Heartwood Avenue Healthcare

Location & what’s nearby

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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

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.

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.

48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.7% 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 55 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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.

Staffing

How full it usually is: this home is certified for 60 beds and averages 55.7 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 3.93 on weekdays — 9% thinner on weekends. RN hours go from 0.44 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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.

35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.

• Actual harm · Gcited before2026-04-14 · 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 interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Facility staff failed to accurately document the use of BiPap ((Bilevel Positive Airway Pressure) machine is a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask, improving oxygen levels) for Resident 1 as ordered by her physician,2. Facility staff administered an opioid medication (controlled drug highly effective for severe, acute, or chronic pain but carries significant risks of addiction, misuse, and overdose) on two occasions without adequate indication for use to Resident 1, and3. Facility failed to order Narcan (naloxone: a life-saving, over-the-counter nasal spray that rapidly reverses opioid overdoses in 2-3 minutes) for Resident 1 while she was being given an opioid medication.These failures resulted in Resident 1's emergency transfer to an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-03 · 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 observations, interviews and records review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free from accidents, when: 1. The facility did not provide two-person assistance to Resident 1 during care, when Resident 1 was dependent (resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) from staff to maintain perineal hygiene (washing the genital and rectal areas of the body) and to turn in bed. This failure resulted in Resident 1 rolling over while receiving perineal care and falling on the other side of the bed sustaining a left tibia (the inner and usually larger of the two bones of the leg between the knee and ankle) fracture (a break on the bone). 2. The facility staff took more than an hour to answer Resident 2's call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 2 turned on her call light…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-01-09 · 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 observation, interview and record review, the facility failed to ensure a resident receive care consistent with professional standards of practice when one out of two sampled residents (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed 4 pressure ulcers: one stage 4 pressure ulcer (PU, the most serious type of pressure ulcer, it extend below the muscle, tendons, and in severe cases, the bone) on his sacrum (the bottom of the spine) and three stage 2 pressure ulcers (PU that extend through deeper tissue and fat but do not reach muscle or bone) on his right inner foot, left inner proximal (near the center) foot and left inner distal (away from the center) foot. These failures led to treatments with antibiotic (medicines that fight infections caused by bacteria) and debridement (the removal of dead or infected skin tissue to help a wound heal). These failures also led to Resident 1 not being able to reach his highest physical level of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-09 · 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 observations, interviews and record reviews, the facility failed to ensure residents were provided an environment that is free from accident hazards over which the facility has control when staff failed to identify, evaluate, analyze hazards and risks and implement interventions to reduce hazards and risks for using a low air loss mattress (LAL, an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to prevent avoidable accidents for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 fall incident on 11/4/23 and Resident 1 being sent to the hospital for further evaluation and treatment. This fall incident also resulted in Resident 1 sustaining a laceration (a cut, referring to a skin wound which tends to be caused by blunt trauma- an injury of the body by forceful impact such as falls) on his anterior scalp (located just in front of the head). The fall also resulted in…

  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 before2026-06-18 · 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 interviews and record review, the facility failed to ensure required 1:1 supervision was provided for one of three sampled residents (Resident 2) when the assigned staff member was not closely supervising Resident 2 and did not intervene when a verbal altercation between Resident 1 and Resident 2 escalated into a physical altercation. This failure resulted in Resident 1 and Resident 2 physically kicking each other placed both residents at risk for physical harm. Findings:Resident 1 was admitted to the facility on September of 2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) (a long term, progressive lung disease that makes it difficult to breathe) and muscle weakness.A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 3/30/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment.A review of Resident 1's Change in Condition (CIC) Evaluation,…

  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 · Ecited before2026-05-07 · tag F0658 — failed to meet professional standards of care — pattern
  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

