Sanford Senior Care Sheldon

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.

Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% 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 70 beds and averages 43.2 residents a day — about 62% occupied, or roughly 27 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.59 on weekdays — 15% thinner on weekends. RN hours go from 0.65 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above 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 unchanged from the previous inspection. 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.

21 citations, most serious first. The 14 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · J2025-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and family interviews, the facility failed to complete accurate assessments and implement interventions for a resident to prevent the development of a Stage 4 pressure sore for 1 of 3 residents reviewed (Resident #1). Certified Nursing Assistant (CNA) staff identified a reddened area on a resident's coccyx in [DATE] and reported it to nursing staff. The record lacked assessments of the area, notification to the physician and treatment orders. On [DATE] an open area on the coccyx was identified and measured 1cm x1 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] the open area to the coccyx measured 1cm x 0.8 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] Resident #1 was admitted to the ER with a diagnosis of sacral decubitus ulcer, stage 4. The resident expired on [DATE] the Death Certificate…

  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
• Immediate jeopardy · Kcited before2024-02-01 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 observation, clinical record review, resident and staff interviews, the facility failed to appropriately perform assessments and interventions for the necessary care and services to maintain the residents' highest practical physical well- being for 5 out of 45 residents reviewed with signs and symptoms of COVID-19 (Residents #2, #3, #4,#5 and #6). Records showed 3 residents required hospitalization after emergency room (ER) visits, (Residents #2, #4 and #5). The failure to assess and test for COVID when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 4:49 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents with respiratory infection symptoms will be evaluated by the charge nurse. B. Any resident exhibiting any signs of symptoms of respiratory…

  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
• Immediate jeopardy · Kcited before2024-02-01 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses by failure to test and isolate residents with respiratory signs and symptoms for 5 out of 45 residents reviewed (Residents #2, #3, #4, #5 and #6). Records showed three residents required hospitalization after emergency room (ER) visits, ( Residents #2, #4 and #5). The failure to test for COVID and isolate when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 5:09 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents who exhibit signs or symptoms of respiratory infection will be immediately evaluated by the charge nurse and isolated in their room in transmission-based precautions under…

  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
• Immediate jeopardy · J2023-06-29 · 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 interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #18). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 9:30 a.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A staff member is to monitor the door at all times until the Wanderguard servicing agent arrives to assess the system. Maintenance also increased the distance for alarm to activate to 8 feet instead of 6 1/2 feet that it was previously set at. Increased to 10 feet on [DATE]. Maglock installation completed to the doors on [DATE]. Added an alarm speaker closer to the Nurse's Station. 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-06-01 · 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

  Based on observation, infection control policy and staff interview the facility failed perform proper hand hygiene during toileting for 1 of 3 residents observed (Resident #2) The facility reported a total census of 42 residents.Findings include:Observation on 6/1/26 at 10:48 a.m., with Staff A, Certified Nursing Assistant (CNA) and Staff B, Licensed Practical Nurse (LPN) assisting Resident #2 to the bathroom. Staff A applied gloves with no hand hygiene prior to applying gloves after assisting the resident to sit on the toilet. Staff A then touched her hair and pulled up her own pants with gloves on and proceeded to lean her hand on the mechanical lift. Staff A picked up the wet wipes package and laid it within reach of the toilet. Staff A then with the soiled gloves on touched the residents incontinent brief she was wearing and with the soiled gloves on adjusted the residents shirt. Staff A with the soiled gloves still on again touched the lift and pulled out 3 wet wipes and rested her right hand on the lift with the soiled gloves still on. Staff B raised the mechanical lift with…

  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 · D2026-03-05 · tag F0609 — failed to report abuse allegations — isolated
  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 record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse within 2 hours of an allegation of abuse for 1 of 5 residents reviewed for abuse (Resident #1). The facility staff removed the deficiency prior to the surveyor entering the facility on March 4, 2026 through the following actions:On 12/18/25 the facility placed education related to no cell phones in resident care areas, and if staff see or hear anything that could be suspected abuse or neglect or an infringement of resident dignity on the scheduling app for all staff. On 12/19/25 the facility implemented all staff receive education on resident dignity, photography, abuse or suspected abuse reporting, abuse definitions and follow up quiz for understanding. The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of depression, hypertension and psychomotor defect…

  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 · Past Non-Compliance
• Potential for harm · E2025-11-06 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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, clinical record reviews, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and care plans for 5 of 9 residents (Resident #4, #9, #30, #117 and #217) reviewed. The facility failed to prepare and serve 5 meals according to the residents' prescribed diet orders. The facility reported a census of 46 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. The document revealed the resident received a mechanically altered diet during the last 7 days of the assessment period. The resident's Care Plan contained a problem area dated 10/15/25 of receiving a mechanically altered diet related to dysphagia. The approach dated 10/15/25 revealed a Level 6 Soft and Bite Sized Diet with moist meat or gravy/mildly thick liquid and no straws. The resident's diet order…

