Bonterra Transitional Care & Rehabilitation

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.

45.1% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.9% 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 34 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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 118 beds and averages 110.5 residents a day — about 94% 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 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.17 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.70 hrs/resident/day on weekends vs 3.06 on weekdays — 12% thinner on weekends. RN hours go from 0.18 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.

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.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to implement the care plan for one of 26 sampled residents (R) (R165) related to nutrition. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received on 3/14/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Quality of Care, C.F.R. 483.25; 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 Assessment and Care Planning Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-03-19 · 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 observations, record reviews, staff interviews, and review of the facility's policies Modified Texture of Food and Resident Food Preferences, the facility failed to provide a pureed snack to one of 26 sampled residents (R) (R165) ordered to receive a mechanically altered diet. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received on 3/14/2025 related to Comprehensive…

  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
• Immediate jeopardy · J2025-03-19 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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, record reviews, and a review of the documents Administrator and Director of Nursing, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements related to Quality of Care for one of 26 sampled residents (R) (R165) receiving an altered diet. Specifically, the facility provided R165 a sandwich, which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received…

  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 · Past Non-Compliance
• Actual harm · G2025-03-19 · 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, resident and staff interviews, record review, and the facility's policy titled Pain Management - Acute, Chronic, and Subacute, the facility failed to ensure that pain management was provided for one of 36 sampled residents (R) (R71) who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. Actual Harm was identified on 3/13/2025, when staples became embedded in R71's amputation surgical site after the facility failed to provide transportation for post-operation (post-op) appointments. Findings included: A review of the facility's policy titled, Pain Management- Acute, Chronic, and Subacute dated February 2025 documented the facility will have an effective pain recognition and management that is ongoing and committed to resident's comfort, identifying and addressing barriers to managing pain and addressing any misconceptions that resident, families, and staff have about managing pain. Recognition and Management of Pain - In…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-03-19 · tag F0774 — isolated
  Help the resident with transportation to and from laboratory services outside of the facility.
  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 and record review, the facility failed to schedule transportation arrangements for a medical appointment for one of 36 sampled residents (R) (R71), resulting in a missed post-operation (post-op) appointment after a surgical procedure. Actual Harm was identified on 3/13/2025, when staples became embedded in R71's amputation surgical site after the facility failed to provide transportation for post-operation (post-op) appointments. Findings included: A review of the electronic medical record (EMR) revealed that R71 was admitted to the facility on [DATE] with a diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, acquired absence of left above knee, type 2 diabetes mellitus with other skin conditions, infection following a procedure, other surgical site subsequent encounter, unspecified complication of procedure subsequent encounter, atherosclerosis of native arteries of extremities with rest pain, right leg, partial traumatic…

  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
• Actual harm · Gcited before2023-08-16 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy 'Care Plan', the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (R) (R#2) that specified the need for two person assistance with Activities of Daily Living (ADL) care. Harm was identified on 5/26/23 when R#2 rolled from the bed while receiving ADL care and receiving fractures to the bilateral lower extremities. Findings included: A review of facility policy 'Care Plans' last revised 11/15/22 revealed: 'Policy Statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standard of Practice 10. Areas of concern and residents strengths will be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goals.' A review of the clinical…

  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
• Actual harm · Gcited before2023-08-16 · 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, staff interviews, and review of facility policy 'Fall Prevention Protocol', the facility failed to protect one of three sampled residents (R) (R#2) from a fall with major injury during Activities of Daily Living (ADL) care. Harm was identified to have occurred on 5/26/23 when R#2 fell while receiving ADL care from staff resulting in bilateral femur fractures. Findings included: A review of facility policy 'Fall Prevention Protocol' last reviewed/revised 10/18/21 revealed 'Standard of Practice: CMS Definition of a Fall: Fall refers to unintentionally coming to a rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident.) A review of the clinical record revealed that R#2 was admitted to the facility 2/19/19 with diagnoses including but not limited to diabetes mellitus with foot ulcer, edema, peripheral vascular disease, and muscle weakness. A review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Enhanced Barrier Precautions Policy, the facility failed to ensure nursing staff used appropriate personal protective equipment (PPE) during catheter care and a bed bath for one of 20 residents (R) (R90) on EBP (enhanced barrier precautions). R90 had a suprapubic catheter, colostomy, and sacral wound, placing them at increased risk for infection.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions Policy, updated February 2025, revealed: Practice Guidelines: .3. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. d. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. e. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities:…

