Yuma Nursing Center
1850 West 25th Street, Yuma, AZ 85364 · For profit - Corporation · 120 certified beds · (928) 726-6700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- about 20% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 27.7% | 10.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.3% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.6% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.6% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 38.2% | 12.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.5% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.7% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.8% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.0% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.5% | 87.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.0% | 23.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.7% | 10.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.61 | 1.47 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.10 | 1.42 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.7% 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 31 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.5%CMS range 39.8–66.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 5.5–15.0 | 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 | 38.7% | 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 | 35.5% | 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 | 38.7% | 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 | 96.8% | 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 | 100.0% | 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 | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 120 beds and averages 84.6 residents a day — about 70% occupied, or roughly 35 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.72 on weekdays — 11% thinner on weekends. RN hours go from 0.55 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2024-12-10 · 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, interviews, review of facility documentation and policy review, the facility failed to ensure resident #4 was free from abuse from resident #5. The deficient practice could result in residents experiencing emotional, physical, and mental trauma from the abuse. Findings include: Related to resident #4- Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia, and unsteadiness on feet. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed resident #4 completed a Brief Interview for Mental Status (BIMS) and scored a 12 which indicated the resident was moderately cognitively impaired. Review of resident #4's Electronic Health Record (EHR) revealed a progress note dated December 1, 2024 at 7:45 p.m. The note indicated that a Certified Nursing Assistant (CNA) informed the nurse that resident #4 was slapped on the right forearm by male peer who stated, you need to stop crying. The progress note also noted that both residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · tag 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 documentation, staff interviews and the facility policy and procedures, the facility failed to ensure that one resident (#12) was free from abuse from other residents (#12). This deficient practice could result in other residents being abused. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included Alheimer's disease, anxiety, generalized muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 08 indicating the resident had a moderate cognitive impairment. Review of a nurse practitioner note dated October 4, 2024 revealed that resident #12 is an [AGE] year old female with a past medical history of Alzheimer's disease and a mixed mood disorder and the resident resides in a memory care unit in a long-term care facility. Review of the progress notes revealed a late entry dated October 4, 2024 at 7:25 p.m. by the Director of Nursing (DON/staff #1), which stated that she was called into the hallway, where 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.
- Potential for harm · Dcited before2024-04-23 · 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 reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#20) was free from physical abuse by other residents (resident #100). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. A behavioral care plan dated January 30, 2024 revealed the resident was at risk of wandering and intruding on another residents' privacy. The goal was noted to be wandering will not contribute to injury, with noted interventions of alerting staff when the resident is wandering, and place resident in area where frequent observation is possible. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant…
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 · D2024-04-23 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy, the facility failed to implement their abuse policy, by failing to report an allegation of abuse within the required time for two residents (#100 and #20). This deficient practice could result in further incidents of abuse not being reported. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. -Resident #100 was admitted to the facility on [DATE], with diagnoses that include Urinary tract infection, metabolic encephalopathy, Alzheimer's disease, dementia, anxiety, and restlessness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS)…
