Hilltop Park Post Acute

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.

37.8% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 79.6% 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 49 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 162 beds and averages 148.5 residents a day — about 92% occupied, or roughly 14 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 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.64 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 2.72 hrs/resident/day on weekends vs 3.02 on weekdays — 10% thinner on weekends. RN hours go from 0.47 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 40% 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.

37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2024-03-07 · 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 interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula 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 · Gcited before2024-07-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide one of three residents (#5) out of 21 sample residents, with timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury that resulted in the development of a stage 4 coccyx wound with osteomyelitis. Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). And, on 6/6/24, x-rays revealed the presence of osteomyelitis, inflammation of the bone due to infection, requiring an extended course of antibiotic treatment. Interviews, observations, and record review revealed the facility failed to provide timely and necessary treatment and services to prevent the development of the resident's pressure…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-08-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to prevent the worsening of stage four pressure ulcers for two of two (#3,#42) out of 29 residents reviewed. The facility failed to ensure all interventions were completed and implemented as ordered by Resident #3's physician. Resident #3 who was admitted with a stage 4 pressure ulcer, and was a known high risk for the development and worsening of the already existing pressure ulcer did not have his pressure ulcer interventions implemented consistently to avoid the Stage 4 pressure ulcer from becoming worse. Resident #3's pressure ulcer went from 2.5cm long by 9 cm wide by 0.1 cm deep on 8/19/21 to 5 cm long by 9.5 cm wide by 1.1 cm deep on 8/25/21. During this time Resident #3 experienced increased and constant pain (cross-reference F697), to the point of Resident #3 making a comment, this really hurts!. during a wound treatment that occurred during the survey. Furthermore, during the wound observation on 8/25/21 the wound dressing that 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 · G2021-08-26 · 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 standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#3 and #42) of three residents reviewed out of 29 total sample residents. Specifically, the facility failed to: -Provide adequate pain management during routine wound care for Residents #3 and #42; -Notify the physician when pain medications were ineffective for Residents #3 and #42; -Ensure Resident #3's pain was managed in line with the resident's goals for effective pain management and acceptable pain level; and, -Conduct a comprehensive pain assessment on a routine basis for Resident #42. These facility failures contributed to Resident #3 and Resident #42 experiencing undue severe pain. The residents did not receive adequate pain management prior to or during routine wound care, and suffered unnecessary pain as a result. The facility staff made multiple statements…

  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 · E2026-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 provide a comfortable and homelike environment in three of four units.Specifically, the facility failed to:-Ensure the blinds, window sills, wall air conditioners and walls in resident rooms were clean and in good repair; and,-Ensure facility spas were in good working condition and the tile was in good repair. Findings include: I. Facility policy and procedure The Homelike Environment Policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/25/26 at 7:55 a.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; inviting colors and décor personalized furniture and room…

  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 plan of correction
• Potential for harm · D2026-06-25 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 revise and implement an effective discharge plan for two (#163 and #155) of three residents reviewed for discharge planning out of 62 sample residents. Specifically, the facility failed to:-Ensure the discharge planning process was documented, including the reason for discharge in Resident #163's electronic medical record (EMR); -Ensure the reconciled medication list, physician's orders and care plan provided to the resident at discharge were documented in Resident #163 and 155's EMRs;-Ensure Resident #155's discharge care plan was updated to include the resident's preference to transfer to another facility; and,-Ensure Resident #155's EMR contained documentation of the preparation provided to the resident prior to transfer to another facility in a form and manner the resident could understand. Findings include: I. Resident #163 A. Resident status Resident #163, age less than 65, was admitted on [DATE] and discharged on 10/31/25. According 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.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2025-12-04 · tag F0565 — failed to support the resident council — isolated
  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 a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to:-Make prompt efforts to work with residents to resolve their food grievances; and;-Fully investigate and document grievance resolutions and corrective action. Findings include:I. Facility policy and procedureThe Grievances/Complaints policy, revised 4/17/25, was provided by the director of nursing (DON) on 10/15/25 around 3:00 p.m. It read in pertinent part, The grievance officer, administrator, and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. The administrator will review the findings with the grievance officer to determine what corrective actions, if any,…

