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Park Avenue Health And Rehabilitation Center

2001 North Park Avenue, Tucson, AZ 85719 · For profit - Limited Liability company · 200 certified beds · (520) 882-6151 Medicare & Medicaid certified

Call the home — (520) 882-6151 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20251 actual-harm citation$25,116 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $25,116 in federal fines (most recent 2024-08-01)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1501 S Campbell Ave · (520) 694-8888 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
730 E Grant Rd · (520) 323-7667 · Call to confirm hours
Grocery
863 E Grant Rd · (520) 624-2474 · Call to confirm hours
Park
2000 N. 4th Ave. · (520) 791-4405 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.3%10.7%15.4%better
Long-stay residents who lose too much weight6.0%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.2%1.2%2.0%better
Long-stay residents with depressive symptoms3.8%3.9%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.7%2.1%3.3%better
Long-stay residents whose ability to walk worsened17.9%12.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.1%21.0%18.9%typical
Long-stay residents given the seasonal flu vaccine86.0%94.6%95.3%typical
Long-stay residents with pressure ulcers3.0%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control28.0%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.7%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.8%87.3%79.4%better
Short-stay residents rehospitalized after admission14.7%23.7%22.6%better
Short-stay residents with an outpatient ER visit11.2%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.

64.3% 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 156 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.3%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
85.2%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 85.2% 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 54 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF64.3%CMS range 56.0–71.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.1–15.410.7%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 discharge85.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge79.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge77.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 hospitalization7.6%CMS range 4.6–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

0.31
RN hours/ resident / day
1.06
LPN hours/ resident / day
1.76
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.19
RN hoursweekends
41.4%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 149.9 residents a day — about 75% occupied, or roughly 50 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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.78 hrs/resident/day on weekends vs 3.28 on weekdays — 15% thinner on weekends. RN hours go from 0.36 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

2
deficiencies at the latest standard inspection (2025-08-22)
6
at the previous standard inspection (2023-05-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2024-08-01 · 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 Based on interviews, records review, policy review, and the SA Complaint Tracking System the facility failed to ensure adequate supervision was provided to one resident (#5) to prevent injury/accident. The deficient practice could result in harm and injury. Findings include: Resident # 5 was initially admitted to the facility on [DATE] with diagnoses of vascular dementia, restlessness and agitation, and senile degeneration of brain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The assessment also included that the resident used a wheelchair and can independently wheel 150 feet in a corridor or similar spaces. The history and physical note dated July 6, 2024 included that the resident had assessments of Chronic Obstructive Pulmonary Disease (COPD), cachectia, mutism and dementia. A psychotherapy evaluation dated July 21, 2024 released the resident had major depressive disorder,…

