Fifth Avenue Health Care

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.1% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 45.2% 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 31 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 100 beds and averages 68.7 residents a day — about 69% occupied, or roughly 31 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.93 hrs/resident/day on weekends vs 3.34 on weekdays — 12% thinner on weekends. RN hours go from 0.22 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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.

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.

18 citations, most serious first. The 13 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-06-23 · 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, staff and resident interviews, record review, and review of the facility policies titled Accidents and Incidents - Investigating and Reporting, Elopement, and Dementia Care, the facility failed to maintain an accident-free environment and provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). This had the potential to affect at least 10 additional residents identified as being at risk for wandering/elopement. Specifically, the facility failed to implement effective interventions to prevent the elopement of R1, creating an ongoing risk for resident elopement and injury. This deficient practice placed residents at risk for serious harm, injury, and death. On 6/16/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 6/16/2026 at 2:53 pm, the Administrator and Director of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-21 · 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, interviews, and record reviews, the facility failed to provide an environment free from accident hazards for one of six residents (R)(R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, peripheral vascular disease, chronic pain, vascular dementia, anxiety, Alzheimer's Disease, morbid (severe) obesity, muscle weakness, and age-related osteoporosis. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed that staff was unable…

  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 before2024-06-21 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working 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 interviews and record reviews, the facility failed to ensure that resident care equipment was maintained in safe operating condition for one of six residents (R) (R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, Alzheimer's Disease, and morbid (severe) obesity. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that staff was not able to conduct the Brief Interview for Mental Status (BIMS) assessment for R1 due to the resident being rarely or never understood and 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-23 · 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

  Based on interviews, record review, and review of the facility policy titled Policy and Procedure Abuse, Neglect, and Exploitation, the facility failed to keep one of three sampled residents (R) (R10) free of sexual abuse by another resident, R11. This failure had the potential to cause physical and psychosocial harm to R10. Findings included:A review of the facility policy titled Policy and Procedure Abuse, Neglect, and Exploitation with a revised date of 9/17/2025, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. It is noted that sexual abuse is non-consensual sexual contact of any type with a resident. Prevention of Abuse, Neglect, and Exploitation: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may…

  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 · D2026-06-23 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 policy titled Medication Administration-General Guidelines, the facility failed to ensure accurate administration of medications for three of 32 medication opportunities observed, resulting in a medication error rate of 9.37%. This deficient practice had the potential to negatively impact residents (R), leading to complications of their current health status. Findings included:During an observation on 6/22/2026 at 8:40 am, Licensed Practical Nurse (LPN) WW revealed medication administration discrepancies for R14 and R13.* LPN WW administered One Daily Multivitamin with Minerals, which did not match the ordered medication. A review of the electronic medical record (EMR) revealed that R14 had a physician order for Multiple Vitamin tablet, give 1 tablet by mouth one time daily for weight loss.* LPN WW administered an Aspirin 81 milligrams (mg) chewable tablet, which was not the ordered dosage form. A review of the EMR revealed that R13 had a physician order for Aspirin EC (enteric-coated) 81 mg…

  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 · F2025-08-28 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interviews, and review of the facility policy titled, Preparing Pureed Foods, the facility failed to prepare pureed food in a manner that preserved the nutrient value of resident meals. The deficient practice had the potential to affect 15 of 15 residents receiving an oral pureed diet.Findings include:A review of the facility policy titled Preparing Pureed Foods last revised March 2024 revealed under Procedure: 1. Prepare food following the recipe for the regular textured foods. Pureed food should have the same flavor as their regular texture counterpart.Review of the recipe for Pureed Spaghetti Noodles dated March 2024 revealed instructions were:1. Place spaghetti noodles in a food processor.2. Add 2% (percent) white milk and butter or margarine and process until smooth.3. Add thickener and process briefly until mixed.Observation and interview on 9/27/2025 at 9:30 am with Head [NAME] (HC) AA revealed that HC AA filled a plastic pitcher with an unmeasured amount of water. She then placed a serving of spaghetti noodles for each resident on the puree…