  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 · F2024-07-29 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure that all nursing staff had the specific competencies and skill sets necessary to identify, intervene, and notify the physician of residents' acute changes of condition related to wound development and treatment measures such as providing wound care and management of pressure relieving mattresses. This affected all residents with pressure wounds or those at risk for developing a pressure wound and contributed to Resident #5's pressure wound from worsening to a Stage 4 pressure wound with osteomyelitis (infection at the bone). Cross-reference F686 for failure to prevent worsening of a pressure injury. Specifically, the facility failed to assess all facility-hired nurse staff registered nurses (RNs), licensed practical nurses (LPNs) and certified nurse aides (CNAs) for competency in caring for residents with pressure injuries. Competencies not assessed included all of the following: reporting and documenting when a resident developed a new or worsening wound, assessing the condition or a wound, development 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-07-29 · tag F0940 — failed to train staff — widespread
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to: -Ensure all direct and non-direct care staff received training in quality assurance and quality improvement (QAPI), compliance and ethics and resident rights; -Ensure all direct and non-direct care staff received training in all components of abuse training including abuse prevention, identification and types of abuse; -Ensure all certified nurse aides (CNA) received at least 12 hours of annual in-service training. Findings include: I. Facility policy and procedure The In-service Training, All Staff policy, dated 2021, was provided by the nursing home administrator (NHA) on 7/28/24 at 9:oo a.m. It read in pertinent part, All staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-29 · 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 resident rights were promoted and dignity was maintained for seven (#10, #15, #17, #18, #19, #20, and #21) of seven residents out of 21 sample residents. Findings include: I. Facility policy The Resident Rights policy, revised February 2021, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.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 right to a dignified existence, to be treated with respect, kindness and dignity, to self determination and to be supported by the facility in exercising his or her rights. II. Resident group interview The resident group interview was conducted on 7/23/24 at 1:00 p.m. The group consisted of seven residents (#10, #15, #17, #18, #19, #20, and #21) who were interviewable based on assessment and facility. The residents stated they continued to have concerns with being treated with respect and dignity. The concerns were as follows: Residents said…

  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 · E2024-07-29 · tag F0622 — pattern
  Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
  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 each resident was permitted to remain in the facility and not transfer or discharge for three (#6, #4 and #3) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to: -Have documentation from Resident #6's physician regarding the reason for the resident's facility-initiated discharge; -Document the specific resident need(s) that could not be met at the facility, the facility's attempts to meet the resident's needs and the services available at the receiving facility to meet the resident's need(s) for Resident #6; -Document the discharge planning process in Resident #6's electronic medical record (EMR); -Ensure Resident #6's necessary information, including the resident's comprehensive care plan goals, was provided to the receiving facility; and, -Provide Resident #4 and Resident #3 with an appropriate and safe discharge process. Findings include: I. Facility policy and procedure The Discharge…

  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 · E2024-07-29 · tag F0661 — pattern
  Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned 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 a discharge summary was in place for three (#2, #3 and #4) of four residents reviewed for discharge out of 21sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay and/or a final summary of the resident's status was completed for Resident #2, #3 and #4. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was provided by regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part, The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the residents status at the time of the discharge in accordance with established regulations governing release of resident information as permitted by the resident. The discharge summary shall include a description of the resident's:current diagnoses; medial history;course of illness,…

  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 · D2024-07-29 · tag F0568 — isolated
  Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
  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 provide evidence that a quarterly statement was provided to the resident and/or resident representative for two (#9 and #12) of three residents reviewed for personal funds out of 21 sample residents. Specifically, the facility failed to: -Provide Resident #9 and Resident #12 or their legal representatives a copy of the resident's personal funds financial statement on at least a quarterly basis; -Ensure Resident #9 and Resident #12 or their legal representatives reviewed and signed the form required to give the facility authorization to manage the resident's personal funds; and, -Ensure Resident #9 and Resident #12 or their legal representatives were informed when the resident's total funds reached an amount that required a spend down. Findings include: I. Facility Policy The Management of Residents' Personal Funds policy, dated 2021, was provided by regional nurse consultant (RNC) #1. The policy read: Should the resident elect to have the facility…

  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 · D2024-07-29 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 provide notice of discharge to the resident or their representative and the Office of the State Long-term Care Ombudsman at least 30 days before the resident's discharge for one (#6) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to provide Resident #6 an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The location to which the resident was being transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; and, -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy and procedure, revised October 2022, was received from regional nurse consultant (RNC)…

  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

$66,307 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $53,372 — penalty dated 2024-07-29
• $12,935 — penalty dated 2024-03-07
• Medicare payment denial — starting 2024-08-27 for 10 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 PACS GROUP — 274 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

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 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. This home reported $247K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CO