Clarion Wellness and Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

45.3% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.9% 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 22 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 0.46 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 76 beds and averages 63.6 residents a day — about 84% occupied, or roughly 12 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 2.83 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.52 hrs/resident/day on weekends vs 2.96 on weekdays — 15% thinner on weekends. RN hours go from 0.43 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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 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 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2024-10-17 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 clinical records review, staff interview, facility investigation review, and policy review, the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of 2 of 2 allegations of physical and verbal abuse within 24-hours of staff learning of the incidents. 1. On 3/20/24 around 11:30 PM, Resident #47 notified a Certified Nursing Aide (CNA) of alleged physical abuse. On 3/26/24 around 5:50 AM a Dietary Aide learned of Resident #47's allegation of physical abuse by a second CNA. No one reported the allegation of abuse until the Dietary Aide reported it to the Director of Nursing (DON) on 3/26/24 around 6:00 PM. The facility began their investigation of the alleged abuse on 3/26/24 and reported the incident to that evening at 10:08 PM. 2. On 6/16/24 around 11:30 PM a CNA documented they witnessed alleged verbal abuse towards Resident #316. The CNA reported the alleged verbal abuse to the DON on 6/20/24 around 3:30 PM. The DON called the DIAL abuse hotline on 6/20/24 around 3:40…

  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
• Immediate jeopardy · K2024-10-17 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 resident's record review, staff interviews, facility investigation review, time card detail, employee files, and policy review, the facility failed to separate staff members accused of alleged physical and verbal abuse from dependent residents in a timely manner for 2 of 2 residents reviewed (Residents #47 and #316). 1. Resident #47 reported an allegation of physical abuse on 3/20/24 to a Certified Nurse Aide (CNA). The CNA failed to report the allegation to Administration, which allowed the alleged abuser to work multiple days after the allegation. In addition, one dietary staff member learned of the allegation in the morning of 3/26/24, but failed to report the allegation until 5:00 PM that evening. This allowed the staff member to continue to work their entire shift on 3/26/24. 2. A CNA witnessed another CNA swear at a behavioral resident on 6/16/24. The CNA didn't report the incident to Administration until 6/20/24, their next scheduled day to work. Due to the lack of the CNA reporting the incident…

  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
• Immediate jeopardy · J2024-10-17 · 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, resident interviews, staff interviews, clinical record review, facility investigation, police report, and facility policy, the facility failed to provide a safe environment free from physical, verbal, and psychosocial abuse for 2 of 2 residents reviewed (Residents #47 and #316). 1. Despite Resident #47 reported alleged physical abuse on 3/20/24, the alleged abuser continued to work until the Director of Nursing (DON) learned of the allegations and started an investigation on 3/26/24. The facility allowed the alleged abuser to return to work on 4/3/24 and he continued to work at the facility. Resident #47 reported the alleged staff member on multiple occasions entered and stayed in her room alone. Resident #47's Care Plan updated on 3/28/24 instructed the alleged staff member to not enter her room alone. Interviews with CNAs revealed the alleged staff member often came in and out of Resident #47's room throughout the day. Observations revealed the alleged staff member entering and exiting…

  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
• Immediate jeopardy · Jcited before2024-10-17 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 clinic record review, staff interviews, resident interview, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #25 and #2) for significant medication errors. 1. The facility failed to provide Resident #25 their ordered Revlimid (anticancer medication that slows the progression of multiple myeloma and various types of cancer) from 4/25/24 to 6/5/24. 2. Resident #2 received medications not prescribed to her. Resident #2 received her roommates' medications (Resident #10) instead of her own. The facility reported a census of 61 residents. The State Agency informed the facility of the Immediate Jeopardy on 10/16/24 at 2:47 PM that began on 4/25/24. The facility staff removed the Immediate Jeopardy on 10/16/24 through the following actions: a. The facility educated all nurses and certified medication aides (CMAs) on following the physician orders policy on 10/16/24. As needed (PRN) staff members will…

  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 · Dcited before2025-11-25 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on clinical record review, staff interviews, and policy review, the facility failed to administer medications as ordered by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 61 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/6/25, listed a diagnosis for hypertension (high blood pressure). The Physician's Order dated 10/22/25 directed to change Resident #1's order for amlodipine from 5 milligrams (mg) daily to 2.5 mg two times daily to start on 10/23/25. The Electronic Medication Administration Record (EMAR) indicated Resident #1 received 2.5 mg two times daily from 10/23/25 to 10/26/25 and on the morning of 10/27/25. In addition, the facility held evening dose for 10/27/25. The Electronic Health Record (EHR) indicated on 10/27/25 Staff A, Certified Medication Aide (CMA), informed Staff B, Licensed Practical Nurse (LPN), the medication cart had amlodipine 5 mg daily, when it should have a dose of 2.5 mg two times a day. Staff B contacted and received an order to hold the evening dose and resume 2.5 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 · Dcited before2025-08-28 · 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 clinical record review, observations, staff interviews, and policy review the facility failed to implement care plan interventions to reduce the risk for falls for 1 out of 20 residents reviewed (Resident #19). The facility reported a census of 62 residents.Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #19 required substantial to maximal assistance with bed mobility and all transfers. The MDS included diagnoses of fractures and other multiple traumas, depression, chronic obstructive pulmonary disease (COPD), muscle weakness, wedge compression fracture of the second lumbar vertebrae (a type of spinal fracture where the front portion of the vertebrae in the lumbar area of the spine collapses, creating a wedge shape), COVID-19, cognitive communication deficits, limitation of activities due to disabilities, other reduced mobility and repeated falls.The Care…

