Michaelsen Health Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

56.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 341 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 38.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 178 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 99 beds and averages 70.5 residents a day — about 71% occupied, or roughly 28 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 4.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above 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 4.20 hrs/resident/day on weekends vs 4.60 on weekdays — 9% thinner on weekends. RN hours go from 1.80 to 1.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2026-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure a resident's arms were positioned safely outside the sling during a transfer using a sit-to-stand mechanical lift. This failure resulted in the resident falling through the sling, sustaining a head injury that required five staples. This applies to 1 of 4 residents (R2) reviewed for mechanical lift transfer safety. The findings include:R2's face sheet documents diagnoses of dementia, anemia, major depressive disorder, degenerative disc disease, gastro-esophageal reflux disorder, history of falling, cognitive communication deficit and dysphagia. R2's MDS (Minimum Data Sheet) dated 3/6/26 documents R2 has severe cognitive impairment, requires substantial/maximal assist with transfers, is frequently incontinent with bladder, and is always incontinent of bowel. On 4/9/26 at 9:30 AM, V5 (RN-Registered Nurse) said on 3/22/26 at approximately 10:00 AM, she responded to V4's (CNA- Certified Nurse Assistant) call for help. V5 said she saw R2 was lying on her right side on the floor in her room. V5 said she saw a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely and comprehensive pain and physical assessment after a fall. This delay resulted in R1 experiencing untreated prolonged pain for five hours from a fracture after a fall and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for fall-related incidents. The findings include: The Electronic Medical Record (EMR) showed that R1, an [AGE] year-old resident, had an extensive medical history, including but not limited to: B-cell lymphoma with lymph node metastasis, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below-knee amputation, chronic kidney disease, anemia, frontal temporal neurocognitive disorder, urinary reflux, phantom limb pain, anxiety, hyperlipidemia, osteoarthritis, Barrette's esophagus, benign prostatic hypertrophy, carotid artery disease, hypomagnesemia, cholecystitis, acute…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs. The findings include: R1's Face Sheet dated 4/2/25 shows R1 was admitted to the facility on [DATE] with a diagnosis of osteitis deformans of other bones (chronic condition affecting bone structure). R1's MDS dated [DATE] shows R1 requires substantial/maximal assistance to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This same MDS also shows R1 is always incontinent of bowel and bladder. R1's Clinical Notes dated 3/13/25 at 6:58 AM show the following excerpt, While…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-20 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow policy on Contact Isolation on a resident with known history of Clostridium Difficile. The facility also failed to follow policy on EBP (Enhanced Barrier Protection). This applies to 16 of 16 residents (R4, R5, R8, R9, R16, R21, R39, R43, R48, R59, R64, R72, R73, R82, R95, R96) reviewed for Infection Control in the sample size of 20.The findings include: 1. On 02/17/26 at 3:00 PM, R4 did not have an EBP (Enhanced Barrier Precaution) or a contact isolation sign on the door or the wall outside of the room. There was no PPE (Personal Protective Equipment) bin outside of the room. On 02/18/26 at 11:37 AM, R4 continued to not have any signage on the door or wall outside of the room before entering for EBP or contact isolation. On 02/17/26 at 11:05 AM, V22 (RN/Registered Nurse) was in the room with R4. V22 was not wearing PPE while in the room. On 02/17/26 at 11:06 AM, V22 stated R4 was not on isolation but was receiving Vancomycin for…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-20 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure 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