  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 · E2025-11-06 · 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 observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards by not practicing accepted hygiene practices. The facility reported a census of 46 residents. Findings include: During a continuous observation on 10/4/25 beginning at 11:42 AM Staff A, Dietary Aide, and Staff B, Dietary Aide, began the meal service. Staff A left the kitchenette area and moved into the main dining room. Staff B requested Staff A's assistance in the kitchenette preparing 3 special request meals. Staff A entered the kitchenette, went to the stove top and initiated making scrambled eggs. The staff did not complete hand hygiene upon entry into the kitchenette. The staff cracked the eggs and proceeded to don a single glove on the left (L) hand. With the gloved L hand Staff A opened the bread wrapper, removed the bread and placed it in the toaster. The staff continued to monitor scrambled eggs until complete, transferred the eggs to the plate, carried the plate with the L gloved hand, placed a cover over the food,…

  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 · Dcited before2025-11-06 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to notify the physician and the resident's representative of a significant weight loss for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #11 had long and short term memory problem, and severely impaired cognitive skills for daily decision making. The resident required supervision or touching assist with eating. The resident's diagnoses included non-Alzheimer's dementia. The resident weighed 125# and did not have a weight loss of 5% or more in a month, or 10% or more in 6 months. The Care Plan dated 10/15/25 identified the resident at nutritional risk related to dementia. The weight record documented the resident weighed: a. 129 on 9/2/25, b. 125.4 on 9/16/25, c. 120.7 on 10/7/25, a 6.4% loss, (5% in 1 month is significant). d. 117.5 on 10/14/25, e. 116.9 at 10/21/25, a 9.4% loss in 50 days, (7.5% in 90 days, and 10%…

  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 before2025-11-06 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, the facility failed to update a resident's care plan with an intervention to prevent further falls for 1 of 2 residents reviewed with falls (Resident #4). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated 7/325, Resident #4 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident demonstrated independence in ambulation. The resident required set up assist with transfers. The resident's diagnoses included cerebral infarction or stroke. The Care Plan with a start date of 4/17/25 identified the resident at risk for falling related to weakness and use of medications. Interventions included encouraging the resident to assume a standing position slowly, ensuring the resident wore eyeglasses, giving the resident verbal reminders not to ambulate/transfer without assistance, keeping in lowest position with brakes locked, keeping the call light in reach at all times, keeping personal items and frequently used items within…

  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 · D2025-11-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure a resident received services to maintain or improve Range of Motion (ROM) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had no limitation in functional Range of Motion (ROM) of the upper or lower extremities. The resident's diagnoses included cerebral infarction or stroke. According to the MDS assessment dated [DATE], Resident #4 scored 9 on the BIMS indicating moderate cognitive impairment. The resident had limitation in functional ROM of both upper extremities. The clinical record lacked documentation the facility consulted the physician about the noted declines for a therapy evaluation. The Care Plan dated 4/17/25 identified Resident #4's limited ability to transfer herself…

  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 · D2025-11-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident received dietary supplements as planned to maintain or increase weight for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #11 had long and short term memory problem, and severely impaired cognitive skills for daily decision making. The resident required supervision or touching assist with eating. The resident's diagnoses included non-Alzheimer's dementia. The resident weighed 125# and did not have a weight loss of 5% or more in a month, or 10% or more in 6 months. The Care Plan dated 10/15/25 identified the resident at nutritional risk related to dementia. The interventions included a regular diet with boost supplementation 3 times a day (TID). The weight record documented the resident weighed: a. 129 on 9/2/25, b. 125.4 on 9/16/25, c. 120.7 on 10/7/25, a 6.4% loss, (5% in 1 month is significant).…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and physician interview, the facility failed to notify the physician and family of significant weight loss for 2 of 3 residents reviewed (Resident #14 and #27) and for 1 resident with a choking incident (Resident #27). The facility reported a census of 49 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #14 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident fed herself. The resident had diagnoses including gastroesophageal reflux disease, diabetes, non-Alzheimer's dementia, anxiety and depression. The resident had a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months, and was not on a physician prescribed weight loss regimen. The clinical record lacked documentation the physician or resident representative were notified of the significant weight loss. On 10/2/24 at 11:15 AM the Dietician stated when a resident had a significant weight loss…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-03 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to notify the long term care (LTC) Ombudsman of resident hospitalizations for 2 residents reviewed (Resident #4 and #8). The facility reported a census of 49 residents. Findings include: 1) The Resident Census page showed Resident #4 was hospitalized [DATE] and returned 5/29/24, 7/21/24 and returned 7/25/24, and 8/19/24 and returned 8/27/24. The monthly Transfers/Discharges forms provided by the facility for ombudsman notification, lacked the resident's transfers to the hospital. 2) The Resident Census page showed Resident #8 was hospitalized [DATE] and returned 8/18/24. The monthly Transfers/Discharges forms provided by the facility for ombudsman notification, lacked the resident's transfer to the hospital. On 10/3/24 at 9:05 a.m. the Social Worker stated she did not include transfers to the hospital on the monthly notification to the ombudsman. She was not instructed to include those. The facility Ombudsman policy dated 12/6/23 included the…

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

  Resident Rights Deficiencies · Deficient, Provider has 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

$11,872 in federal fines across 1 penalty.

• $11,872 — penalty dated 2024-02-01

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.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in IA