  Based on observation, interview, and record review, the facility failed to meet professional standards of quality for three of 19 sampled residents (Resident 7, Resident 22 and Resident 60) when:1. Resident 7's blood pressure was not accurately assessed;2. Resident 22 was administered a blood pressure medication outside of the ordered parameters;3. Resident 60 was administered a lower than prescribed dose of medication; and4. Resident 60's oxygen was not accurately documented and monitored. These failures increased the risk for an inaccurate blood pressure for Resident 7, low blood pressure for Resident 20, subtherapeutic dose of medication, breathing problems, and hallucinations for Resident 60.1.Resident 7 was admitted to the facility in early 2026 with diagnoses that included high blood pressure and heart failure. During an observation and interview on 5/4/26 at 1:30 p.m. of Licensed Nurse (LN3), LN 3 was in the hallway taking Resident 7's blood pressure. Resident 7 was wearing a long sleeve down jacket. LN 3 placed the cuff end (the part of the blood pressure cuff that wraps…

  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 · E2026-05-07 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure accurate reconciliation and accountability of controlled medications for three of 19 sampled residents (Resident 22, Resident 56 and Resident 57) when discrepancies were found during the random controlled medication audits.These failures resulted in the facility lacking accurate accountability of controlled substances and increased the potential for diversion in a 60-certified-bed facility. Findings:The controlled medication record for three randomly selected residents (Resident 22, Resident 56 and Resident 57) who received as-needed controlled medications were requested for review during the survey.During a review of Resident 22's Medication Administration Record (MAR) dated 4/20-4/25/26, the MAR indicated an order for Morphine Sulfate [medication to treat pain] Solution 20 mg/ml (mg, milligrams: unit of measurement. ml, milliliter: measurement for a volume of liquid) Give 0.25 ml by mouth every 4 hours as needed.for pain.During a review of Resident 22's CONTROLLED DRUG RECORD [CDR], [a form that…

  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 · E2026-05-07 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure that two of 19 sampled residents (Resident 4 and Resident 9) were free from significant medication errors when nursing staff did not administer prescribed as needed antihypertensive medications during repeated, documented episodes of elevated systolic blood pressure.This failure compromised the residents' safety and placed both Resident 4 and Resident 9 at increased risk for serious and potentially life threatening outcomes, including hypertensive crisis, stroke, and cardiac arrest.1.Resident 9 was admitted to the facility in late 2022 with diagnoses that included a stroke, an irregular heartbeat, and heart disease. During a review of Resident 9's Order Summary Report [OSR], order dated 4/2/26, the OSR indicated, cloNIDine HCl Oral Tablet 0.1 MG [milligram, unit of measurement].Give 0.1 mg by mouth every 12 hours as needed for SBP [systolic blood pressure, top number of blood pressure reading] >150. A review of Resident 9's documented blood pressure readings from 4/2/26-4/30/26, showed 15 systolic blood pressure…

  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 · Ecited before2026-05-07 · tag F0761 — failed to label and store drugs safely — pattern
  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 observation, interview and documentation review, the facility failed to implement their medication storage policy when: Multiple medications were unlabeled, and Expired medications were stored and available for use.These failures had the potential for residents to receive unsafe, ineffective, or inappropriate medications for a census of 56.Findings:1. A review of the tuberculin (bacteria extract used to diagnose tuberculosis infections) manufacturer's box indicated that the tuberculin vial should be discarded 30 days after opening. During a concurrent observation and interview on 5/5/26 at 9:20 a.m., with the Director of Nurses (DON), a vial of tuberculin was observed to be open without an opened date in the medication storage fridge. The DON confirmed the finding and stated, it is not labeled.During a concurrent observation and interview on 5/5/26 at 9:47 a.m. with Licensed Nurse 1 (LN 1), two 15mg mirtazapine tablets (a prescription antidepressant drug) , one tablet of 8mg ondansetron (a medication used to treat nausea), and three 4mg tablets of ondansetron were found…