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 before2024-04-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, staff interviews, facility documentation and policy review and the State Agency (SA) database, the facility failed to ensure that an allegation of abuse for one resident (#20) was reported to the State Agency as required. The deficient practice could result in abuse not being identified and investigated. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. -Resident #100 was admitted to the facility on [DATE], with diagnoses that include Urinary tract infection, metabolic encephalopathy, Alzheimer's disease, dementia, anxiety, and restlessness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for…
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 before2023-06-23 · 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 observations, clinical records, staff interviews and facility policy, the facility failed to ensure adequate supervision was provided to prevent elopement for two residents (#178 and #179). The deficient practice could result in increase the risk of resident for harm and injury. Findings include: -Resident #178 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, restlessness, agitation and wandering. A progress note dated January 8, 2021 included the resident was admitted at the facility, was alert, oriented to self only, pleasant and responding well and had a steady gait and balance with sufficient strength to extremities. A progress note dated January 10, 2021 revealed the resident was roaming and refused to go to her room. Per the note the resident made statement about wanting to go outside and was told that she was not able to at this time. Per the documentation, staff attempted to divert the resident's attention but had no positive effect and the resident continued to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure transmission-based precautions for one resident (#157) were implemented. The deficient practice could result in the spread of the COVID-19 virus. Findings include: Resident #157 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, hyperlipidemia, and major depressive disorder. Review of the baseline care plan dated May 20, 2022 included a plan for the resident to self-quarantine for 7 days. The Summary Orders included an order dated May 20, 2022 for COVID-19 screening - monitor for cough, shortness of breath, fever, headache, repeated shaking with chills, new loss of taste of or smell, diarrhea, muscle pain, sore throat or vomiting every shift. Review of the clinical documentation dated May 23, 2022, revealed that the resident's family members declined to have the resident vaccinated for the COVID-19 virus. On May 24, 2022 at 8:30 a.m., resident #157 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 · E2022-05-27 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee record reviews, facility documentation, staff interview, and facility policy and procedures, the facility failed to conduct COVID-19 testing based on the frequency set forth by state and federal guidelines for three staff (#3, #57, #62). The deficient practice could result in the spread of the COVID-19 virus. Findings include: Review of facility documentation revealed that the county positivity rate was substantial/high from May 9, 2022 through May 23, 2022 and required COVID-19 testing 2 times per week. -Staff #3's (Speech Therapist) employee record included an exemption form from the COVID-19 vaccine approved on December 5, 2021. Review of staff #3's employee records revealed that he received a POC (Point of Care) COVID-19 test on May 10, 13, and 24 and the results were negative. The Time Card from May 9, 2022 through May 23, 2022 for staff #3 revealed that staff #3 worked at the facility on May 9, 10, 11, 13, 17, 18, 23, and 24. Comparison of the test dates and Time Card revealed that staff #3 worked on May 17 and 18, 2022, but was not tested for COVID-19 during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 resident and staff interviews, the facility investigation report and document, clinical record review, and policy review, the facility failed to ensure one resident (#18) was treated in a dignified manner. The sample size was 15 residents. The deficient practice could negatively impact the psychosocial wellbeing of residents. Findings include: Resident #18 was admitted on [DATE] with diagnoses that included heart failure, dehydration, diabetes mellitus, peripheral vascular disease, morbid obesity, chronic kidney disease, and major depressive disorder. During the initial part of the survey, an interview was conducted with resident #18 on May 23, 2022 at 12:19 PM, who stated that a CNA (certified nursing assistant) had said the resident was fat, and was a problem to move and was lazy. The resident also stated that she asked the CNA to leave or get another staff member to assist, but the CNA continued the care and gave the resident an evil smile. The resident stated that she had not told the administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure that one sampled resident's (#39) needs and preferences were addressed, regarding a wheelchair and cushion. The deficient practice could result in residents' needs/preferences not being addressed. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, chronic obstructive pulmonary disease, type 2 diabetes mellitus (DM), Parkinson's disease, limitation of activities due to disability, muscle weakness, and lack of coordination. An observation and interview conducted on May 24, 2022 at 10:00 AM revealed the resident lying in the bed. During an interview with the resident, she stated that she asked for a bigger wheelchair, and that some people came in to talk to her about it a month ago, but she has not heard back. The resident further stated that she cannot go to activities because the wheelchair is not comfortable. Review of 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.