  Based on observation, interview, and record review, the facility failed to ensure resident medication regimens remain free from unnecessary medications.This applies to 1 resident (R81) reviewed for medication regimen in a sample of 20 residents. Findings include:On 2/18/26 R81's POS (Physician Order Sheet) was noted to show the following active orders:Triamcinolone acetonide 0.1% topical ointment two times daily for fungal dermatitis start date 9/17/25. No stop date.Miconazole nitrate 2% topical cream daily for groin fungus start date start date 5/27/25. No stop date.R81's MAR (Medication Administration Record) was reviewed from May of 2025 through February 2026 and showed R81 had been receiving both topical ointments since their start dates, as ordered. Triamcinolone steroid ointment was given for 5 consecutive months, twice daily. Miconazole antifungal cream was given for 9 consecutive months, daily.On 2/20/26 at 10:46 AM, V7 (LPN/Licensed Practical Nurse) said R81's groin redness has been present on and off and is related to R81's hygiene. V7 said he has administered both…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-18 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's emergency contact representative regarding a fall incident. The failure to notify placed the resident at risk for compromised advocacy and potentially delayed medical decision making. This applies to 1 of 3 (R1) residents reviewed for notification of significant medical change. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old with extensive diagnoses that included B cell lymphoma with metastasis to lymph nodes, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below knee amputee, chronic kidney disease, anemia, frontal temporal neuro cognitive disorder, urinary reflux, phantom limb syndrome with pain, anxiety, hyperlipidemia, osteoarthritis, Barrette's esophagus, benign prostate hypertrophy, carotid artery disease, hypomagnesemia, cholecystitis, acute kidney…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-12-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who require assistance from staff for ADLs. This applies to 4 of 4 residents (R11, R46, R52, R60) reviewed for ADLs in a sample of 23. The findings include: 1. On 12/17/24 at 12:02 PM, R52 was observed in her bed and a mat was on the floor next to her bed and her lunch plate and dessert cup was on her over the bedside table out of her reach. On the plate was mashed potatoes and a scoop of a brown substance. There was also a cup of a pureed brown substance in a dessert cup. None of the food had been touched. At 12:23 PM, R52 was observed in her bed, her food was still on her over the bedside table out of reach untouched, and R52 said she was hungry. At 01:03 PM, R52 was still in her bed, her lunch was still out of reach on her over the bedside table and R52 again said that she was hungry. The plate of food was still full and untouched. The surveyor then left R52's room and stood next to R52's door and at 01:04 PM V5 (Kitchen staff) went into R52's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-12-20 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were safely and securely stored. This applies to 4 of 4 residents (R61, R68, R137, R139) reviewed for medications in a sample size of 23. The findings include: 1. On 12/17/24 at 12:05 PM, R61 was not in her room. On two of her end tables in her room, the following medications were noted: Baush and [NAME] soothe lubricant eye drops, Equate Ultra Strength pain relieving cream which contained (camphor, menthol, methyl salicylate), Refresh plus lubricant eye drops, Gas-x simethicone 125 MG (Milligrams) anti-gas soft gels, extra strength gas relief simethicone 125 MG chewable tablets, and Lidotral 3.88% cream (Lidocaine HCL). On 12/19/24 at 1:50 PM, surveyor went back to her room. The medications were still in her room. R61 stated the medications are always kept in her room. V3 (R61's sister) stated that she brought all those medications for R61 from home and the pharmacy. She stated that R61 has pain and spasms in her legs…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-12-20 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygeine and handled and transported soiled linen in a sanitary manner, and ensure visitors were educated on isolation practices. This applies to 6 of 6 residents (R50, R21, R56, R52, R58, R188) reviewed for infection control in a sample of 23. Findings include: 1. On 12/17/24 at 12:33 PM, during a dining observation, V4 CNA (Certified Nurse's Assistant) was observed feeding R21, touching her peanut butter and jelly sandwich and giving R21 a spoonful of strawberry ice-cream. Then V4 went to R56's table and began feeding R56. V4 did not clean her hands after feeding R21 her food. Then V4 went back to R21's table and was feeding R21 and feeding R50. V4 was using her same hand she used to feed R56, and she never cleaned her hands after she finished feeding R56. V4 continued feeding R21, R56, and R50 their entire lunches and never stopped to clean her hands in between assisting each resident. On 12/19/24 at 01:30…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-20 