    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 · D2025-10-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, the State Agency (SA) complaint portal, and review of facility policy and procedure, the facility failed to ensure the facility investigation and medical record were complete and accurate for one resident (#2), and regarding an incident of abuse. The deficient practice could result in care team members not being adequately informed regarding the status of the resident and lead to missed or delayed care.Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses that include generalized muscle weakness, subsequent encounter for closed fracture with nonunion, other specific joint derangements of the right hip not elsewhere classified, and acute pain due to trauma.An admission Minimum Data Set (MDS), dated [DATE], indicated Resident #2 completed a Brief Interview for Mental Status (BIMS) and scored a 15, indicating the resident was cognitively intact.The SA complaint portal received an allegation related to Resident #2 being abused by a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure infection control policies were followed during therapy sessions for five residents (#44, #45, #55, #180, and #181). The deficient practice could lead to spread of infection.Findings include:An observation was conducted on August 21, 2025, at 10:10 a.m. of a group therapy session occurring in the first-floor lounge room. Residents #44, #45, #55, #180, and #181 were present in the lounge, and being led in various therapy activities by a Physical Therapy Assistant (PTA/ staff #100). There was no hand sanitizer or handwashing station/sink or sanitizing agents such as spray or wipes observed in the lounge room. The PTA removed an ankle weight off of a female resident in a wheelchair and set the ankle weight on a chair without sanitizing it. The PTA did not sanitize or wash his hands. Then, the PTA picked up the ankle weight off of the chair and without sanitizing it, placed the ankle weight on Resident #44's leg. The PTA did not wash or sanitize his…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that the catheter bag was covered for one resident (#176). The deficient practice could result in resident not being treated with dignity and respect.Findings include:Resident #176 was readmitted to the facility on [DATE], with diagnoses that included acute kidney failure, elevated white blood cell count, depression, and dysphagia.The Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment also included that the resident had an indwelling catheter.The indwelling catheter care plan initiated on July 30, 2025, included interventions to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. There was no evidence of a cover on the catheter bag. During an observation that was conducted on August 19, 2025, at 1:22 p.m., 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 date of correction
  • Potential for harm · Dcited before2025-08-01 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, facility documentation and review of the facility policy, the facility failed to ensure that a change of condition, for one resident (#3) out of 3 sampled, was immediately reported to the physician. The deficient practice could result in clinically adverse outcomes for the resident.Findings include:Resident #3 was admitted on [DATE] with diagnosis including muscle weakness, difficulty walking, pressure ulcer of the sacral region, type 2 diabetes mellitus with hyperglycemia, fluid overload, essential hypertension, pneumonia, acute on chronic systolic congestive heart failure, nonrheumatic mitral valve disorder, edema, acute respiratory failure with hypoxia, pleural effusion, sepsis and dyspnea.A review of discharge MDS (minimum data set) dated January 28, 2024 did not show evidence of a BIMS (brief interview of mental status) score, but did document that there were no potential indicators of psychosis or no evidence of behaviors.A review of the progress notes 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, interviews, and policy and procedures, the facility failed to ensure that an allegation of abuse was reported to the state agency for one of of three residents. The deficient practice could further endanger the resident and impede an investigation.Findings include:Resident #7 was admitted on [DATE] with diagnosis including bipolar disorder, anxiety disorder, atherosclerotic heart disease, chronic pain, fibromyalgia, dependence on supplemental oxygen, dementia without behavioral disturbance, insufficient sleep syndrome and post-traumatic stress disorder.A review of the annual MDS (minimum data set) dated May 4, 2025 revealed a BIMS (brief interview of mental status) score of 01, indicating severe cognitive impairment. The total mood severity score noted was a 9, indicating mild depression. There were no noted potential indicators of psychosis or behaviors noted.An encounter note dated July 14, 2025 in the electronic health record revealed that in light of current accusations 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 · D2025-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 14 sampled residents (Resident # 28) was free from abuse by another resident (Resident # 23). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident (#23) Resident (#23) was admitted to the facility on [DATE], with diagnoses of dementia and altered mental status. A nursing note dated August 10, 2022 at 9:52 p.m., revealed that Resident (#23) was hallucinating stating she was going to die because she was told by two ladies that the building was falling down. The note also indicated that the Resident (#23) was combative towards staff and yelling in the hallway. A nursing note dated September 10, 2022 at 3:38 a.m. revealed Resident (#23) was very combative with staff and threatening to kill a Certified Nursing Assistant (CNA). A nursing note dated September 22, 2022 at 7:12 p.m., indicated staff attempting to administer eye drops 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 · D2025-06-11 · 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 provide care and services in accordance with the resident's care plan for one resident (#34) regarding administration of scheduled medications as ordered by the physician. This deficient practice has the potential to result in residents not receiving necessary antibiotic treatment as planned, placing them at increased risk for unresolved infections and adverse health conditions. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnosis that included Traumatic Brain Injury, seizures, sepsis, and Methicillin Susceptible Staphylococcus Aureus (MSSA) infection. A review of the admission Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had was cognitively intact. A review of the physician's orders, dated September 28, 2022, revealed Resident #34 was to take Cefazolin Sodium…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to ensure that care and services related to pressure ulcers was provided for two residents (#535 and #537). The deficient practice resulted in lack of thorough pressure ulcer assessments and/or identifying wound deterioration timely. The facility census was 101 and the sample was 22. Findings include: -Resident # 535 was admitted on [DATE] with diagnoses of osteomyelitis, acute respiratory failure with hypoxia, muscle weakness, dysphagia, pressure ulcer of sacral region, Stage 4, Type 2 DM, encephalopathy, bacteremia, idiopathic aseptic necrosis of unspecified toes, and nutritional anemia. Review of the clinical record revealed that there were three ulcers present upon admission on [DATE], that included: -Coccyx pressure ulcer, stage 4 -Left heel pressure ulcer, deep tissue injury (DTI) -Left outer foot pressure ulcer, non-stageable. A care plan dated [DATE] revealed the resident had diabetes mellitus and…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-05-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy and procedure, the facility failed to ensure the resident representative was notified after a change in condition for one resident's (#537). The deficient practice could result in resident representative not notified and the required decisions for the resident are not made. The facility census was 101, and the sample was 22. Findings include: Resident #537 was admitted on [DATE] with diagnoses of ESRD (end stage renal disease), muscle weakness, diabetes, hemiplegia/hemiparesis related to cerebral infarction affecting left non-dominant side. The care plan initiated on February 9, 2021 revealed the resident had a pressure ulcer or potential for pressure ulcer development, coccyx, related to poor mobility. Interventions included to assess/monitor/record wound healing; to report improvements and declines to the doctor; and, to monitor/document/report to doctor as needed (PRN) changes in skin status: appearance, color, wound…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, policy and procedures review, the facility failed to ensure one resident (#68) was free from restraint. The deficient practice could result in harm to a resident secondary to restricted mobility of extremities. Findings include: Resident #68 was readmitted on [DATE] with diagnoses of muscle weakness, cerebral infarction, pruritus, end stage renal disease, aphasia and flaccid hemiplegia affecting the left side. Review of the clinical record revealed the resident had an order for a DPM (Dr Pillow Mattress) mattress to enhance boundary awareness. The nursing progress note dated March 13, 2023 included resident was scratching and opening skin with fingernails; and that, the resident had a glove on right hand and still managed to break skin open. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) a score of 0, indicating the resident had severe cognitive impairment. The assessment included 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2023-05-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical records, facility documents, resident and staff interviews, the facility failed to ensure the necessary dermatology appointment was scheduled for one resident (#104). The deficient practice could result the resident missing the appointment and not receiving the appropriate and necessary treatment. Findings include: -Resident #104 was admitted on [DATE] with diagnoses of abrasion of other part of the head, candida stomatitis and anxiety disorder. A Social Services note dated September 1, 2022 included that dermatology appointment was rescheduled September 20, 2022 at 8:40 a.m. The appointment/procedure note dated October 19, 2022 included that dermatology appointment was scheduled for October 25, 2022 at 11:50 a.m. However, there was no evidence found in the clinical record that the resident went to the dermatology appointment as scheduled for October 25, 2022. The undated care plan revealed the resident had an actual impairment to the skin integrity related to an abrasion to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, Influenza Vaccine Manufacturer's Guidelines and the Centers for Disease Control and Prevention (CDC)guidelines, the facility failed to ensure expired medications were not readily accessible for resident use; and, the facility failed to ensure open multi-dose vials were dated and discarded according to manufacturer's guidelines. The deficient practice could result in alterations in the effectiveness of the medications that the residents are receiving. Findings include: During an observation of a medication cart in 300 hall conducted with a licensed practical nurse (LPN/staff #171), there was large white bottle of sodium bicarbonate (alkalinizing agent) 650 milligrams with an expiration date of January 2023. The bottle was marked as a house supply and was ¾ full of white tablets. The LPN (staff #171) stated the sodium bicarbonate was expired; and that, it should have been placed in the expired bin located in the medication room so that it was not available for the nurses to use. In an observation of the medication refrigerator in the medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews and facility assessment review, the facility failed to ensure that assistance in making the necessary dental appointment was provided for one resident (#81). The deficient practice could result in resident having dental complications. Findings include: Resident #81 was admitted on [DATE] with diagnoses of hemiplegia, and cerebral infarction due to thrombosis of cerebral artery. The annual Minimum Data Set (MDS) assessment dated [DATE] included that resident had intact cognition. A progress note dated March 5, 2023 revealed the resident had his first dose of Amoxicillin for dental abscess. A dental visit note with dental clinic/services dated March 27, 2023 included the resident had a chief complain of bottom left pain and dental recommendation was to schedule the resident for dental extraction of tooth #20. However, the clinical record revealed no evidence that the resident was scheduled for or had the dental extraction procedure as recommended until…