  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 · F2025-03-19 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  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, staff interviews, and review of the facility policy titled, Antibiotic Stewardship, the facility failed to establish and maintain an Antibiotic Stewardship program related to clinical signs and symptoms, laboratory reports, stop dates on antibiotics, and monitoring systems in place for residents returning to the hospital. This had the potential to affect all 114 residents residing in the facility. Findings included: A review of the facility's policy titled Antibiotic Steward in April 2024 documented that the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in our residence. Prescribers will provide complete antibiotic orders including the following elements: (c) frequency of administration; (d) duration of treatment; start and stop date or number of days of therapy. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 make handrails accessible on two of two wings (East Wing and [NAME] Wing); and failed to adequately assess one of 36 sampled residents (R) (R20) for self-administration of medication. Findings included: 1. During observations conducted on 3/10/2025 at 10:24 am, 3/11/2025 at 11:01 am, 3/12/2025 at 3:11 am, 3/13/2025 at 10:47 am, 3/14/2025 at 11:21 am, 3/15/2025 at 9:30 am, 3/16/2025 at 10:21 am, 3/17/2025 at 1:32 pm and 3/18/2025 at 9:37 am on East Wing, the following was revealed: * One dresser was observed between rooms [ROOM NUMBERS], blocking the handrail. * One dresser was observed between rooms [ROOM NUMBERS], blocking the handrail. * Four dressers were observed between rooms [ROOM NUMBERS], blocking the handrail. * Three dressers were observed between rooms [ROOM NUMBERS], blocking the handrail. * Six dressers were observed between rooms [ROOM NUMBERS], blocking the handrail. * One dresser was observed between rooms [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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-19 · tag F0761 — failed to label and store drugs safely — pattern
  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, staff interviews, and a review of the facility policy titled Administration of Medications, the facility failed to properly lock and secure three of four medication carts (Medication Carts A and B on the East Wing and Medication Cart C on the [NAME] Wing). Findings included: A review of the facility policy titled Administration of Medications with a review date of October 2024 revealed that staff will maintain the medication cart locked at all times when unattended. 1. During an observation and interview on 3/14/2025 at 5:18 am, Licensed Practical Nurse (LPN) LPN BB was observed on the East Wing using Medication Cart A. She unlocked the medication cart (Medication Cart A) outside the nurse station with the outward side facing accessibility to three male residents sitting within distance. LPN BB left the cart and was observed sitting behind the nurse station on a computer. LPN BB confirmed she had just come from a resident's room, that a staff member stopped her, and she sat down to do something in a resident's charts. The LPN BB confirmed that she had all…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-19 · tag F0800 — pattern
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, staff interviews, and review of facilities policy titled Therapeutic Diets, the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect six residents on a pureed diet. Findings included: A review of the facility's policy titled Therapeutic Diets with a revision date of September 2017, it was documented that a mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietician's order. Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. During an observation on 3/11/2025 at 1:54 pm, [NAME] FF was observed prepping for the puree observation and the Dietary Kitchen Manager (DKM) was observing KC FF. The DKM revealed [NAME] FF was pureeing boiled carrots. [NAME] FF stated she was pureeing carrots for 10 servings, and she was going to use 15 scoops. No formal recipe for guidance…

