Karcher Post Acute
1127 Caldwell Blvd, Nampa, ID 83651 · For profit - Corporation · 66 certified beds · (208) 465-4935 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 4 actual-harm citations
- a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $41,603 in federal fines (most recent 2025-11-07)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.7% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.6% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 18.1% | 15.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.6% | 16.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 16.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 3.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 2.2% | 22.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.4% | 20.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.8% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 91.8% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.1% | 17.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.8% | 12.3% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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.
43.2% 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 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.4% 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 28 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.2%CMS range 33.6–51.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 7.7–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 25.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 21.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 2.9–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 66 beds and averages 55.0 residents a day — about 83% occupied, or roughly 11 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.56 hrs/resident/day on weekends vs 4.16 on weekdays — 14% thinner on weekends. RN hours go from 0.43 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
39 citations, most serious first. The 14 most serious are shown; the remaining 25 are one tap away and print in full.
- Actual harm · G2025-11-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 record review and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 3 residents (Resident #50) whose incidents during transferring were reviewed. This failure resulted in actual harm when Resident #50 was injured during a transfer from her bed to a wheelchair against her will. Findings include: The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM), Appendix PP, dated 7/23/25, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as defined in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including dementia, history of stroke, history of fractures, and age-related osteoporosis (a bone disease that causes bones to become weak, fragile,…
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.
- Actual harm · Gcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 the Long Term Care State Reporting Portal, Incident and Accident (I&A) report, record review and staff interview, it was determined the facility failed to provide an environment free from accidental hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents. This was true for 1 of 4 residents (Resident #36) reviewed for accidents. Resident #36 was harmed when a CNA failed to notify the nurse Resident #36 was using a heating pad. Resident #36 was found to have a burn at the hospital. Findings include: Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including surgical amputation of the left leg above the knee, diabetes, kidney disease, depression, anxiety, chronic pain symptom, and hypertensive heart disease without heart failure.An annual MDS Assessment, dated 7/16/25, documented Resident #36 was cognitively intact.Resident #36's medications included, but was not limited to:- Duloxetine (an…
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.
- Actual harm · G2025-04-04 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 of residents, resident representatives, and staff, and record review, it was determined the facility failed to ensure a resident's cultural/religious rights were honored. This was true for 1 of 1 resident (Resident #28) whose record was reviewed for resident rights. This failure resulted in psychosocial harm to Resident #28 when a certified nursing assistant (CNA) cut her hair without her consent. Findings include: Resident #28 was admitted to the facility on [DATE], for care following a stroke and had multiple diagnoses including chronic kidney disease and dementia. A facility incident report, dated 2/12/25, documented staff were pulling Resident #28's hair while brushing it, then cut her hair. The report documented CNA #1 stated Resident #28 was uncooperative with staff attempting to brush the knots out of her hair, and CNA #1 cut about an inch or inch and a half from Resident #28's hair. The report did not specify if Resident #28 was asked for her consent before CNA #1 cut her hair. On…
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.
- Actual harm · Gcited before2024-07-02 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure a resident's right to stay in the facility and the right to appeal the decision for a facility-initiated discharge. This was true for 1 of 3 residents (Resident #1) reviewed for facility-initiated discharges. This deficient practice caused Resident #1 to experience psychosocial harm when he was discharged to a motel without the ability to check his blood sugar and safely administer insulin. Findings include: The facility's Notice of Transfer or Discharge policy, dated 4/2020, documented the notice of transfer/discharge shall be made 30 days prior to transfer/discharge unless the health and/or safety of the resident or residents residing in this center are endangered. Appendix PP, State Operations Manual, states there may be rare situations, such as when a serious crime (e.g., attempted murder or rape) has occurred, that a facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-05-29 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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, review of the FDA Food Code, policy review, and staff interviews, it was determined the facility failed to ensure 3 of 3 dumpsters and 1 of 1 garbage can were properly closed to prevent attracting pests and rodents into the facility. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: The U.S. Food and Drug Administration 2022 Food Code, 5-501.115 (Outside Storage): Specifies that outside receptacles (like dumpsters) must be designed with tight-fitting lids, doors or covers that keep pests out and contain odors. The facility's policy titled, [NAME] Post Acute Trash and Dumpster Policy, undated, stated, all trash must be placed inside designated dumpsters. Do not leave trash on the ground. Close lids after use and do not overfill dumpsters. On 5/29/26 at 10:30 AM, three dumpsters and one outside garbage can were observed uncovered. [NAME] #1 stated, the dumpsters should be closed and the garbage can should be covered. On 5/29/26 at…
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.
