Arbor View Care Center, LLC

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

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 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 110 beds and averages 103.7 residents a day — about 94% occupied, or roughly 6 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.10 hrs/resident/day on weekends vs 3.56 on weekdays — 13% thinner on weekends. RN hours go from 0.56 to 0.37 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.

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 14 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · J2024-03-13 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 ensure one (#3) of three out of six sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #3 was administered anticoagulant medication (Pradaxa) for atrial fibrillation per physician's orders. The facility failed to ensure the resident's anticoagulant prescription was picked up from a specified pharmacy by facility staff and brought to the facility. This failure resulted in Resident #3 not being administered the anticoagulant medication for a total of nine doses from [DATE] to [DATE]. As a result of the facility's failure, the resident was sent to the hospital with potential signs of a stroke on [DATE], was admitted to the hospital and died at the hospital on [DATE] due to a cerebral vascular accident (defined as an interruption in the flow of blood to the cells of the brain-stroke). Findings include: Record review and interviews confirmed the facility corrected the deficient…

  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 · Past Non-Compliance
• Actual harm · G2026-02-18 · 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 record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents.Resident #1 was admitted on [DATE] for long-term care with a diagnosis of dementia. According to the care plan, Resident #1 was determined to be a high fall risk. The resident was independent with ambulation. On 1/16/26 Resident #1 was found on the floor in another resident's room. The resident was not wearing appropriate footwear at the time of fall. After the fall, Resident #1 was not able to walk and required the use of a wheelchair. Resident #1 did not participate in her usual daily activities, her pain level increased and she was confused.Two days after the fall, on 1/18/26, Resident #1 was transported to the hospital for further evaluation for her increased confusion, increased pain and continued inability to walk. Resident #1 was admitted to the hospital and diagnosed with a subdural hematoma…

  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 before2024-07-30 · 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 ensure one (#93) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being out of 51 sample residents. Resident #93 was admitted to the facility for long term care on 3/27/24 with diagnoses of severe dementia with mood disturbance, hypothyroidism (underactive thyroid), depression and dysphagia of the oropharyngeal stage (food sticks to the mouth or throat or gets pocketed in cheeks). Upon admission [DATE]), Resident #93 weighed 114.6 pounds (lbs). On 4/4/24 the facility placed the resident on restorative dining services, however, observations during the survey revealed the resident did not receive consistent assistance at meals. On 5/20/24, the resident weighed 112.6 lbs and on 6/20/24 the resident weighed 106 lbs. The resident sustained a 5.9% (6.6 lbs) weight loss from 5/20/24 to 6/20/24 in one month, which was considered severe. On…

  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 before2023-03-16 · 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 nutritional interventions for one (#89) of four residents reviewed for nutritional parameters out of 37 sample residents to maintain acceptable parameters of nutritional status. Resident #89, age [AGE], was admitted to the facility on [DATE] with diagnoses of dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). Resident #89 sustained a weight loss of 9.9% (17.6 lbs) from admission on [DATE] through 2/26/23, and an 11% (20.2 lbs) weight loss from admission to 3/12/23, which was considered significant. He also lost more than three lbs weekly from 1/18/23 to 1/25/23 (4.3 lbs loss), 2/16/23 to 2/19/23 (4 lbs loss) and from 2/19/23 to 2/26/23 (6.9 lbs loss). According to Resident #89'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-30 · tag F0550 — failed to protect resident dignity and rights — pattern
  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

  Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity in two out of four dining rooms. Specifically, the facility failed to: -Ensure an adequate system was in place to provide meal service in a timely fashion to residents waiting to be served their meals in the Aspen and Pine Ridge dining rooms, which resulted in some residents at the same table receiving their meals 40 to50 minute after other residents; and, -Ensure residents were treated with respect and dignity by staff in the dining rooms, including engaging with residents and addressing residents by his/her preferred name. Findings include: I. Facility policies and procedure The Quality of Life - Dignity policy, revised February 2020, was requested and received from the nursing home administrator (NHA) on 7/30/24. It read in pertinent part, Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. The Assistance with Meals policy, revised March…

  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 · E2024-07-30 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  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 honor resident choices for three (#56, #6 and #65) of five residents reviewed for activities of daily living (ADL) out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #56, Resident #6 and Resident #65 received two showers a week per their preferences; and, -Ensure Resident #65 was assisted with a leg catheter bag on Sundays when he was attending church. Findings include: I. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial maximal assistance with showers and did not…