  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 · Fcited before2025-08-28 · 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, interviews, and a review of the facility policy titled Food Storage Guidelines, the facility failed to discard food items past the best-by date. This deficient practice had the potential to affect 66 of 66 residents receiving an oral diet.Findings include:Review of facility policy titled Food Storage Guidelines last revised August 2017 revealed under Procedure: .2. Discard will be up to the expiration and/or Used By Date on the Product.Observation on 8/26/2025 at 10:00 am of the walk-in cooler revealed a box containing one open bag of bacon with a best by date of 8/23/2025. Continued observation of the walk-in cooler revealed a rolling cart containing six 240 ml (milliliter) boxes of whole milk, which had a best by date of August 2025.Observation on 8/26/2025 at 10:10 am of the dry food storage revealed three 14 ounce boxes of thickened cranberry cocktail juice with a best by date of July 2025.During an interview on 8/26/2025 at 10:01 am, the DM confirmed the opened box of bacon had a best by date of 8/23/2025, the six boxes of whole milk had a best by date of…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-28 · tag F0880 — failed to prevent and control infections — widespread
  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, and review of the facility policies titled, Legionella Water Management Program and Handwashing/ Hand Hygiene, the facility failed to develop an effective water management program and failed to perform hand hygiene or wash hands when entering and exiting resident rooms when serving lunch trays. The deficient practice of not developing an effective water management program had the potential to affect the health and safety of all residents that reside in the facility and failing to perform hand hygiene or hand washing to affect 64 residents who received a food tray from the kitchen. The facility census was 66 residents.Findings include: Review of facility's undated policy titled Handwashing/ Hand Hygiene with a revised date of February 2021 revealed under Policy Statement: The facility considers hand hygiene to be the primary means of preventing the spread of infection. Under Policy Interpretation and Implementation: .2. All personnel shall follow the handwashing/hand…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of facility policy titled, Medication Administration, the facility failed to assess one of 41 sampled residents (R) (R12) for self-administration of medication. The deficient practice had the potential to result in negative outcomes such as medication errors, incorrect dosages, or access by other residents. Findings include: Review of the facility's policy titled Medication Administration indicated under Preparation and General Guidelines: .B. Administration.14. Residents are allowed to self-administer medication when specifically authorized by attending physician and in accordance with procedures for self-administration of medication.A review of the electronic health record (EHR) for R12 revealed the resident was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, type 2 diabetes mellitus, ischemic heart disease, and heart…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · 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, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to maintain a safe, clean, comfortable, homelike environment in two of 25 rooms on East Hall (room [ROOM NUMBER] and room [ROOM NUMBER]) and free of black substance in one of 34 rooms on [NAME] Hall (room [ROOM NUMBER]). Specifically, ceiling tiles were stained with brown and black marks. The deficient practice had the potential to compromise the hygiene and safety of the room environments, negatively impacting the health and well-being of residents.Findings include: 1. Observation on 8/26/2025 at 10:58 am and 8/27/2025 at 3:46 pm of room [ROOM NUMBER] revealed brown stains on ceiling tiles above the bed and above the window. Observation on 8/26/2025 at 10:35 am and 8/27/2025 at 3:45 pm of room [ROOM NUMBER] revealed brown stains on ceiling tile above the bed. Interview and observation on 8/28/2025 at 11:24 am with the Maintenance Director of room [ROOM NUMBER] and room [ROOM NUMBER]…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · 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 observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plan, the facility failed to develop and implement a comprehensive care plan for eye glasses and tobacco use for one of four residents (R) (R50) care plans reviewed. The deficient practice had the potential for unmet care needs for R50.Findings include:Review of the facility policy titled Comprehensive Care Plan revised January 2021 revealed under Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.Review of R50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R50 had moderate cognitive impairment. Section B (Hearing, Speech, and Vision) revealed R50 had impaired vision.Review of R50's care plan indicated a focus…

  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 · Dcited before2025-08-28 · 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, resident and staff interviews, and record review, the facility failed to protect one of 41 sampled residents (R) (R28) from an accident with a fall. Specifically, R28 fell from a wheelchair to the floor.Findings include:Review of the electronic medical record (EMR) revealed resident R28 was admitted to the facility with diagnoses including but not limited to history of falling, acquired absence of right leg below knee, contracture, left ankle, other long term (current) drug therapy, and other reduced mobility.Review of R28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R28 is moderate cognitively impaired. Section GG (Functional Status) revealed R28 requires extensive assistance for activities of daily living (ADLs) with two or more-person assistance with transfers. Mobility not rated.Review of R28's care plan dated 6/27/2025 indicated a focus of R28 has potential for injury and is at risk for…

  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 · D2024-06-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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, and record review, the facility failed to provide the necessary care and services to maintain good oral hygiene for one of 31 sampled residents (R) (R55) reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to provide the resident with oral hygiene supplies, staff assistance, and/or reminders to complete oral hygiene care. Findings included: A review of the electronic medical record (EMR) revealed that R55 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to dementia with behavioral disturbance, metabolic encephalopathy, and Alzheimer's disease with late onset. A review of R55's annual Minimum Data Set (MDS) assessment, dated 5/21/2024, revealed R55 presented with a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) of the assessment indicated R55 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

“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

$8,512 in federal fines across 2 penalties.

• $4,256 — penalty dated 2024-06-21
• $4,256 — penalty dated 2024-06-21

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 RELIABLE HEALTH CARE MANAGEMENT — 6 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 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in GA