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide care with dignity to 3 of 3 residents (R21, R56, and R50) reviewed for resident rights in a sample of 23. The findings include: On 12/17/24 at 12:33 PM, during a dining observation, V4 CNA (Certified Nurse's Assistant) was observed standing over R21 while feeding R21 her lunch. Then V4 moved to a nearby table and stood over R56 and began feeding R56. Then after giving R56 a few spoons of food, V4 returned to the first table and stood between R21 and R50, feeding both. This was done for the entire lunch for R21, R56, and R50. On 12/19/24 at 01:30 PM, V2 DON (Director of Nursing) said that the staff should be sitting next to the residents while feeding them for dignity and home life environment. R50's 11/10/24 MDS (Minimum Data Set) showed his mental cognition is severely impaired and he needs partial/moderate assistance from staff for eating. R56's 10/25/24 MDS showed that her cognition is severely impaired and she needs partial/moderate assistance from staff for eating. R21's 9/30/24 MDS showed that…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview the facility failed to ensure a resident's mattress fit the bedframe to prevent injury. This applies to 1 of 6 residents (R334) reviewed for accidents in a sample of 23. Findings include: R334 has diagnoses that include streptococcal sepsis, urinary tract infection, atrial fibrillation, pulmonary embolism, heart failure, spinal stenosis, history of transient ischemic attack, history of cerebral infarction, abnormalities of gait and mobility and unsteadiness on feet. R334's current care plan includes at risk for falls related to history of falls, impaired mobility, impaired balance / gait, psychotropic and cardiac meds, sensory impairment and cognitive impairment. R334's care plan also includes problem related to skin integrity. On 12/17/24 at 11:56 AM, R334 was observed lying in bed. Approximately eight inches of the metal bed frame was exposed on the right side of the bed. On 12/17/24 at 01:23 PM, V13 CNA (Certified Nursing Assistant) stated informed the nurse on 12/16/24 of R334's exposed bed frame. On 12/17/24 at 01:30 PM, V14 RN (Registered…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-20 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were addressed. This applies to 2 of 5 residents (R21 and R51) reviewed for medication review in a sample of 23. The findings include: On 12/19/24 at 10:44 AM, surveyor requested V2 (DON--Director of Nursing) to provide all the pharmacy monthly medication reviews for R21 and R51 as well as physician responses to pharmacy recommendations from March 2024 to the current date. On 12/19/24 at 03:24 PM, V2 stated he did not have any monthly pharmacy regimen reviews to provide. V2 stated it is his responsibility to submit the pharmacy reviews to the physician for review but he has been behind. V2 stated the process is for pharmacy to email him the recommendations. He is supposed to place the recommendations in a binder for the physician to sign off on, and the physician leaves the addressed recommendations in the binder for him to follow up on. V2 stated documentation for R21 and R51 was not available. The facility policy Medication Utilization and Prescribing- Clinical Protocol dated April…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-20 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transcribe physician medication orders upon admission, which caused a resident to miss her significant medications for four days. This applies to 1 of 3 residents (R135) reviewed for significant medication errors in a sample of 23. Findings Include: On 12/17/2024 at 5:53 PM, V20 (R135's family member) said Eliquis (a blood thinner) and Atorvastatin medications were on R135's admission/transfer form and didn't know why it was not prescribed. V20 said R135 missed a total of eight doses, and the doctor should have been notified. V20 said R135 is [AGE] years old and has atrial fibrillation, mitral valve prolapse, and heart conditions with a pacemaker, and the missing Eliquis could have caused severe conditions. On 12/19/24 11:40 AM, R135 said the faicility failed to give her the Eliquis and cholesterol medication. R135 said something happened when they were transferring the information. She said because she didn't receive the Eliquis, she felt very tired.…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$9,110 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $9,110 — penalty dated 2025-04-03
• Medicare payment denial — starting 2025-04-25 for 3 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COVENANT LIVING — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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.

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