findings include: An initial kitchen observation was conducted on March 4, 2025 at 8:30 A.M. in conjunction with the dietary manager (Staff #34). During the refrigerator observation it was observed that dough, a package of 4, was not labeled or dated, which was identified by the dietary manager as pizza dough. A plastic bag containing breaded fish and a bag of tortillas were also not labeled or dated. An observation was conducted on March 5, 2025 at 11:38 A.M. for purred food. It was observed that the cook, (Staff #143) had touched the outside of the food ladle with the fingers of her left hand and then proceeded to use the same ladle to obtain more ham and beans to add to the food processor. It was further observed that she touched…

    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 · Dcited before2024-12-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews and policy review, the facility failed to provide incontinence care for one resident (#2). The deficient practice could result in an increased risk for resident discomfort and or infection. Findings include: Resident #2 was admitted on [DATE] with diagnosis including end stage renal disease, surgical aftercare on the circulatory system, type 2 diabetes with diabetic neuropathy, chronic diastolic congestive heart failure, chronic pain syndrome, and major depressive disorder-recurrent. A review of the admission MDS (minimum data set) dated July, 18, 2023 revealed no noted BIMS (brief interview of mental status) score. A review of the resident's care plan revealed that the resident required a one person assist for all activities of daily living to include toileting and hygiene. The care plan further revealed that the resident had the potential for skin breakdown and pressure related injuries due to the normal aging process and incontinence, further…

    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 before2023-02-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical records, staff interviews and facility policy, the facility failed to ensure that an appropriate order for catheterization was in place and failed to ensure catheter care followed infection control practices for 1 resident (#40). The deficient practice could result in unnecessary catheterization and spread of infections. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region, stage 4, schizophrenia, and anxiety disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident is cognitively intact. This document included that this resident is total 2 person assistance for most activities of daily living. This document also included that this resident has an indwelling catheter and that a voiding trial has not been attempted on admission or reentry. A physician's order dated November 8, 2022 included foley…

    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 before2023-02-16 · 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

    Based on observation, staff interviews, policy and procedures review, the facility failed to ensure that wet cleaning rags were not stored on the counter in proximity of food preparation areas. The deficient practice could result in foodborne illness and food not safe for consumption. Findings include: An initial kitchen observation was conducted on February 13, 2023 at 8:32 a.m. At 9:18 a.m. a wet cleaning rag was observed on the counter where ham was being sliced. This was brought to the attention of the Dietary Manager, staff #5, who then asked staff to remove the rag and clean the counter A follow-up kitchen observation was conducted on February 14, 2023 at 11:32 a.m. Another wet cleaning rag was stored on the counter next to the puree preparation station. The Food Services Manager also saw the rag and proceeded to immediately remove it and clean the area. An interview with Food Services Manager was conducted on February 14, 2023 at 12:15 p.m. Both incidents of cleaning rag storage, when not in use, were reviewed. The Food Services Manager stated that cleaning rags are 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · 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 record review, staff interviews and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure accurate completion of the MDS (Minimum Data Set) assessment for one resident (#104). The deficient practice could result in assessments that are not accurate and data that is not accurate for quality monitoring. Findings include: Resident #104 was admitted on [DATE] with diagnoses that included: Acute and chronic respiratory failure with hypoxia, pedestrian injured in traffic accident involving unspecified motor vehicles, schizoaffective disorders, and psychotic disorder with delusions due to known physiological condition. A quarterly MDS dated [DATE] revealed that a BIMS (Brief Interview of Mental Status) was not accurately completed, as evidenced by section C of the MDS. Section C of the MDS revealed a code '0' indicating that the resident is rarely or never understood. No BIMS score was observed and the resident was scored a '3' in the area of cognitive skills for daily decision making,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 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 2 of 51.8+0.2 vs chain
Health inspection 1 of 52.2-1.2 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 5 of 53.2+1.8 vs chain
The other 11 homes this chain runs (chain average 1.8★, per CMS)

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
ROTHNER, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST40%since 10/05/2011
ROTHNER, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 10/05/2011
ROTHNER, MELISSAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 10/05/2011
ROTHNER, RACHELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 10/05/2011
OKEKE, PATRICKIndividualW-2 MANAGING EMPLOYEEsince 03/06/2017
ZIMMERMAN, JOEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2012

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.

$17.8M
Net patient revenuemost recent cost report
-7.2%
Operating marginrevenue minus expenses
$1.8M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 3%Other / private 24%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$439per resident / day
operating cost
$13,331per month
≈ monthly operating cost
$409per 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 035064. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-28, 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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