- Potential for harm · E2026-05-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 5 of 16 residents (#16, #33, #37, #38, and #52) whose respiratory devices were not cleaned and stored properly and 2 of 16 residents (#22 and #38) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen. Findings include: The facility's policy, titled Oxygen Administration, revised 10/2010, documented the purpose of the procedure is to provide guidelines for safe oxygen administration. Under the section titled, Preparation, 1. documented, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including…
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.
- Potential for harm · Ecited before2026-05-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, FDA Food Code review, resident and staff interviews, it was determined the facility failed to appropriately store, distribute and label foods. This deficient practice had the potential to affect all residents who received food prepared in the facility. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food borne illnesses. Findings include: 1. The FDA Food Code, Section 3-501.19, titled, Time as a Public Health Control, stated, once a Time/Temperature Control for Safety (TCS) food is removed from temperature control (the kitchen steam table or refrigeration), it must be consumed or discarded within 4 hours. Leaving a tray in a residents room for hours violates professional standards for food safety and distribution. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including heart failure (a chronic condition where the heart muscle doesn't pump blood as effectively as it should)…
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.
- Potential for harm · D2026-05-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 1 resident (Resident #16) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished self-worth. Findings include: The facility's Dignity policy revised February 2021, documented staff were expected to promote dignity by helping residents to keep urinary bag covered.Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including neuromuscular dysfunction of the bladder and paraplegia (the partial or complete loss of motor and sensory function in the lower half of the body typically caused by spinal cord injury or disease).On 5/26/26 at 12:45 PM and 5/27/26 at 1:16 PM, Resident #16 was observed sitting in his wheelchair outside the Assisted Dining Room with his urinary bag containing urine uncovered.On 5/26/26 at 1:18 PM, the DON who…
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.
- Potential for harm · D2026-05-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 review of the State Operations Manual (SOM), record review, and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 3 residents (Resident #33) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include:The State Operation Manual (SOM), Appendix PP, defined an Advance Directive is a written instruction such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event…
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.
- Potential for harm · Dcited before2026-05-29 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 policy review, record review, review of the facility grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #6) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon. Findings include:The facility's Grievance policy and procedure revised March 2019 documented concerns/grievances may be presented verbally or in writing. The policy also documented grievance should be completed with appropriate actions and follow-up. The Social Service Director/Designee should:-assist concerned resident(s), resident representative, other family members(s), or advocated that have issues or concerns to complete a Grievance/Concern Form. If the person with concern does not want to complete a Grievance Form, any format should be accepted.-log all concerns/grievances received onto 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.
- Potential for harm · D2026-05-29 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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, staff interview, policy and record review, it was determined the facility failed to ensure a seatbelt was assessed as potential restraints and a consent from the residents and/or their representatives was obtained. This was true for 1 of 1 resident (Resident #6) reviewed for potential restraint. This deficient practice had the potential for harm if the seatbelt were improperly used. Findings include: The facility's Use of Restraints policy revised April 2017, documented prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms. The policy also stated restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Resident #6 was admitted to 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.
- Potential for harm · D2026-05-29 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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, it was determined the facility failed to ensure residents were appropriately monitored for side effects of anti anxiety medication. This was true for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. This failure created the potential for inappropriate pharmacological interventions and adverse outcomes, including oversedation. Findings include:Resident #9 was admitted on [DATE] with multiple diagnoses including dementia with behavioral disturbances, history of falls, and anxiety.A review of Resident #9's care plan showed no documentation of monitoring for anti anxiety medication side effects, despite the resident's diagnosis of anxiety and use of anti anxiety medication.A physician order dated 3/16/26 documented: Anti anxiety medication: monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior.A review of Resident #9's TAR for anti anxiety side effect monitoring from 3/16/26 through 5/26/26 documented only a check mark…
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.
