Pioneer Health Care Center

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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 101 beds and averages 77.5 residents a day — about 77% occupied, or roughly 24 beds typically open. It usually has some room. 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.02 hrs/resident/day on weekends vs 3.50 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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.

24 citations, most serious first. The 14 most serious are shown; the remaining 10 are one tap away and print in full.

• Actual harm · Gcited before2024-04-18 · 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 observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#13) of three residents reviewed for accidents/hazards out of 28 samples residents. Resident #13 had been evaluated and determined to be a supervised smoker, which included she was not able to keep smoking supplies with her. The supplies were to be kept and monitored by the facility. During the scheduled smoke breaks, the facility would provide the resident with the cigarette and light the cigarette with a lighter. On 3/29/24 at 12:30 a.m. certified nurse aide (CNA) #8 heard screams coming from Resident #13's room. When she went in the room to check on Resident #8 she found the dressing on her lower left leg on fire. CNA #8 yelled for help and put out the fire with a towel and water. Resident #8 was transferred to the emergency department (ED) where it was determined she had first…

  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 · Past Non-Compliance
• Actual harm · Gcited before2021-09-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#34, #62 #65 and #69) residents involved in three facility reported incidents on the South unit out of 46 sample residents. The facility failed to prevent an altercation between Resident #65 and Resident #34. Resident #34 was physically abused by Resident #65, which resulted in Resident #34 requiring hospital treatment where he received 12 staples to his head and medication for pain. Resident #62 was physically abused by Resident #34. Resident #34 pushed Resident #62's wheelchair into a wall resulting in Resident #62's bilateral lower extremities making contact with the wall. Resident #34 also made a comment he wanted to break Resident #62's legs. Resident #69 was physically abused by Resident #65 which in resulted in Resident #69 being shoved to the floor by Resident #65. Cross-reference F744, the facility failed to implement person centered approches to dementia…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-09-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observations, the facility failed to ensure one (#60) of three residents reviewed for post surgical wounds and monitoring out of 46 sample residents received treatment, care and monitoring in accordance with professional standards of practice. Specifically, the facility failed to monitor Resident #60's new post surgical wound and clinically monitor changes in vital signs timely for which she required rehospitalization. Resident #60 admitted to the facility on [DATE] and readmitted on [DATE] with an Intra-abdominal and pelvic mass (which required surgical repair with staples). The facility failed to monitor Resident #60's surgical site for infection for five days (from 9/5/21 to 9/10/21), Resident #60's wound dehisced (the wound had green/yellow discharge) and ultimately was sent to the emergency department and admitted for sepsis and septic shock, required intravenous (IV) antibiotics and an abscess draining procedure (see record review below). Findings include: I.…

  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 before2021-09-16 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#34, #62 #65, #50 and #69) of five out of 46 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #65's dementia care services to address triggered physically aggressive behavior in order to prevent physical altercations with other residents on the secured unit. The facility was aware Resident #65 had a diagnosis of dementia and occasionally displayed episodes of verbal and physical aggression. The care plan for Resident #65 revealed the facility was to ensure a calm environment, redirect the resident when escalated, and encourage him to seek staff assistance when another resident was disturbing him. Furthermore, due to the facility's failures, Resident #65…

  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 before2025-03-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#4 and #6) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #4 from physical abuse by Resident #5; and, -Protect Resident #6 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse and Neglect policy, undated, was provided by the director of nursing (DON) on 3/4/25 at 11:14 a.m. It read in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The physician and staff will help identify risk factors for abuse within the facility. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. II. Incident of physical abuse towards Resident #4 by Resident #5 on 2/8/25 A. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-29 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated 2/15/19, pp. 94-95, retrieved on 9/5/24 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-29 · 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 staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 28 of 55 resident rooms. Specifically, the facility failed to ensure: -The walls, ceilings, baseboards and floors were properly maintained; -The resident's rooms were cleaned and free of mice feces, flies; and, -The wooden handrails in the hallways were cleaned and free of wood splinters. Findings include: I. Observations Observations of the resident's living environment were conducted on 8/27/24 at 9:44 a.m. and revealed the following: room [ROOM NUMBER]: The ceiling had three missing 12 inch by 12 inch tiles. The walls had several sections approximately four inches in circumference on the wall next to the bathroom. The resident had a five drawer dresser in the corner of his room with each drawer containing dried mice droppings. The floor was sticky. There were tissues and other trash under the resident's bed. room [ROOM NUMBER]: The wall next to the bathroom had chipped…