  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 · E2025-03-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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, staff interviews, record review, and a review of the facility's policies titled Receiving, Food Storage: Dry Goods, Food Storage: Cold Foods, and Ice, the facility failed to properly label food items with expiration dates, properly cover opened food items, and keep the ice machine free of debris. This deficient practice had the potential to affect 112 residents who received food orally. Findings included: A review of facility policy titled Receiving with a revision date of February 2023 documented that all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. A review of the facility policy titled Food Storage: Dry Goods with a revision date of February 2023 documented that the storage areas will be neat, arranged for easy identification, and the date marked as appropriate. A review of the facility policy titled Food Storage: Cold Foods with a revision date of February 2023 documented that all food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent…

  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 · Ecited before2025-03-19 · 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

  Based on observations, record review, staff interviews, and review of the facility's policy titled Infection Prevention and Control Program Overview, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 114 out of 114 residents residing in the facility. Furthermore, the facility failed to remove personal clothing items from the unit linen cart and failed to cover the resident's clean clothing while transporting the laundry cart. Findings included: 1. A review of the facility's policy titled Infection Prevention and Control Program Overview dated 4/1/2018, documented that the goals of the infection prevention program are to decrease the risk of infection to residents and personnel; to monitor for occurrences of infection; and to implement appropriate control measures. The major activities of the program are surveillance of infections, with the implementation of control measures and prevention of infections. There is ongoing monitoring for infections among residents and personnel, and subsequent documentation of infections that…

  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 · E2025-03-19 · tag F0949 — failed to train staff on dementia and abuse — pattern
  Provide behavior health training consistent with the requirements and as determined by a facility assessment.
  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 and resident interviews, record review, and review of the facility's policy titled Education and Training Requirements, the facility failed to provide an effective behavioral health training program consistent with the facility assessment and person-centered care for three of 36 samples residents (R) (R55, R66, and R76). Findings included: A review of the facility's policy titled Education and Training Requirements, revised August 2024, revealed that the facility's objective is to provide competent care based on the identified needs of the resident population, based on findings from the facility resource assessment. Educational needs can be identified by the utilization of the Facility Resource Assessment Tool. 1. A review of R55's electronic medical record (EMR) revealed R55 was admitted to the facility on [DATE] with diagnoses of, but not limited to, cerebrovascular disease, mental disorder, and schizoaffective disorder/bipolar type. A review of the quarterly Minimum Data Set (MDS)…

  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 · Dcited before2025-03-19 · 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 observations, staff interviews, record reviews, and the review of the facility's policy titled Resident's Rights, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one of 36 sampled residents (R) (R6). Findings included: A review of the facility's policy titled Resident's Rights dated 5/30/2024 documented that the resident has the right to exercise his or her rights in the facility and as a citizen or resident of the United States. All residents have rights guaranteed to them under Federal and State laws and regulations. Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R6 had a Brief…

  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 before2025-03-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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, record review, interviews, and review of the facility's policies titled Cleaning and Disinfecting Residents' Rooms and 5-Steps to Room Cleaning, the facility failed to maintain a clean home-like environment for one of 24 rooms (room [ROOM NUMBER]) located on the East Wing. Findings included: A review of the facility's policy titled Cleaning and Disinfecting Residents' Rooms with the revision date of November 2020 revealed that the walls, blinds, and window curtains in residence areas will be cleaned when these surfaces are visibly contaminated or soiled. The staff will clean curtains, window blinds, and walls when they are visibly soiled or dusty. A review of the facility's policy titled 5-Steps to Room Cleaning revealed that the facility staff will spot clean walls daily using a clean rag, spot clean light switches, door handles, and walls. During observations on 3/10/2025 at 11:25 am, room [ROOM NUMBER] was observed with brown stains on the wall located to the left of the entrance.…

  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

$40,596 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $17,660 — penalty dated 2025-03-19
• $4,587 — penalty dated 2023-11-20
• $4,587 — penalty dated 2023-11-13
• $13,762 — penalty dated 2023-10-23
• Medicare payment denial — starting 2025-05-13 for 16 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 WELLINGTON HEALTH CARE SERVICES — 14 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 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

This home reported $561K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 GA