- Potential for harm · D2026-05-29 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 interviews, it was determined the facility failed to ensure the required discharge process was followed when residents were transferred to a higher level of care. This was true for 2 of 2 residents (#6 and #16 ) reviewed for hospital discharge process. This failure created the potential for incomplete information of transfers, delay in care, and lack of required notifications. Findings include: 1.Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dependence on supplemental oxygen, chronic pain, and major depressive disorder. a. A nursing progress note dated 4/18/26 at 10:42 PM documented, Resident #16 was found unresponsive to verbal and physical stimulation. The LN documented Resident #6's oxygen saturation at 70% (normal 95–100%) and noted respiratory distress with snoring and gasping respirations. The LN called 911, and Resident #6 was transported to a higher level of care. A review of Resident #16's record showed no documentation that 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.
- Potential for harm · D2026-05-29 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was completed when new mental health diagnoses were identified for 1 or 4 residents (Resident #4), whose records were reviewed for PASRR screenings. This failure created the potential for harm if the resident required but did not receive specialized services for mental health while residing in the facility. Findings include:Appendix PP of the State Operations Manual, revised 7/23/25, documented any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including aphasia (inability to communicate verbally), hemiplegia and hemiparesis (paralysis and weakness on one side 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.
Show the remaining 25 citations
- Potential for harm · D2026-05-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, it was determined the facility failed to ensure PASRR screening for serious mental illness, intellectual disability, or related conditions were completed accurately. This was true for 2 of 4 residents (#22 and #44) whose PASRR records were reviewed. This failure placed Resident #22 at risk for harm if their needs went unmet when a diagnosis of serious mental illness was omitted from their PASRR level 1, and placed Resident #44 at risk for harm when a new PASRR level 1 was not completed. Findings include: 1. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, depression, and chronic respiratory failure. Resident #22's record documented a PASRR level 1 dated 5/14/26. The PASRR level 1 documented Resident #22 did not have any major mental illnesses, such as bipolar disorder. On 5/28/26 at 2:22 PM, the ADON stated Resident #22's PASRR level 1 from 5/14/26 was not accurate and should have been corrected upon her admission.…
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.
- Potential for harm · Dcited before2026-05-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 policy review, record review, and staff interviews, it was determined the facility failed to ensure residents were provided with a comprehensive, person centered care plan as required. This was true for 2 of 17 residents (Residents #5 and #6) reviewed for care plans. Comprehensive, person centered care plans are essential for identifying resident needs, directing staff actions, and ensuring coordinated care. This deficient practice created the potential for unidentified or unmet care needs. Findings include:The facility's policy titled Care Plans, Comprehensive Person Centered, revised 3/22, documented: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 1. Resident #5 was admitted on [DATE], with diagnoses including unspecified psychosis, depression, and insomnia. A Comprehensive MDS assessment dated [DATE] documented, under Section…
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.
- Potential for harm · D2026-05-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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, the National Council of State Boards of Nursing (NCSBN) website, and staff interview, it was determined the facility failed to ensure physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 2 residents (Resident #2) whose physician orders were reviewed. This deficient practice created the potential for harm if residents were to receive oral medications when they were ordered to receive nothing by mouth. Findings include:According to the NCSBN website, accessed 6/4/26, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. The facility's policy, titled Administering Medications, stated, medications are administered in a safe and timely manner, and as prescribed. Section 10 stated, the individual administering medications checks the label three times to verify the right resident, right medication, right dosage, right time and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, policy review, and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #2) reviewed for enteral feeding. This failure created the potential for adverse outcomes when Resident #2's physician orders were not followed for enteral flush and medication administration. Findings include: The facility's policy titled Enteral Feeding Tubes, reviewed 4/2022 stated, it is the policy of this center that residents receiving enteral tube feedings receive appropriate treatment and services to prevent complications. It further stated under Water Flush/Administration, the licensed nurse administers water flushes per physician order using lukewarm or room temperature water. If physicians orders are not specified, the recommendations are as follows:A. 15-30 cc pre/post medication administration.B. 5-10 mL prior to individual medication administration. Resident #2 was admitted to the facility on [DATE], with multiple…
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.