  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 · E2024-07-30 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 16.1%, or five errors out of 31 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, retrieved on 7/31/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-30 · tag F0882 — pattern
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Control and Surveillance policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 7/23/24. The policy documented in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP is developed to address the facility-specific infection control needs, requirements identified in the facility assessment and the infection control risk assessment. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention 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 · Dcited before2024-07-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  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 observations, record review and interviews, the facility failed to ensure two (#56 and #21) of five residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #56's CPAP (continuous positive airway pressure) machine was working appropriately and used as ordered by the physician; and, -Ensure Resident #21 was wearing oxygen as ordered by the physician. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, reviewed June 2023, was provided by the nursing home administrator (NHA) on 7/30/24 at 4:43 p.m. It read in pertinent part, Oxygen is administered under orders of the physician. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. -The policy did not include any pertinent information for the use of CPAP/biPAP (bilevel positive airway…

  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 · E2024-07-30 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 residents were provided prompt efforts by the facility to resolve any grievances for six (#65, #6, #81, #92, #58 and #87) of ten residents reviewed for grievances out of 51 sample residents. Specifically, the facility failed to ensure grievances regarding competency of agency staff were followed up timely with a satisfactory resolution for Residents #65, #6, #81, #92, #58 and #87. Findings include: I. Facility policy The Grievance policy, dated 5/8/23, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:15 p.m. It read in pertinent part, To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegations/concerns. The appropriate…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-03-16 · 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 the resident representative was notified for one (#89) of five residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #89's representative was notified of his significant weight loss. Findings include: I. Facility policy The Weight Management policy, dated 10/24/22, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:10 a.m. The policy read in pertinent part, Nursing staff were responsible to communicate weight changes to the attending physician and resident's family. The nurse documented the notification in the medical record. Nursing staff was to notify food and nutrition services and the registered dietitian (RD) of a resident's weight change. The Changes in Resident Condition Policy, revised 11/23/19 was provided by the RCR on 3/16/23 at 10:10 a.m. The policy read in pertinent part, The resident, attending physician and legal representative or interested family member were…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-03-16 · tag F0685 — isolated
  Assist a resident in gaining access to vision and hearing services.
  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 ensure proper treatment and assistive device to maintain hearing and vision abilities for two (#32 and #29) of three residents reviewed for vision and hearing out of 37 sample residents. Specifically, the facility failed to: -Provide working hearing aids and repair glasses for Resident #32; and, -Offer Resident #29 audiology services. Findings include: I. Facility policy and procedure The Ancillary policy and procedure, dated 8/19/14, were provided by the nursing home administrator (NHA) on 3/15/23 at 11:35 a.m. It read in pertinent part, Ancillary services, including, but not limited to, dental, vision, audiology, and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family member's request; and as needed. Any resident needing or requesting ancillary services such as dental, vision, audiology or podiatry will have their needs met timely. The facility will keep available 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 · D2023-03-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 ensure a resident with limited mobility receives appropriate equipment, and assistance to maintain or improve mobility for one (#26) of three residents reviewed for limited range of motion out of 37 sample residents. Specifically, the facility failed to provide the resident with a hand splint and assistance for right hand contracture. Findings include: I. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, 2001 and revised in July 2017, was provided by the director of clinical operations (DCO) on 3/16/23 at 2:48 p.m. In pertinent part, it read: -Residents will not experience an avoidable reduction in range of motion (ROM). -Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction 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 before2023-03-16 · tag F0700 — isolated
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 inspection and maintenance of a halo safety ring (fixed bed rail assistive device) for one (#29) of two residents using bed halo (type of bed rail) for positioning out of 37 sample residents. Specifically, for Resident #29, the facility failed to: -Inspect and regularly check the mattress and halo safety ring for areas of possible entrapment; -Check bed rail/halo safety ring regularly for ongoing maintenance to make sure device was still installed correctly as rails may shift or loosen over time; and, -Ensured the bedrail/halo safety ring was securely attached to the resident bed frame and prevented unstable movement and wobbling of the assistive device. Findings include: I. Professional standard The U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and pulled 3/22/23 from…

  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

“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

$22,271 in federal fines across 3 penalties.

• $4,305 — penalty dated 2026-02-18
• $7,930 — penalty dated 2024-07-30
• $10,036 — penalty dated 2024-03-13

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 LONG PEAK OPERATING COMPANY — 8 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 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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 85% 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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. 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