Springs Village Care Center

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.

49.9% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 58.6% 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 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 91 beds and averages 82.8 residents a day — about 91% occupied, or roughly 8 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.80 hrs/resident/day on weekends vs 3.32 on weekdays — 16% thinner on weekends. RN hours go from 0.83 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

Inspection trend

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

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 13 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · G2023-09-14 · 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 record review and interviews, the facility failed to ensure two (#8 and #52) of two out of 47 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure call lights were answered timely for Resident #8 and Resident #52, who were both dependent on staff for assistance. Resident #8 said she felt lonely and ignored when staff took over an hour to answer her call light and Resident #52 said she felt humiliated when her call light was not answered timely resulting in an episode of incontinence. Findings include: I. Facility policy and procedure A. The Answering the Call Light policy and procedure, revised in March 2021, was provided by the nursing home administrator (NHA) on 9//14/23 at 7:25 p.m. It read in the pertinent part, The purpose of this procedure is to ensure timely responses to the resident's request and needs. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Ask the resident to return 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
• Actual harm · Gcited before2023-09-14 · 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, observations, and interviews, the facility failed to ensure one (#32) of four out of 47 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #32, who had a history of falls, was a high fall risk and was identified by the facility upon admission to be impulsive and not ask for assistance, received the care and services indicated in her comprehensive care plan. The facility failed to ensure Resident #32 received the supervision required to prevent the resident from getting up without assistance. The facility failed to implement the interventions effectively and identify the trend that the resident's falls focused around the resident using the bathroom. On 4/24/23 and 4/26/23, Resident #32 sustained a fall in the bathroom. The resident complained of severe pain to the left shoulder. Upon further studies, the resident had sustained a left shoulder fracture. Additionally, on 9/14/23 (during the survey process), a certified…

  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 before2023-09-14 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such 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, interviews, and record review, the facility failed to manage pain in a manner consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#3) of three residents reviewed for pain out of 47 sample residents. Resident #3 had a diagnosis of schizophrenia (brain disorder), developmental disorder, anxiety, post-traumatic stress disorder (PTSD), restless leg syndrome, and pain. In an interview on 9/11/23 the resident, holding her left knee and grimacing, said the knee pain had started a couple of months ago. Resident #3 said her pain level had increased on 9/10/23 and progressively gotten worse. It was more intense, frequent, and extreme which made it difficult for her to complete her daily activities of living and to attend facility activities. In an interview on 9/13/23, Resident #3 was crying and holding her knee. She said her pain was so bad she did not want her dinner; she said she wanted to go to the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-06 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 four residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 11 sample residents. Specifically, the facility failed to allow Resident #1 to return to the facility after an unplanned discharge to the hospital.Findings include: I. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia, respiratory failure, diabetes and asthma. The 9/11/25 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment indicated the resident was dependent on staff for eating, personal hygiene, dressing and transferring. B. Record review A nursing progress note on 10/26/25 at 10:32 p.m. documented 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-15 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  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 prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about missing clothing that were brought up by the resident council. Findings include: I. Facility policy and procedure The Grievance/Complaints Filing policy, revised July 2022, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. II. Resident group interview Six alert and oriented residents (#40, #76, #51, #25, #64 and #20) who regularly attended the resident council meetings were interviewed on 5/14/25 at 10:08 a.m. The residents were identified as alert and oriented through the facility and assessment. The group of residents said the facility did not follow up 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #62, Resident #27 and Resident #30, who were on enhanced barrier precautions (EBP); and, -Ensure Resident #46 followed appropriate infection control procedures when emptying her own indwelling catheter. Findings include: I. Failure to wear appropriate PPE when providing care for Resident #62, Resident #27 and Resident #30, who were on EBP A. Professional reference According to 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), retrieved on 5/16/25 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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's right to be informed of, and participate in his or her treatment for one (#77) of two residents out of 32 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to inform Resident #77 and/or her legal representative of her laboratory (lab) bloodwork values before being sent to the hospital for a transfusion or her lab values after returning from the hospital. Findings include: I. Facility policy and procedure The Resident Rights policy, undated, was provided by the nursing home administrator (NHA) on 5/13/25 at 2:29 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be notified of his or her medical condition and of any changes in his or her condition, be informed of, and participate in, his or her care planning and treatment and access personal and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#46) of one resident out of 32 sample residents. Specifically, the facility failed to ensure Resident #46 was assessed for self-administration of Visine eye drops. Findings include: I. Facility policy and procedure The Self Administration of Medication policy, revised February 2021, was provided by the nursing home administrator (NHA) on 5/15/25 at 1:45 p.m. It read in pertinent part, Residents have the right to self-medication administrations if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers several factors when determining resident self-medication…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 three (#44, #45 and #41) of four residents were free from chemical restraint out of 32 sample residents. Specifically, the facility failed to: -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #44, Resident #45 and Resident #41's psychotropic medications; and, -Document consistent behaviors or a physician's rationale for Resident #44, Resident #45 and Resident #41 to justify the continued use of psychotropic medications. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, Diagnosis alone does not warrant the use of antipsychotics. Antipsychotic medications will generally only be considered if the following conditions are met: behavior interventions have been attempted and included in the plan 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is 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 provide provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for one (#45) of two residents reviewed out of 32 sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #45, who required physical assistance with meals due to tremors. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) Support policy, revised March 2018, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. Interventions to improve or minimize a resident's functional abilities will be in accordance with the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · 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, record review, and interviews, the facility failed to ensure an environment free from risk of accident and hazards for two (#84 and #6) of five residents reviewed for accident hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure the grab bar/hand rail in Resident #84's bathroom was repaired and a second one installed, per the recommendations of the occupational therapist (OT) as a fall intervention; and, -Ensure Dakin's solution (a topical antiseptic used in wound treatment) was not left unsecured in Resident #6's room. Findings include: I. Failed to ensure grab bar/hand rail was repaired and a second one installed in the bathroom for Resident #84 A. Facility policy and procedure The Falls Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 5/15/25 at 12:53 p.m. It read in pertinent part, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  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 (#74) of two residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to monitor Resident #74, who had a history of suicide attempts, for worsening signs and symptoms of identified depression. Findings include: I. Resident #74 A. Resident status Resident #74, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included mild dementia with anxiety, personality disorder, adjustment disorder, major depressive disorder, suicidal ideations and bipolar disorder. The 4/23/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. B. Resident interview Resident #74 was interviewed in her room 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
• Potential for harm · Dcited before2025-05-15 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication storage refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the inside of the medication storage refrigerator. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/13/25 at 4:45 p.m. It read in pertinent part, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observation On 5/14/25 at 10:32 a.m. the medication storage room on the third floor was observed with registered nurse (RN)…

  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

“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

$26,845 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $26,845 — penalty dated 2023-09-14
• Medicare payment denial — starting 2023-10-13 for 6 days

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 STELLAR SENIOR LIVING — 7 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 59 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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 81% 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