- Potential for harm · D2026-05-29 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and performance reviews. This was true for 1 of 3 CNAs reviewed for skills and qualifications. This failure created the potential to affect resident safety by limiting staff competency in providing care. Findings include:On 5/29/26 at 12:57 PM, a request was made for CNA education records and performance reviews.On 5/29/26 at 1:50 PM, the Administrator stated that 1 of 3 CNAs did not have documentation of the required 12 hours of annual training or a performance review.
- Potential for harm · D2026-05-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure resident records accurately reflected active medical diagnoses. This was true for 1 of 17 residents (Resident #5) reviewed for accuracy of records. This failure created the potential for miscommunication and unmet or unidentified care needs. Findings include:Resident #5 was admitted on [DATE], with multiple diagnoses, including unspecified psychosis, depression, and insomnia.A physician progress note dated 4/30/26 at 8:00 AM documented, Resident #5 had an active diagnosis of generalized anxiety disorder.A review of Resident #5's record showed generalized anxiety disorder was not listed as an active diagnosis in the resident's medical record.On 5/29/26 at 10:03 AM, the ADON stated Resident #5's record did not include generalized anxiety disorder as an active diagnosis and confirmed the record would be updated to reflect the physician's documented diagnosis.
- Potential for harm · D2026-05-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 policy review, record review, and staff interview, it was determined the facility failed to ensure immunizations were offered and/or provided as indicated. This was true for 1 of 5 residents (Resident #4) reviewed for pneumococcal immunization. This deficient practice placed residents at risk of developing pneumococcal pneumonia and developing serious, potentially life-threatening complications. Findings include:The CDC webpage titled, Pneumococcal Vaccination accessed on 6/1/26, documented there are two types of pneumococcal vaccines. They are Pneumococcal conjugated vaccines (PCV) and Pneumococcal polysaccharide vaccine. The CDC recommended pneumococcal vaccination for:-All adults 50 years or older.-Adults 10 through [AGE] years old with certain risk conditions.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including aphasia, hemiplegia, and hemiparesis affecting right dominant side following a stroke.Resident #4's Immunization Information, documented he refused to receive…
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.
- Potential for harm · Ecited before2025-11-07 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 record review, review of Incidents and Accidents (I&A's) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 8 of 8 residents (#4, #5, #6, #7, #8, #9, #10, and #11) reviewed for medication errors. Resident #4 was harmed after being administered her roommate's opioid pain medication and required medical intervention. Resident #5 was harmed when her narcotic medication was omitted resulting in increased pain. There was potential for harm and adverse outcomes when Residents #6, #7, #8, #9, #10, and #11's medications were not administered following physicians' orders. Findings include:The online Nursing 2025 Drug Handbook accessed on 11/10/25, stated the eight rights of medication administration were: - Right drug- Right patient- Right dose- Right time- Right route- Right reason- Right response- Right documentation 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including…
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.
- Potential for harm · Dcited before2025-09-03 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's missing property was investigated and prompt corrective action was taken. This was true for 1 of 3 residents (Resident #28) whose missing items were reviewed. This failure created the potential for psychological harm if residents' missing items were not investigated. Findings include:The facility's Grievances/Complaints, Recording and Investigating policy, revised April 2017 documented all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s).Resident #28 was admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including stroke, cancer of right retina (part of the eye) and dementia.A care plan dated 8/29/24, documented Lost glass eye, MD (physician) recommended to leave out.A care plan dated 2/28/24, documented Resident #28 had history of cancer to her right eye and it was removed.…
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.