  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 clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to provide adequate nursing supervision to prevent an accident and injuries for 1 of 1 resident reviewed (Resident #23) related to a suicide attempt. Resident #23 voiced he wanted to kill himself and had a plan on 5/17/25 (he attempted to use his fingernails to try to dig out a vein) and 5/18/25 (he placed a pen over his wrist and inner arm bend), the facility sent him to the emergency room (ER) on both dates. Upon return on 5/17/25 the facility implemented temporary one-to-one (1:1) supervision. The facility discontinued the supervision the same day around 9:30 PM without putting any further safety interventions in place. Resident #23 returned to the ER on [DATE] related to suicide ideation and gestures. The facility reported a census of 62 residents. Findings include:Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score 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
• Potential for harm · Dcited before2025-08-28 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 1 out of 1 resident reviewed (Resident #23) for significant medication errors. The facility reported a census of 62 residents. Findings include: Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #23 as independent with bed mobility, transfers. He required partial/moderate assistance with ambulation. The MDS included diagnoses of anxiety, depression, and schizophrenia.The Care Plan Focus revised 10/7/24 reflected Resident #23 took psychotropic medications (antipsychotic medication Haldol and Geodon) related to diagnoses of bipolar (frequent changes in mood), schizoaffective disorder (a mixture of mood and schizophrenic symptoms), and auditory hallucinations (hearing things not there). The Interventions directed staff to administer medications as…

  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 · D2025-08-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  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 clinical record review and staff interviews, the facility failed to have a complete and accurately documented medical record for 1 of 20 residents reviewed (Resident #23). The facility reported a census of 62 residents.Findings include: Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #23 as independent with bed mobility, transfers. He required partial/moderate assistance with ambulation. The MDS included diagnoses of anxiety, depression, and schizophrenia.A Physician order dated 4/9/24 directed staff to administer benztropine mesylate (Cogentin, medication to treat side effects of other drugs) 1 milligram (mg) at bedtime related to schizoaffective disorder, bipolar type.The Secured Conversations Note dated 5/10/25 at 8:33 PM indicated the nurse sent a message to the primary care physician (PCP) identified the facility didn't have Resident #23's Cogentin medication in…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 2 surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 areas of concern. The facility reported a census of 62 residents. Findings include: The survey identified a concern with infection prevention and control at the current recertification survey and during the last 2 recertification surveys: The undated facility Quality Assurance and Performance Improvement (QAPI) Plan documented the facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also included tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan, do,…

  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 · D2025-08-28 · tag F0868 — isolated
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — the official record, unedited, may be distressing

  Based on facility record review and staff interview, the facility failed to have the minimum required members present at their quarterly Quality Assessment and Performance Improvement (QAPI) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 62 residents. Findings include:The facility provide the list of sign-in sheets of the QAPI meetings. The review of the staff sign-in lacked documentation of the Infection Preventionist (IP) presence during the 2/18/25 meeting. An email from the Director of Nursing reflected all people who attended the QAPI meeting, signed the forms the day of the meet.During an interview on 8/28/25 at 9:05 AM the Administrator acknowledged the IP didn't sign the form to indicate attendance on the quarterly February 2025 QAPI meeting as expected. The Administrator added he planned to have QAPI meetings monthly instead of quarterly.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · 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 observation, record review and staff interview, the facility failed to provide wound care in a manner to prevent infection for 1 of 3 residents reviewed with wounds (Resident #3). The facility reported a census of 63 residents.Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental status (BIMS) score of 13, indicating no cognitive impairment. The MDS included diagnoses of diabetes, chronic obstructive pulmonary (lung) disease, and pressure ulcer of the sacral region.The Care Plan Focus dated 7/9/25 identified Resident #3 had an actual skin impairment of a pressure ulcer to her coccyx. The Care Plan identified Resident #3 had a risk for additional pressure ulcers. The Goals listed his ulcers would remain free from infection. The Care Plan Identified Resident #3 had a diabetic ulcer of the right front leg, with a secondary etiology (cause) of a venous (impaired blood flow of the veins) leg ulcer. The Goals indicated Resident #3 wouldn't have…

  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 · D2025-07-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, hospital record review, policy review, resident and staff interviews, the facility failed to provide care and services to promote healing of pressure wounds for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 56 residents.Finding include:The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue…

  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 before2025-07-09 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 interview, facility records review, staff interview, and policy review, the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #6 and #7) for 2 of 5 resident reviewed for call lights. The facility reported a census of 56 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The Census listed Resident #6 resided in private room [ROOM NUMBER]. On 7/8/25 at 3:23 PM, observed Resident #6's call light on. At 3:50 PM observed someone answer the call light. The observation revealed Resident #6 had his call light on for 27 minutes. On 7/9/25 at 8:36 AM, Resident #6 reported his call lights can be on for half an hour or more. He reported the long call lights happened a lot and was his biggest concern. Resident #6 reported he kept track of the call light times with his phone and his…

  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

“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

$24,174 in federal fines across 1 penalty.

• $24,174 — penalty dated 2024-10-17

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 THE ENSIGN GROUP — 342 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 23 rows in the source record cover these 18 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.

10 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 $610K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 IA