Washington County Nursing Home

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.

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 40 beds and averages 38.5 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 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 4.09 hrs/resident/day on weekends vs 4.40 on weekdays — 7% thinner on weekends. RN hours go from 0.75 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are 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.

This trend is not current. The most recent of these two inspections was over 2 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.

20 citations, most serious first. The 15 most serious are shown; the remaining 5 are one tap away and print in full.

• Actual harm · Gcited before2023-05-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#26) out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #26, age [AGE], was admitted to the facility on [DATE] with diagnoses of heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. Resident #26 sustained a weight loss of 10.6% (20.5 lbs) from admission on [DATE] through 1/31/23, which was considered significant. According to Resident #26's nutrition care plan, pertinent interventions initiated 3/4/23 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss and obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. Resident #26's labwork, dated 2/17/23, revealed his Albumin was 2.8 (ranges 3.4-5) indicating it was…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2019-11-21 · tag F0606 — failed to not employ staff found guilty of abuse — isolated
  Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure individuals with a finding entered into the State nurse registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property for one of five sampled staff members. Specifically, the facility failed to ensure residents were free from employee negligence by employing LPN #5 with a known history of negligence entered into the State nurse registry. Cross reference: F690 (Catheters), the facility failed to follow physician's orders for catheter placement resulting in harm to Resident #4. Findings include: I. Facility policy and procedure The Background Screening policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It revealed, in pertinent part, Our campus conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For any licensed professional applying for a position that may involve direct contact with elders, his/her respective licensing board…

  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
• Actual harm · G2019-11-21 · 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 II. The facility failed to ensure an RN assessment for injury was completed prior to moving a resident who had fallen A. Resident #36 1. Resident status Resident #36, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included displaced fracture of base of neck of right femur, joint replacement surgery, dementia with behavioral disturbance and anxiety disorder. The 10/29/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. It indicated the resident had a fracture related to a fall prior to the resident's readmission to the facility and had hip replacement surgery. 2. Record review The fall care plan, initiated on 1/17/17 and revised on 9/13/19, revealed the resident was at risk for falls related to confusion,…

  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 · G2019-11-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policies, it was determined the facility failed to provide the appropriate care and services for one resident (#4) of one with a suprapubic catheter with a total sample of 26 residents. Specifically, the facility failed to: -Insert the indwelling catheter into the superpubic area, for Resident #4. The indwelling catheter was wrongly inserted into the penis meatus which resulted in bleeding, bruising and pain (Cross Reference F 606 failure to not employ staff with a history of negligence). Findings include: I. Professional reference According to [NAME], P., [NAME], A., Stockert, P., & Hall, A. (2017) Fundamentals of Nursing (9th ed.), p.1112, .A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon similar to an indwelling catheter. Suprapubic…

  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 before2019-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#23) of two residents reviewed for nutrition out of 26 sample residents. Specifically, Resident #23, diagnosed with hypokalemia, anemia, hypocalcemia, gastro-esophageal reflux disease, and hyperlipidemia. On 5/3/19 the resident's weight was recorded at 143.0 lbs (pounds) and six months later on 10/16/19 the resident weighed 125.0 lbs. This was a 17.5 lbs significant weight loss, which was 12.24% over six months. On 9/3/19 the resident weighed 141.3 lbs and 18 days later on 9/21/19 the resident weighed 129.5 lbs. This was an 11.8 lbs significant weight loss, which was 7.8%. On 9/21/19 the resident weighed 129.5 lbs and 26 days later on 10/16/19 the resident weighed 125.0 lbs. This was a 4.5 lbs and 3.8% weight loss. Review of the resident's medical records revealed the facility continued to review and document the resident's weight loss from 1/4/19 to 11/20/19, but failed to implement…

  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 · D2026-02-10 · 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 record review and interviews the facility failed to ensure one (#1) of three residents received treatment and care in accordance with professional standards of practice out of three sample residents.Specifically, the facility failed to ensure Monitor Resident #1's blood sugar after long acting insulin was administered to ensure the effectiveness of the medication. Findings include:I. Professional ReferenceAccording to the manufacturer, Sanofi, Patient Information Lantus Insulin Glargine Injection, 2025, retrieved on 2/20/26 from https://www.lantus.com/new-to-insulin/starting-insulin The most common side effect of insulin, including [NAME], is low blood sugar (hypoglycemia), which may be serious and life threatening. It may cause harm to your heart or brain. Symptoms of serious low blood sugar may include shaking, sweating, fast heartbeat, and blurred vision.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to February 2026 computerized physician orders (CPO),…

