Life Care Center of Tucson
6211 North La Cholla Boulevard, Tucson, AZ 85741 · For profit - Corporation · 162 certified beds · (520) 575-0900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Apr 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,380 in federal fines (most recent 2026-07-10)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.1% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.5% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 11.2% | 3.9% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.0% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.7% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.3% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.2% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.0% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 23.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.3% | 10.4% | 12.0% | typical |
‡ 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.
60.4% 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 151 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.4% 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 38 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 0.35 therapist hours per resident per day in 2025Q4 — more than 60% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.4%CMS range 52.3–68.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 9.0–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 4.2–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 162 beds and averages 84.2 residents a day — about 52% occupied, or roughly 78 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 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 2.19 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 3.33 hrs/resident/day on weekends vs 3.89 on weekdays — 15% thinner on weekends. RN hours go from 0.76 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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
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.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-07-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, review of facility documentation, clinical records and facility policy, the facility failed to ensure that one resident (Resident #15) out of one sampled resident was free from preventable accident by failing to ensure appropriate safety measures during a transfer. The universe was sixty. The deficient practice could place other residents at risk for preventable falls and serous injury.Findings include: Resident #15 was admitted to the facility on [DATE], with multiple diagnoses that included a historical fracture of the right shoulder girdle and need for assistance with personal care. The quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for mental Status (BIMS) score of 14 indicating intact cognition. Review of the MDS also revealed that the resident required substantial assistance with transfers from the bed to the chair. The care plan initiated on January 30, 2026 revealed a focus area related to a risk for falls, with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident #1) was free from verbal abuse by a staff member. The deficient practice could result in other residents being abused.Findings Include:-Regarding Resident #1:Resident # 1 (alleged victim) was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with foot ulcers, absence of left foot, morbid obesity, and mood disorder. A comprehensive care plan initiated on August 25, 2025 revealed that the resident had an activity of daily living (ADL) self care performance deficit due to activity intolerance. The care plan further revealed interventions that included toilet use requiring maximum assistance and requiring 2-person dependent assist with transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. The MDS also revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one of three sampled residents (#119) to be free from abuse by another resident (#103). The deficient practice could lead to ongoing abuse, leading to harm to other residents.-Findings include:Regarding Resident #119Resident #119 (alleged victim) was admitted to the facility on [DATE], with diagnoses including displaced fracture of the surgical neck of the right humerus, cognitive communication deficit, unsteadiness on feet, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, age-related cognitive, mood affective disorder, and insomnia.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #119 had exhibited no verbal 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.
- Potential for harm · Dcited before2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for one of the 5 sampled residents. The deficient practice could result in injury to residents.Findings Include:Resident #119 was admitted to the facility on [DATE], with a diagnoses of Essential (primary) hypertension, hyperlipidemia, unspecified severe protein-calorie malnutrition, chronic kidney disease, stage 3, chronic obstructive pulmonary disease, anemia, nonrheumatic aortic (valve) stenosis, occlusion and stenosis of left carotid artery, nonrheumatic aortic (valve) insufficiency, dysphagia following cerebral infarction.An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating moderate cognitive impairment. The elopement assessment was assessed as not a risk for the resident (#119).According to the progress notes dated August 25, 2025, it was revealed that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-15 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY BBased on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure 4 out of 4 residents' (#47, #48, #52, and #53) medications were not misappropriated by nursing staff. The deficient practice resulted in the facility not keeping an accurate record of controlled substances. Findings include:Related to Resident #47-Resident #47 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the right femur, generalized muscle weakness, stage 3 kidney disease and cognitive communication deficit.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #47 had a Brief Interview for Mental Status (BIMS) and scored a 12 which indicated he had moderate cognitive impairment. The same MDS also indicated the resident was taking opioids as part of his medication regimen.The care plan, revised on May 24, 2024, revealed Resident #47 was on a PRN (Pro Re…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policy and procedures, the facility failed to ensure a resident (#40) received medications according to physician's orders. The deficient practice could result in resident experiencing unnecessary pain.Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included Dementia, fusion of the spine in the cervical region, and a fracture of the humerus in the right arm. The care plan, initiated on August 9, 2023, indicated Resident #40 was on pain medication therapy related to chronic pain syndrome. Interventions included administering analgesic medications as ordered by the physician and to observe for side effects and effectiveness of the medications.A physician's order, dated September 18, 2023, revealed an order for Dilaudid (Hydro-morphine HCI) Oral Tablet 2 MG (milligrams). The order indicated that .5 mg tablet was to be given every 4 hours as needed for pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-17 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 58 and the sample was 14. Findings include: On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. This deficient practice could result in placing residents at risk for food-borne illnesses. The facility census was 58. Findings include: During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-17 · tag F0906 — patternProvide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-17 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents: Findings include: Regarding safe environment: During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed: - Doorway frame missing in room [ROOM NUMBER], light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch. - Corner handrail by room [ROOM NUMBER] was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Corner handrail 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.