  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 · Dcited before2024-08-29 · 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 residents received proper respiratory treatment and care for three (#3, #2 and #7) of four residents reviewed for supplemental oxygen use out of 10 sample residents. Specifically, the facility failed to: -Administer oxygen in accordance with the physician's order for Resident #3 and #2; and, -Ensure a physician's order was in place for Resident #7's continuous use of oxygen. Findings include: I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/29/24 at 10:47 a.m. by the corporate consultant (CC). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. II. Resident # 3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included depression, delusional disorder, chronic obstructive pulmonary disease (COPD). According to the 7/17/24 minimum data…

  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 · F2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure the kitchen was clean and sanitary; and, -Ensure food was held at appropriate temperatures. Findings include: I. Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen. A. Facility policy and procedure The Sanitation policy, revised November 2022, was provided by the dietary supervisor (DS) on 4/18/24 at 11:45 a.m. It read in pertinent part, The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas will be kept clean, free from garbage and debris. All equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use. B. Observations During the initial tour of 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-04-18 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #9, CNA #11, CNA #12, CNA #13 and CNA #14. Findings include: I. Record review CNA #9 (hired on 3/13/18), CNA #11 (hired on 7/1/16), CNA #12 (hired on 4/22/22), CNA #13 (hired on 5/7/21) and CNA #14 (hired on 7/1/16) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interview The director of nursing (DON) was interviewed on 4/16/24 at 2:23 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-18 · 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 notify the provider according to physician orders for one (#29) of three residents reviewed for unnecessary medications out of 28 sample residents. Specifically, the facility failed to notify and document Resident #29's elevated blood sugar levels to the provider as directed on the physician's order. Findings include: I. Facility policy and procedures The Diabetic Care Policy, revised November 2020, was provided by the director of nursing (DON) on 4/18/24 at 11:20 a.m. The policy read in pertinent part, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. II. Resident #29 A. Resident status Resident #29, over the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included type II diabetes mellitus with diabetic autonomic…

  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 · D2024-04-18 · 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 assistance with activities of daily living (ADL) for one (#8) of five residents reviewed for ADL care out of 28 sample residents. Specifically, the facility failed to ensure Resident #8 received oral and personal hygiene daily. A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot), unspecified fracture of lower end of right tibia (larger bone of the two lower leg bones) and multiple sclerosis (deterioration of the nerves). The 12/1/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean up assistance with oral hygiene and eating. She required partial/moderate assistance with personal hygiene, showering/bathing 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-18 · 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 one (#40) of three residents out of 28 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #40's supplemental oxygen was on the correct ordered liter flow per the physician's order. Findings include I. Facility policy and procedure The Oxygen administration policy, revised October 2010, was received from the director of nursing (DON) on 4/18/24 at 11:40 a.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician order for this procedure. Documentation in medical records includes: rate of oxygen flow, route, frequency, and duration. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards of practice II. Resident #40 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 · D2024-04-18 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts. Specifically, the facility failed to: -Discard an expired Anoro inhaler; -Date an Anoro inhaler when opened; and, -Date a Lantus insulin pen when opened. Findings include: I. Professional reference According to the Anoro inhaler manufacturer's guidelines, retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Anoro_Ellipta/pdf/ANORO-ELLIPTA-PI-PIL-IFU.PDF, Discard Anoro Ellipta 6 (six) weeks after opening the foil tray or when the counter reads '0', whichever comes first. According to the Lantus insulin pen manufacturer's guidelines, retrieved on [DATE] from https://products.sanofi.us/lantus/lantus.html#section-15, Storage conditions for the 3 ml (milliliter) single patient use solostar pen in-use (opened) 28 days room temperature only. II. Observations…

  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

$10,033 in federal fines across 1 penalty.

• $10,033 — penalty dated 2024-04-18

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 MADISON CREEK PARTNERS — 13 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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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 88% 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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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.

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