  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 before2026-02-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections.Specifically, the facility failed to follow proper infection control practices during insulin injection via insulin pen by using Resident #3 insulin pen to inject insulin to Resident #1. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC), Considerations for Blood Glucose Monitoring and Insulin Administration (revised 8/7/24) was retrieved on 2/17/26 from https://www.cdc.gov/injection-safety/hcp/infection-control/. It read in read in pertinent part, Insulin pens and other medication cartridges and syringes are for single patient use only. Never use them for more than one person. II. Facility policy and procedureThe Insulin Pen Use Policy, dated November 2025, read in pertinent part Insulin pens contain multiple doses 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-25 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop 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 record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for three (#38, #24 and #3) of five residents reviewed for care plans out of 19 total sample residents. Specifically, the facility failed to: -Ensure Resident #38 had a care plan for the use of an anticoagulant medication; -Ensure Resident #24 had a care plan for the use of supplemental oxygen; and, -Ensure Resident #3 had a care plan for the use of a diuretic medication. Findings include: I. Facility policy and procedure The Care Plan policy, revised 8/12/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.…

  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 · D2024-09-25 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced their dignity and respect for one (#35) of three residents reviewed for dignity out of 19 sample residents. Specifically, the facility failed to ensure Resident #35's fall intervention sensor alarm was discussed with the resident on how it made her feel. Findings include: I. Facility policy and procedure The Elder rights policy, revised 7/8/24, was provided by the nursing home administrator (NHA) on 9/25/24/at 2:53 p.m. It read in pertinent part, All elders will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The campus will ensure that all staff members are educated on the rights of elders and the responsibility of the campus to properly care for its elders. II. Resident status Resident #35, age above…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#38) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to ensure Resident #38 was adequately monitored and side effects were documented for the use of an anticoagulant medication. Findings include: I. Facility policy and procedure The Anticoagulant policy, revised 8/24/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. For example, those with a recent history of deep vein thrombosis (DVT), or heart valve replacement, atrial fibrillation or those who have had recent joint replacement surgery. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence…

  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 before2024-09-25 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/26/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-05-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  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, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#19) of five residents reviewed for use of psychotropic medication out of 20 sample residents. Specifically, the facility failed to for Resident #19: -Ensure staff monitored the resident for effectiveness of antidepressant medication therapy since the resident was prescribed two antidepressant medications with one being used for a diagnosis of insomnia; -Ensure staff identified depressive target behaviors; -Ensure staff accurately monitored the resident for depressive target behaviors and hours of sleep for the antidepressant being used for insomnia; and, -Ensure staff monitored the resident for her response to antidepressant medication. Findings include: I. Facility policy The Use of Psychotropic Medication, undated, was received on 5/16/23 from the nursing home administrator (NHA), which read 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2019-11-21 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for four (#36, #12, #10, and #18) out of 26 sample residents. Specifically, the facility failed to: -Ensure the care plan was revised and updated with fall interventions for Resident #36, #12, #10 and #18; -Ensure the care plan was revised and updated with Resident #10 current functional status, recent functional decline and newly developed pressure ulcers; and -Ensure the care plan was revised and updated following a suicidal ideation by Resident #10. Cross reference to F689 (Free of Accident Hazards/Supervision/Devices), the facility failed to consistently implement specific, effective, interventions to attempt to prevent Resident #18 from a fracture of the clavicle, pelvis and bruising to the head; and ensure interventions were put into place following falls for Residents #10, #12 and #36. Findings…

  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 · E2019-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that two (#3 and #6) out of two residents reviewed for oxygen out of 26 total sampled residents received necessary respiratory care and services. Specifically, Resident #3 and #6 were administered oxygen; however, the facility failed to have a physician's order for the resident's oxygen. Findings include: I. Facility policy and procedure The undated policy, titled Oxygen Administration was received from the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. The policy documented in pertinent part oxygen was administered under the orders of a physician. Staff shall document the initial and ongoing assessment of the residents condition warranting oxygen and the response to oxygen therapy. The residents care plan shall identify the interventions for oxygen therapy based on the resident assessment and orders such as the type of oxygen delivery system, when to administer, flow rates, equipment setting, monitoring of oxygen…

  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 · D2019-11-21 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure physician notification for two (#10 and #23) out of 26 sample residents. Specifically, the facility failed to ensure the physician was notified of Resident #10's change of condition and Resident #23's weight loss. Cross reference: F657 (Care Plan Timing and Revision), the facility failed to ensure the care plan reflected the current activities of daily living (ADL) status of Resident #10 following a recent decline. Findings include: I. Facility policy and procedure The Acute Condition Changes policy and procedure, not dated, was provided by the nursing home administrator on 11/21/19 at 1:10 p.m. It revealed, in pertinent part, Our campus shall promptly notify the elder, his or her attending physician, and representative of changes in the elder's medical/mental condition and/or status. II. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the…

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

  Resident Rights Deficiencies · Deficient, Provider has 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

$24,668 in federal fines across 1 penalty.

• $24,668 — penalty dated 2024-09-25

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.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. 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 CO