- Potential for harm · E2024-07-17 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). The deficient practice could impact the safety, rights, and care provided to residents. Findings include: Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness. -Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023. -Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2024-07-17 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment. Findings include: Resident #222 was admitted on [DATE] with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated [DATE] revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections. Findings include: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism. The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a residents' care was not neglected. Neglected care could result in increased morbidity for residents. Findings include: Resident #48 was admitted on [DATE] with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene. A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed. However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care. This deficient practice could result in resident's or their representatives not being able to make their own healthcare decisions. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff. The deficient practice could result in further incidents of neglect of the residents. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of State agency documentation revealed the report for this incident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was assessed according to professional standards. The deficient practice could result in a delay of clinically necessary treatment. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#10) was free from physical abuse by staff. The deficient practice could result in further incidents of staff to resident abuse. Findings include: -Resident #10 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, weakness, aphasia, Bipolar disorder, depression, and anxiety. A behavioral care plan revised February 6, 2023 revealed the resident was at risk for mobility performance deficit related to Alzheimer's dementia. The goal was to maintain a current level of functional mobility through the next review period, and a noted intervention that staff are to assist her turn and reposition in bed as necessary. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had significant cognitive impairment. A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-14 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 and staff interviews, the facility failed to ensure that three residents (#17, #67, #275 ) and/or the resident's representative received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare services terminated. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #17 was admitted [DATE] with diagnosis including congestive heart failure, metabolic encephalopathy, chronic kidney disease-stage 4, unspecified dementia, and type 2 diabetes mellitus. The resident was discharged to home with home health services on March 6, 2023. However, review of the clinical record for resident #17 did not reveal the resident and/or the resident's representative had been provided the SNFABN. Resident #67 was admitted [DATE] with diagnosis including intracapsular fracture of the left femur, severe protein-calorie malnutrition, and pressure ulcer of the sacral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-14 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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, clinical record reviews, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for two of three sampled residents (#26 and #48). The medication error rate was 10.71%. The deficient practice could result in additional medication errors. Findings include: -Resident #26 readmitted to the facility on [DATE] with diagnoses which included primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder, single episode. A physician's order dated 12/04/22 included duloxetine HCl (antidepressant) capsule delayed release sprinkle 60 milligrams (mg); give one capsule once daily for depression as evidenced by verbalizing sadness. On 03/13/23 at approximately 8:56 a.m. an observation of medication administration was conducted with a Licensed Practical Nurse (LPN/staff #45). Per review of the resident's duloxetine medication card, the dose per capsule…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Based on observations, staff interviews, and policy review, the facility failed to maintain an environment for residents that was free of pervasive odors. The deficient practice could result in residents not having a homelike environment. Findings include: During a facility observation conducted on March 13, 2023 at 09:11 AM, a strong urine odor was noted in the vicinity of resident #38's room. It was noted again at 12:10 PM, and 3:27 PM the same day. On March 14, 2023 the same strong urine odor was noted outside resident #38's room at 9:23 AM, 12:04 PM, and 2:38 PM the same day. An interview was conducted on March 13, 2023 with the Resident #38 at 12:15 PM. The resident stated that the room always smells of urine and that it comes from her bathroom which is regularly cleaned but the smell remains. She stated that the smell is of urine and stated that it always smells that way. An interview was conducted on March 15, 2023 at 11:53 AM with a Certified Nursing Assistant (CNA/staff #67), who stated that she has noticed a urine odor this morning but that typically it doesn't smell. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, resident interview, staff interviews, observation, and review of facility policy and procedure, the facility failed to ensure nail care was provided for one resident (#18). The deficient practice could result in residents not receiving necessary care and services to maintain good grooming and personal hygiene Findings include: Resident #18 was admitted on [DATE] with diagnosis that included cerebrovascular disease, type 2 diabetes, long term use of insulin, polyneuropathy, neuralgia, neuritis and other symptoms and signs involving the circulatory system. The MDS (minimum data set) dated December 29, 2022 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. The MDS further did not reveal psychosis or behaviors. Review of the care plan goal dated February 11, 2023 included that resident #18 has an ADL (activities of daily living) self-care deficit due to left-sided hemiparesis. The noted intervention included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident (#60) received care and services in accordance with physician's orders, professional standards of practice and his person-centered care plan. The sample size was 23. The deficient practice could increase the risk for complications and/or rehospitalization. Findings include: Resident #60 readmitted to the facility on [DATE] with diagnoses including urinary tract infection, acute respiratory failure with hypoxia and heart failure. A physician's order dated 02/24/23 included monitoring for edema every shift for congestive heart failure (CHF). A physician's order dated 02/25/23 revealed for furosemide (diuretic) 20 milligrams (mg); give one tablet a day for fluid retention for 14 days. The Admission/readmission Collection Tool dated 02/26/23 included the resident's most recent weight at 298.2 pounds (lbs). A physician's order dated 02/26/23 included weight every night shift for CHF before breakfast.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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, resident and staff interviews, clinical record review, and review of facility policy, the facility failed to ensure one resident (#4) received appropriate catheter care and services in accordance with professional standards. Two residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection. Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for routine healing, acute kidney failure with tubular necrosis and a UTI. An indwelling Foley catheter care plan dated 02/21/23 related to obstructive uropathy had a goal for no complications related to indwelling catheter use. Interventions included catheter care every shift. A skilled nursing note dated 02/26/23 at 10:36 a.m. included that the resident's Foley catheter was intact and patent and draining yellow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure medication was obtained and available to meet the needs of one resident (#43). The sample size was 5. The deficient practice may result in residents not receiving medications necessary to treat their medical conditions. Findings include: Resident #43 readmitted to the facility on [DATE] with diagnoses including atherosclerosis of coronary artery bypass graft(s) without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy and hyperlipidemia. A history of nonrheumatic aortic valve disorder care plan dated 02/01/23 related to a history of myocardial infarction had a goal for the resident to verbalize less difficulty breathing. Interventions included to give medications as ordered. Review of a physician's order dated 02/08/23 included rosuvastatin calcium (HMG-CoA reductase inhibitor) 40 milligrams (mg) at bedtime for hyperlipidemia. The admission Minimum Data Set assessment dated [DATE] revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, staff interviews, and policy, the facility failed to ensure that medications were stored safely and secured in the medication cart. The deficient practice could increase the risk for unsecured medications, including/and/or schedule II - V medications, to be unsecured. Findings include: Prior to a medication administration observation conducted on 03/13/23 at 8:31 a.m. a medication cart was identified on the [NAME] hallway near room [ROOM NUMBER]. A medication cup containing approximately 8 pills was noted on top of the cart. The medication cart was unlocked. The computer on top of the cart had been left open and a resident's private health care information was visible. There were no residents identified in the hallway. The nurse returned to the cart within approximately 3 minutes. An interview was conducted on 03/13/23 at 8:58 a.m. with a Licensed Practical Nurse (LPN/staff #45). He stated that the earlier situation was not normal. He stated that typically, he does keep his cart locked. He…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$14,380 in federal fines across 1 penalty.
- $14,380 — penalty dated 2026-07-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/25/2014 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| IDRISSOU, LAURA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 06/28/2015 |
| KILLINGSWORTH, CORRINE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2026 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 11/10/2014 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 11/10/2014 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 11/10/2014 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2014 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2021 |
| FRANCO, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/12/2025 |
| LAY, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/24/2017 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/06/2025 |
| SARAH, ALIF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/27/2019 |
| SMITH, FRANK | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/19/2025 |
| SWANKER, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/25/2014 |
CMS files one row per role, so the 23 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 035140. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-10, 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.