Show the remaining 12 citations
- Potential for harm · Dcited before2022-05-27 · 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, staff interviews, facility investigative report, and policy review, the facility failed to ensure that an allegation of possible verbal abuse for one sampled resident (#18) was reported immediately to the facility administrator. The deficient practice could result in additional abuse allegations not being reported to the administrator. Findings include: Resident #18 was admitted on [DATE] with diagnoses that included heart failure, dehydration, diabetes mellitus, peripheral vascular disease, morbid obesity, chronic kidney disease, and major depressive disorder. During the initial part of the survey, an interview was conducted with resident #18 on May 23, 2022 at 12:19 PM, who stated that a CNA (certified nursing assistant) had said the resident was fat, and was a problem to move and was lazy. The resident also stated that she asked the CNA to get out of there, or get another staff member to assist, but the CNA continued the care and gave her an evil smile. The resident stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that care plan interventions for pressure ulcers were implemented for one resident (#36). The sample was 15 residents. The deficient practice could affect the quality of residents' care. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included unspecified acute kidney failure and contusion of an unspecified part of the head. A care plan dated October 8, 2021 revealed the resident had a pressure ulcer to the right ischial hip. Interventions included performing wound care as ordered, assessing skin daily with routine care, full skin evaluation with bath/shower, and assessing the wound healing weekly. Review of paper weekly skin/body assessment forms completed by the CNAs (certified nursing assistant) after a shower/bath had been provided revealed no evidence that the weekly skin/body assessments were completed from November 24, 2021 to April 14, 2022. 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 · D2022-05-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 policies and procedures, the facility failed to ensure timely assessments and consistent treatments were provided to one sampled resident (#36) with pressure ulcers. The deficient practice could result in delayed healing of pressure ulcers. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included unspecified acute kidney failure and contusion of an unspecified part of the head. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was receiving hospice care. The assessment also included the resident did not have one or more unhealed pressure ulcers at stage 1 or higher. Review of wound assessment documentation in the medical record revealed the pressure ulcer to the right buttock was initially present on October 7, 2021. A physician order dated October 7, 2021 stated to apply zinc barrier cream to the right ischial hip pressure ulcer as needed with brief change. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
Based on personnel record review and staff interviews, the facility failed to provide evidence that one of ten sampled staff (#61) was provided training on dementia management. The deficient practice could result in staff not being knowledgeable of how to care for residents with dementia. Findings include: A review of the personnel file for a Certified Nursing Assistant (staff #61) revealed a hire date of 6/30/2021. Continued review of the personnel file revealed the orientation checklist for staff #61 was completely blank. An interview was conducted on 05/27/2022 at 11:36 PM with the Administrator (staff #7) and the Director of Nursing (staff #83) who indicated that they have no evidence to prove that staff #61 was provided training on dementia management. In an interview conducted with Human Resources (staff #56) on 05/27/2022 at 11:36 PM, staff #56 stated there was no policy on required annual training for staff.
- Potential for harm · Ecited before2019-10-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 interview, clinical record review, and policy review, the facility failed to consistently implement the care plan for one sampled resident (#38) with wandering behavior. The deficient practice could result in residents' care plan not being implemented resulting in avoidable incidents. Findings include: Resident #38 was admitted [DATE], with diagnoses that included Alzheimer's disease, wandering, restlessness and palliative care. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely impaired regarding cognitive skills for daily decision making. The assessment included the resident had wandering behavior which significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to a potentially dangerous place. Review of the care plan initiated 8/28/19 revealed the resident wanders the hall and goes into other residents' room. The goal was that the resident would not display any inappropriate or disruptive…
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 before2019-10-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, staff interviews, clinical record review, and policy review, the facility failed to provide adequate supervision for one sampled resident (#38) that wandered. The deficient practice could result in avoidable accidents. Findings include: Resident #38 was admitted [DATE], with diagnoses that included Alzheimer's disease, wandering, restlessness and palliative care. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely impaired regarding cognitive skills for daily decision making. The assessment included the resident had wandering behavior which significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to a potentially dangerous place. Review of the care plan initiated 8/28/19 revealed the resident wanders the hall and goes into other residents' room. The goal was that the resident would not display any inappropriate or disruptive behaviors. Interventions included monitoring and documenting resident#38's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-10 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, family and staff interviews, and policy review, the facility failed to ensure one sampled resident (#73) had the right to personal privacy during visits with family by allowing another resident (#38) to wander into resident #73's room. The deficient practice could result in residents not having privacy when visiting with family. Findings include: -Resident #73 was readmitted to the facility on [DATE], with diagnoses that included osteoarthritis, dementia with behavioral disturbance, and anxiety and delusional disorder. -Resident #38 was admitted on [DATE], with diagnoses that included Alzheimer's disease, wandering, restlessness and palliative care. Review of nursing notes from 9/4/19 - 10/9/19 revealed multiple entries of resident #38 pacing, going into other residents' rooms, pulling blankets off of sleeping residents, pushing residents in wheelchairs down the hall, and hitting a Certified Nursing Assistant (CNA) in the face causing the CNA's lip to bleed. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-10 · 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, staff interviews and policies and procedures, the facility failed to report an injury of an unknown source involving one resident (#73) to the State Survey Agency, within 2 hours as required. The deficient practice could result in additional incidents regarding injuries of an unknown source not being reported to the State Agency; resulting in the State Agency not being informed of possible abuse situations. Findings include: Resident #73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia with behavioral disturbance, anxiety and delusional disorder. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had a severe cognitive impairment. The MDS also revealed the resident was totally dependent on staff assistance when moving from one place to another on the unit. Review of a progress note dated September 4, 2019…
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 · D2019-10-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policies and procedures, the facility failed to ensure that an injury of an unknown source was thoroughly investigated for one resident (#73) and failed to report the results of the investigation to the State Agency, within 5 working days of the incident as required. The deficient practice could result in causative factors related to injuries of an unknown source not being identified, including possible abuse and not implementing corrective action to prevent further occurrences. Findings include: Resident #73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia with behavioral disturbance, anxiety and delusional disorder. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had a severe cognitive impairment. The MDS also revealed the resident was totally dependent on staff assistance when moving…
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 · D2019-10-10 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#73) and/or the resident's representative was provided written information regarding the facility's bed hold policy before transfer to the hospital. The deficient practice could result in residents not being informed of the facility's bed hold policy. Findings include: Resident #73 was readmitted on [DATE], with diagnoses that included osteoarthritis, dementia with a behavioral disturbance, and anxiety and delusional disorder. Review of a nursing progress note dated September 4, 2019, revealed the resident was observed lying on her left side on the floor by her wheelchair. The note included the resident was transferred to the hospital and admitted due to a femoral neck fracture. However, review of the clinical record including the progress notes dated September 4, 2019, did not reveal the resident or the resident's representative had been informed of the facility's bed hold policy. A copy 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 · D2019-10-10 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure discharge planning included developing a discharge care plan, which is part of the comprehensive care plan for one sampled resident (#85). The deficient practice could result in the facility failing to develop discharge care plans that address all the needs for residents being discharged . Findings include: Resident #85 was readmitted on [DATE], with diagnoses that include Methicillin-resistant Staphylococcus aureus (MRSA) of the left leg with osteomyelitis needing 6 weeks of intravenous (IV) antibiotics. Review of the admission care plan and the 48-hour care plan dated June 11, 2019, revealed no discharge care plan had been developed. Review of the PPS (Prospective Payment System) 5 day Minimum Data Set assessment dated [DATE] revealed there was an active discharge plan in place for the resident to return to the community. A care plan conference summary signed by the social service director dated June 20, 2019,…
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 · D2019-10-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 review, staff interviews and policy review, the facility failed to ensure one resident (#64) had clinical indications regarding antibiotic medication use. The deficient practice could result in residents receiving unnecessary antibiotics, which could result in infectious microorganisms with increased drug resistance. Findings include: Resident #64 was re-admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia, inflammatory disorders of the scrotum, and cystostomy. Review of the admission physician's orders revealed orders dated September 4, 2019 for Bactrim DS (antibiotic), 1 tablet every 12 hours for 9 days for urinary tract infection (UTI) and/or methicillin resistant staphylococcus aureus (MRSA), and ciprofloxacin (antibiotic) 500 milligrams (mg) twice a day for 10 days for UTI/MRSA. Further review of the physician's orders revealed orders dated September 5, 2019, for a wound culture for a scrotal wound and a urinalysis (UA) with culture 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CIRCLE B ENTERPRISES — 36 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 | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 3 of 5 | 2.0 | +1.0 vs chain |
| Quality measures | 2 of 5 | 1.9 | +0.1 vs chain |
The other 35 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CIRCLE B ENTERPRISES HOLDING COMPANY INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/1997 |
| BEDELL, DONALD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2001 |
| BEAIRD, TODD | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| AGH1 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2025 |
| SOVEREIGN HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/06/2025 |
| HENTGES, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2026 |
| MAHONEY, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/26/2023 |
| SILAO, RAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2015 |
| SMITH, STACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/07/2025 |
| BEDELL, BRYAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/27/2025 |
| FG LLC | Organization | ADP OF THE SNF | — | since 12/02/2016 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 08/16/2021 |
| MID STATES INC | Organization | ADP OF THE SNF | — | since 11/01/2010 |
| VAN DE VEN LLC | Organization | ADP OF THE SNF | — | since 01/01/2000 |
CMS files one row per role, so the 24 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035152. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-06-23, 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.