    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 · E2022-04-01 · 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 reviews, staff interviews, and policy review, the facility failed to ensure three residents (#53, #415 and #426) and their representatives were provided a summary of the baseline care plan. The sample size was 24. The deficient practice could result in a summary of the baseline/comprehensive care plan not being provided to residents and their representatives. Finding include: -Resident #53 was admitted to the facility on [DATE] with the following diagnoses: Peritoneal Abscess; Fistula of Stomach and Duodenum; Sepsis, Unspecified Organism; Bipolar Disorder, Unspecified; Anxiety Disorder, Unspecified; Major Depressive Disorder, recurrent, unspecified and Acute Kidney Failure and Chronic Kidney Failure, Stage 3, Unspecified. Review of the clinical record revealed a care plan initiated on February 3, 2022 that the resident has acute pain related to surgical incision and ADL (Activities of Daily Living) Self-Care Performance Deficit. The care plan also included the resident has…

    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 · E2022-04-01 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that two residents (#81 and #28) did not receive unnecessary medications. The sample size was 5. The deficient practice increases the risk of residents receiving medications unnecessarily. Findings include: -Resident #81 admitted to the facility on [DATE] with diagnoses that included primary hypertension, post-traumatic stress disorder, and chronic pain. An opioid care plan dated 06/19/19 related to potential adverse outcomes from opioid use had a goal to be free from adverse reactions. Interventions included administering opioid as prescribed. Review of physician orders dated 07/19/20 included acetaminophen (non-steroidal anti-inflammatory) 325 milligrams (mg); Give 2 tablets every 4 hours as needed for mild to moderate pain of 1-6, and for oxycodone HCl (opioid analgesic) 5 mg every 12 hours as needed for severe pain 7-10. Review of the January 2022 Medication Administration Record (MAR)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-01 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure that meals were served at an appetizing temperature. The deficient practice could lead to issues with nutrition and impact residents' quality of life. Findings include: During interviews conducted with residents, multiple residents complained that the food was not palatable. The complaints included that the food was cold. An observation was conducted on 03/30/22 at 12:52 PM during the tray line. At 12:52 PM, a test tray was plated and placed on the last cart for the last hall with the other trays to be served to residents. The cart was taken up the elevator and onto the hall, and at 12:58 PM, meal service in the hall began. At 1:27 PM, the test tray was the last remaining tray on the cart. The consultant registered dietician nutritionist (RDN/staff #162) obtained the following temperatures with a facility provided thermometer: mechanical meat (turkey) 102 degrees Fahrenheit (F), mashed potato 109 degrees F, veggies 96 degrees F, milk 52 degrees F, cake 61 degrees F, apple juice (does not require refrigeration)…

    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 · E2022-04-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and the dishwasher manual, the facility failed to ensure food safety requirements were followed. The deficient practice could result in foodborne illness. Findings include: An observation was conducted on 03/28/22 at 10:10 AM during the initial kitchen walk-through with the Kitchen Manager in Training (staff #53). In the walk-in freezer was a box of open, uncovered veggies, and an open uncovered bag of uncooked veal steak fritters. After leaving the walk-in freezer, the quaternary ammonia sanitation-buckets were tested. While conducting a quaternary ammonia sanitation-bucket test, staff #53 stuck his hands and the test strip into the bucket solution to get a result. Immediately after reading the result, staff #53 tossed the test strip into the garbage and then grabbed a gravy ladle with his wet hands from the quaternary ammonia sanitation bucket. He then began to stir the gravy being prepared on the stove. At 10:40 AM, it was observed that the temperature gauges for each cycle of the dishwashing machine were at 120 degrees Fahrenheit (F) wash…