- Potential for harm · D2025-04-04 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to report alleged verbal abuse to the State Survey Agency within 5 days. This was true for 1 of 6 residents (Resident #11) reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: Resident #11 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes and morbid obesity. Resident #11's admission MDS assessment, dated 9/15/24, documented Resident #6 was cognitively intact. The Grievance Logs from October 2024 to April 2025 were reviewed. A grievance, dated 10/18/24, documented Resident #11 felt publicly shamed by the dietitian in front of other residents when the dietitian asked about her ordering habits such as chicken fried steak and other high-calorie items. When Resident #11…
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.
- Potential for harm · D2025-04-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 record review, review of facility Grievance Logs, and staff interview, it was determined the facility failed to ensure allegations of verbal abuse were thoroughly investigated for 1 of 6 residents (Resident #11) reviewed for abuse. This failure created the potential for Resident #11 to be subjected to ongoing abuse without detection and intervention. Findings include: Resident #11 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes and morbid obesity. Resident #11's admission MDS assessment, dated 9/15/24, documented Resident #11 was cognitively intact. A review of Grievance Logs from October 2024 to April 2025, included a grievance, dated 10/18/24. The grievance documented Resident #11 was publicly shamed by the dietitian in the lobby area while other residents were present. The dietitian asked Resident #11 about her ordering habits such as chicken fried steak and other high-calorie items. When Resident #11 responded about the weight she had lost, the dietitian…
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.
- Potential for harm · D2025-04-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents' MDS documented correct assessment information. This was true for 2 of 14 residents (#16 and #30) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/24, documented if a PASARR (Preadmission Screening and Resident Review) level II determined a resident has a serious mental illness, then section A1500 of the MDS should be marked yes. 1. Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with the diagnosis of bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and activity levels, oscillating between periods of mania and depression, significantly impacting daily functioning). Resident #16's medical record documented a PASARR level II, dated…
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.
- Potential for harm · Dcited before2025-04-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interviews of residents, resident representatives, and staff, and record review, it was determined the facility failed to ensure a resident's cultural/religious preferences were included in their care plan. This was true for 1 of 14 residents (Resident #28) whose care plans were reviewed. This failure placed Resident #28 at risk for their religious rights not being honored. Findings include: Resident #28 was admitted to the facility on [DATE] for care following a stroke, and had multiple diagnoses including chronic kidney disease and dementia. On 4/3/25 at 5:00 PM, Resident #28 stated, I don't cut my hair, my hair came from Jesus. Resident #28's representative added Resident #28 chooses not to cut her hair for religious reasons and she informed the facility of this on the day of her admission. Resident #28's care plan, dated 11/24/24, documented she required assistance to complete her daily hygiene tasks, such as bathing and caring for her hair. Resident #28's care plan did not document her preference…
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.
- Potential for harm · D2025-04-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents and their representatives were provided the opportunity to participate in care planning and attend care conferences. This was true for 1 of 14 residents (Resident #27) whose care plans were reviewed. This placed resident #27 at risk for adverse outcomes if care and services were not provided due to care plans not being reviewed and revised as the resident's needs changed. Findings include. The Facility's Care Conference policy, dated February 2019, documented, Care conferences will be scheduled with the resident and/or resident representative to review care plan goals and interventions. Care Conferences will be held upon admission, quarterly and with any significant change in conjunction with MDS Assessment. Review of the care plan with the resident and/or resident representative shall be documented in the EHR [Electronic Health Record]. Resident #27 was admitted to the facility on [DATE], 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.
- Potential for harm · Dcited before2025-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 reviews of incident reports and medical records, and staff interviews, it was determined the facility failed to implement interventions to reduce residents' risk of accidents. This was true for 1 of 4 residents (Resident #20) reviewed for accidents. This failure resulted in Resident #20 experiencing a fall when her soft touch call light was not available for use. Findings include: Resident #20 was admitted on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, and encounter for palliative care. A facility accident report, dated 1/17/25, documented facility staff found Resident #20 on her right side, on the floor next to her bed. She was assessed by a nurse and no injuries were found. The report concluded that Resident #20 attempted to transfer herself without assistance, and the facility implemented [the] use of [a] soft pad call light as [an] intervention to prevent falls in [the] future. A care plan intervention, revised on 1/22/25, instructed staff to keep a soft touch call light…
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.