  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 · Ecited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 54 residents who received food prepared from the kitchen, when: 1. Food debris and dried watermarks was observed on several kitchen utensils stored inside the plastic container. The bottom of the container, which was designated for storing clean utensils, contained visible dirt and food debris; 2. Several kitchen utensils, stock pot, plastic trays, metal pans were found stacked wet and stored at the clean and ready-to-use storage areas; 3. A plastic coffee carafe on the countertop contained a white substance adhered to the interior walls and debris collected at the bottom; 4. A staff used wiping cloth from the red bucket to wipe the countertop during cooking and food preparation without wearing gloves. The staff returned the used cloth to the red bucket and continued cooking and preparing food without washing their hands; and 5. The inside of the van which used to transport food to the facility from an off site kitchen contained…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for one of three sampled residents (Resident 9) when:Resident 9 did not receive diclofenac sodium gel 1% (a gel used treat joint pain and inflammation from osteoarthritis) to his leg or as needed clonidine (fast acting medication to lower blood pressure).These failures resulted in two medication errors out of 35 opportunities, yielding a medication error rate of 5.71%.Findings:During a review of Resident 9's Order Summary Report [OSR], order dated 4/30/25, the OSR indicated, Diclofenac Sodium External gel 1% .Apply to left leg topically [to the skin] four times a day for pain.During a medication pass observation on 5/4/26 at 8:42 a.m. with Licensed Nurse (LN 4), LN 4 did not apply the diclofenac gel 1% to Resident 9's left leg. LN 4 looked through the cart and stated there was no diclofenac gel 1% available. LN 4 checked Resident 9's blood pressure and recorded a reading of 189/73.During a review of Resident 9's OSR, order date 4/2/26, the OSR indicated, cloNIDine…

  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 · Dcited before2026-02-25 · 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 interview and record review the facility failed to provide quality care to one of two sampled residents (Resident 1) when:The facility failed to create specific and measurable care plan interventions for Resident 1's risk for elopement.The facility staff failed to follow physician orders for monitoring elopement attempts.These failures had the potential for Resident 1 to have an increased risk for elopement, had the potential for staff caring for Resident 1 to be unaware of his elopement attempt on 2/19/26 and had the potential to contribute to Resident 1's elopement attempt on 2/19/26.1.During a review of Resident 1's Facesheet dated 2/25/26, facesheet indicated, Resident 1 was admitted to the facility 29 days ago. Resident 1 had diagnoses including Respiratory failure, Falls, and Alzheimer's Disease (disease characterized by memory loss and cognition decline).During a review of Resident 1's Elopement Risk assessment dated [DATE], Assessment indicated, Resident was scored a 7 indicating he was 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-29 · 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 interviews and record review, the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 hit Resident 1, a deficient practice identified for one of four sampled residents.This failure resulted in an injury to Resident 1's lip.Findings:Resident 1 was admitted to the facility in late 2025 with diagnosis which included difficulty in walking, a fall with head injury, and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/8/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 8/15 which indicated moderately impaired cognition.Resident 2 was admitted to the facility in early 2025 with diagnosis which included dementia and an anxiety disorder.During a review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 13/15 which indicated intact cognition.During a review of Resident 1's IDT Notes [Interdisciplinary Team] dated 10/23/25, the IDT notes indicated, On 10/23/25 at…

  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 · D2025-08-08 · 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

  Based on interview, and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents (Resident 1) when an allegation of abuse was not reported to the State Agency.This failure resulted in delays in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in September 2024 with diagnoses that included anxiety disorder (repeated episodes of sudden feelings of anxiety and fear or terror), dementia (a progressive state of decline in mental abilities), and depression (persistent feeling of sadness and loss of interest). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment.During a review of Resident 2's admission records, the records indicated Resident 2 was admitted in March 2025 with diagnoses that included metabolic encephalopathy (occurs when…

  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

“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.

Fines & penalties

$16,988 in federal fines across 2 penalties.

• $8,970 — penalty dated 2024-05-03
• $8,018 — penalty dated 2024-01-09

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 BVHC, LLC — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 16 rows in the source record cover these 8 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.

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 89% 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 $306K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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 CA