    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 · D2022-04-01 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASRR) accurately reflected one resident's diagnoses (#28), and failed to ensure two residents (#28 and #50) received PASRR Level I screening after remaining in the facility longer than 30 days. The sample size was 3. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs. Findings include: -Resident #28 admitted to the facility on [DATE] with diagnoses that included heart failure, unspecified, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder, recurrent, severe with psychotic symptoms. Review of the Initial admission Record dated 07/18/21 included that the resident was admitted from an acute care hospital for rehabilitation services, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, observation, and resident and staff interviews, the facility failed to ensure that one of two sampled residents (#6) received care and treatment in accordance with professional standards regarding a rash. The deficient practice could result in treatment being delayed or not being provided. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, aphasia following cerebral infarction and cerebrovascular disease affecting left non-dominant side. A Care Plan dated December 20, 2021 included that this resident has a potential for impairment to skin integrity. Interventions included weekly and as needed skin checks, and monitoring and documenting location, size and treatment of skin injury. This Care Plan stated to report abnormalities, failure to heal, signs and symptoms of infection, and maceration etc. to the Medical Doctor. An annual Minimum Data Set (MDS) assessment dated [DATE] included that this resident required…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure that one of two sampled residents (#69) received treatment and services to prevent/heal a pressure ulcer/injury consistent with professional standards of practice. The deficient practice increases the risk for infection and rehospitalization. Findings include: Resident #69 readmitted to the facility on [DATE] with diagnoses that included dysphagia following cerebral infarction, type 2 diabetes mellitus, and end stage renal disease (ESRD). A physician order dated 02/11/22 included an order for weekly skin checks, every day shift, every Saturday. A potential for skin breakdown care plan dated 02/12/22 related to decline with functions, history of cerebrovascular accident, incontinence, ESRD, diabetes, and an active peg (percutaneous endoscopic gastrostomy) tube had a goal to be free from injury. Interventions stated to monitor/document location, size and treatment of skin injury. Report…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and the glucometer guide, the facility failed to ensure infection control standards were maintained regarding glucometers. The deficient practice could result in transmission of infection. Findings include: An observation was conducted on March 28, 2022 at 11:39 a.m. of a Registered Nurse (RN/staff #20) obtaining residents blood sugar levels. The RN donned in PPE (Personal Protective Equipment) was observed to enter the room of two residents that were on transmission-based precautions. The RN went to the resident near by the window, and reached into her pocket, and pulled out a glucometer, lancet, glucose strips, and alcohol pad, and directly placed all items on the bedside table. The RN was observed to check the resident's blood sugar level. The RN discarded the lancet, changed gloves, and immediately went to the resident located by the door in the same room. She wiped the glucometer with an alcohol pad, put in a new strip, and obtained the blood sugar sample. After the testing was completed, the RN disposed of the lancet and glucose strips…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-01 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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, family and staff interviews, and policy and procedure, the facility failed to ensure the call light for one resident (#74) was functioning correctly. The sample size was 24. The deficient practice could result in residents not having the means to communicate with staff and not receiving care and services in a timely manner. Findings include: Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included right femur fracture, muscle weakness, fall, and acute respiratory failure with hypoxia. Review of the fall risk care plan updated on December 23, 2020 included the intervention to encourage the resident to ask for assistance and to keep needed items, water, etc. within reach. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The assessment also stated the resident required extensive assistance with bed mobility, toilet…

    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.

    Environmental 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

$25,116 in federal fines across 1 penalty.

  • $25,116 — penalty dated 2024-08-01

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

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
PETERSON, FORRESTIndividualCORPORATE DIRECTORsince 01/01/2019
BURNAM, SOONIndividualCORPORATE OFFICERsince 10/18/2006
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
COTE, ELLENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/12/2008
VO, ELISEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/05/2021
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/30/2025
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 08/01/2003

CMS files one row per role, so the 9 rows in the source record cover these 7 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.

$17.6M
Net patient revenuemost recent cost report
+10.0%
Operating marginrevenue minus expenses
$2.1M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 6%Other / private 26%

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$349per resident / day
operating cost
$10,605per month
≈ monthly operating cost
$388per 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 035174. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-22, 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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