- Potential for harm · D2025-04-04 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a resident was free from duplicate pain medication therapy without clear parameters for administration. This was true for 1 of 6 residents (Resident #9) whose records were reviewed for unnecessary medications. This failure created the potential for harm and adverse effects if Resident #9 was to receive inappropriate opioid medication. Findings include: Resident #9 was re-admitted to the facility on [DATE] with multiple diagnoses including dementia, fibromyalgia, and chronic pain syndrome. Resident #9's electronic health record (HER) documented the following medications ordered by her physician on 3/24/25: -acetaminophen (an analgesic) oral tablet 500 mg, give 1 tablet by mouth, every 6 hours, as needed for pain -hydrocodone-acetaminophen (an opioid analgesic) oral tablet 5-325 mg, give 1 tablet by mouth, every 6 hours, as needed for hip pain related to chronic pain syndrome -Tramadol (an opioid) HCL oral tablet 50 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.
- Potential for harm · Dcited before2025-04-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 record review, review of facility's policy and procedure, review of Incidents and Accidents reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 2 of 2 residents (#11 and #16) reviewed for medication errors. Findings include: The facility's Medication Administration policy, dated January 2023, documented: Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. Verify medication is correct three times before administering the medication: 1. When pulling medication packages from the medication cart, 2. When dose is prepared, and 3. Before dose is administered. Residents are identified before medication is administered using at least two resident identifiers: 1. Check identification band, 2. Check photograph attached to medical record,…
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.
- Potential for harm · D2025-04-04 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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 observation, resident interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure food was served at an appropriate temperature. This affected 1 of 4 residents (Resident #40) who were reviewed for dietary concerns. This failed practice created the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: On 3/31/25 at 3:11 PM, Resident #40 stated, I eat my meals in my room. The food is not warm when I get it. On 4/3/25 at 12:55 PM, a lunch meal test tray was evaluated by three surveyors and the Registered Dietitian. The main dish of taco salad (lettuce, ground beef, kidney beans, cheese) had an internal temperature of 85-degrees Fahrenheit. The side of cooked beans had an internal temperature of 113-degrees Fahrenheit. The yogurt had an internal temperature of 52-degrees Fahrenheit, and the custard dessert had an internal temperature of 57-degrees Fahrenheit. The dietitian confirmed the food had been placed incorrectly in the food cart where the cold side of the tray was placed on…
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.
- Potential for harm · Dcited before2025-04-04 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained, cleaned, and sanitized. These deficiencies had the potential to affect the 54 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: 1. FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. On 3/31/25 at 8:30 AM, and 4/4/25 at 9:56 AM, a layer of dark brown dust was observed coating the pan drying rack, and a darker brown coating of dirt was observed in the corner of the walk-in freezer. On 4/4/25 at 10:10 AM, the Dietary Manager (DM) stated the pan drying rack was dusty and should have been cleaned. She also…
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.
- Potential for harm · Ecited before2024-01-26 · tag F0622 — patternNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital for 3 of 3 residents (#2, #7, and #41) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's policy, Notice of Transfer or Discharge, dated 4/2020, stated when the center transfers or discharges a resident, the center documents the transfer or discharge in the medical record and appropriate information is communicated to the receiving care institute or provider. As a minimum the following information is provided: - Contact information of the practitioner responsible for the care if [sic] the resident. - Resident representative information, including contact information. - Advance Directive information. - Special instructions or precautions for ongoing 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.
- Potential for harm · E2024-01-26 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 3 of 3 residents (#2, #7 and #41) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed Hold (when a healthcare center holds a bed for a resident when he/she is hospitalized and /or goes on therapeutic leave) policy, reviewed March 2019, directed staff to provide the resident or resident representative a copy of the bed hold policy upon transfer or discharge. 1. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including heart failure and chronic respiratory failure with hypoxia (low level of oxygen in the body tissues). A nursing progress note, dated 11/10/23…
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.
- Potential for harm · Ecited before2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and staff interview, the facility failed to ensure food was stored, labeled, and food served in a sanitary manner in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 53 residents residing in the facility who consumed food prepared by the facility at risk for contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: During the kitchen tour on 1/22/24 at 7:20 AM with the Dietary Manager, the following observations were made. 1. Food items without a use-by date or expired use-by date: - On a metal cart was a bottle of blended season oil without an open date and oil running down the side of the bottle along with a bottle of soy sauce without open date. - On the shelf above the food preparation table was a container of whole celery seeds spice with a use by date of 6/15/22, a container of powdered onion with a use by date of 7/29/23, a container of spice and herb seasoning with a use by date of 11/15/22, and curry powder with a use by date of 1/23/22. On…
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.
- Potential for harm · Dcited before2024-01-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 13 residents (#28, and #41) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include: 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low oxygen levels in the body tissues). A physician's order, dated 1/19/24, included an order for Resident #28 to receive oxygen continuously at 6 liters/minute. Resident #28's care plan did not document she was using oxygen. On 1/22/24 at 11:13 AM and 1/24/24 at 9:54 AM, Resident #28 was observed receiving oxygen at 6 liters/minute via nasal cannula. On 1/24/24 at 9:58 AM, the Regional Support Nurse reviewed Resident #28's care plan and stated her oxygen was not…
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.
- Potential for harm · Dcited before2024-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, policy review, record review and resident and staff interview, it was determined the facility failed to ensure a resident was assessed quarterly to determine if they were safe to smoke cigarettes for 1 of 1 resident (Resident #39). This failure created the potential for negative outcomes if Resident #39 was not assessed for safe smoking. Finding include: The facility's Smoking policy, revised 3/2020, stated residents who smoke are reevaluated at least quarterly. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including kidney disease and nicotine dependence. A Smoking Safety Evaluation dated 8/2/23, documented Resident #39 was safe to smoke with supervision. Resident #39's comprehensive care plan, initiated 4/11/23, did not identify his smoking or smoking interventions. On 1/22/24 at 9:26 AM, Resident #39 stated he smoked 2-3 cigarettes about once a day. He stated cigarettes were kept in the medication cart. A lighter and 8 packs of cigarettes were observed 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.
- Potential for harm · D2024-01-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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, it was determined the facility failed to ensure residents receiving a psychoactive medication had resident-specific target behaviors identified and monitored. This was true for 1 of 5 residents (Resident #41) reviewed for psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include: Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including depression and anxiety. A physician's order, dated 11/29/23, documented Resident #41 was to receive sertraline (antidepressant) HCL 100 mg, one tablet once a day, for his depression. Resident #41's care plan, did not document he was taking a psychoactive medication and what specific target behavior he manifested for depression. On 1/24/24 at 10:13 AM, the SSD reviewed Resident #41's record, and stated Resident #41 was on sertraline. She…
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.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$41,603 in federal fines across 4 penalties.
- $10,549 — penalty dated 2025-11-07
- $10,546 — penalty dated 2025-09-03
- $11,190 — penalty dated 2025-04-04
- $9,318 — penalty dated 2024-07-02
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 PACS GROUP — 274 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.9 | -1.9 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
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
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MURRAY, JASON | Individual | INDIRECT OWNERSHIP INTEREST | since 09/01/2024 |
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 08/27/2025 |
| JERGENSEN, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 09/01/2024 |
| MITCHELL, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 09/01/2024 |
| ALLEN, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| GRAVES, BRYE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/30/2024 |
| MCBRIDE, RACE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/03/2025 |
| NAMPA 1127 REALTY, LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
| NEXT SADDLE REALTY LLC | Organization | ADP OF THE SNF | since 06/01/2024 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 09/01/2024 |
CMS files one row per role, so the 15 rows in the source record cover these 10 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.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $832K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 ID
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Idaho Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 135110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.