Henson Park Health & Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% 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.

Staffing

How full it usually is: this home is certified for 90 beds and averages 79.1 residents a day — about 88% occupied, or roughly 11 beds typically open. It runs fairly full. 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.75 hrs/resident/day on weekends vs 3.25 on weekdays — 15% thinner on weekends. RN hours go from 0.39 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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.

30 citations, most serious first. The 22 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. The facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. The facility's failure to ensure residents were protected from abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-21 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-21 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor 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 Resident's Advanced Directives, it was determined the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment, and to formulate an advanced directive for one (1) of twenty-five (25) sampled residents (Resident #10). Review of the resident's Advanced Directives revealed the resident had an Advanced Directive for Full Code on [DATE]. However, there was no evidence the Advanced Directive was updated to ensure accuracy. Review of Resident #10's admission Record revealed the facility admitted the resident on [DATE] with an Advanced Directive designated as Full Code. Further review revealed the resident's code status had changed on [DATE] to Do Not Resuscitate (DNR). However, review of the resident's Face Sheet revealed the facility failed to update the resident's code status to DNR on [DATE]. The facility transferred the resident to the hospital on [DATE] with a Full Code status and the resident was intubated and placed on a ventilator. The facility'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-29 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, it was determined the facility failed to ensure each resident's comprehensive care plan was developed and/or implemented for four (4) of twenty-five (25) sampled residents, (Residents #4, #9, #15, and #13). 1. Record review revealed Resident #4's care plan was not developed and/or implemented to ensure the resident was monitored related to his/her history of stroke and migraine headaches. 2. On 08/31/2023, at approximately 7:00 PM, Resident #9 attempted to exit the facility through the facility's front lobby door and was brought back inside the facility. However, facility staff did not implement Resident #9's care plan intervention for providing one-to-one (1:1) supervision as needed. Therefore, approximately an hour later, Resident #9 was able to exit the facility without staffs' knowledge. 3. Closed record review revealed Resident #15 sustained a femur fracture on 04/16/2022, after he/she rolled out of his/her low air loss mattress while only one…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise each resident's Comprehensive Person Centered Care Plan for two (2) of twenty-five (25) sampled residents (Resident #10 and Resident #14). 1. On 08/10/2022, the facility failed to revise Resident #10's Care Plan related to a new order to change the resident's code status to Do Not Resuscitate. Record review revealed the facility initiated a Comprehensive Care Plan on 06/29/2022 for a Full Code Advanced Directive. Continued review revealed on 08/10/2022, the resident's medical record included a signed and notarized Emergency Medical Services (EMS) Do Not Resuscitate (DNR) form. However, the facility failed to ensure the resident's Care Plan and Facesheet were revised to update the change in the resident's code status on 08/10/2022. Therefore, the facility transferred Resident #10 to the hospital on [DATE], as a Full Code. The resident was intubated and placed on a ventilator, which…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · 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, record review and facility policy review, it was determined the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that met each resident's physical, mental, and psychosocial needs for two (2) of twenty-five (25) sampled residents (Resident #4 and Resident #10). 1). On [DATE] at approximately 8:30 AM, the facility's Certified Nursing Assistants (CNAs) reported to Licensed Practical Nurse (LPN) #2 and LPN #3 that Resident #4 exhibited signs and symptoms of a stroke. The LPNs; however, failed to assess the resident immediately when staff reported to them the resident had a change in his/her condition. Subsequently, when LPN #2 arrived to Resident #4's room, approximately one-hour and a half (1 1/2) after staff notified the LPN of the resident's condition, the resident was found unresponsive. The resident was transferred to the Emergency Department (ED)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents received adequate supervision to prevent accidents for three (3) of twenty-five (25) sampled residents (Residents #9, #15, and Resident #14). 1. On 08/31/2023 at approximately 7:00 PM, Resident #9 exhibited exit-seeking behaviors and was witnessed attempting to exit the facility by staff. Staff responded to the alarm and assisted Resident #9 back into the facility; however, failed to increase the resident's supervision. Subsequently, Resident #9 followed closely behind the Social Service Director (SSD) and exited the facility without staff's knowledge. 2. On 04/16/2022, Resident #15 sustained a fracture to his/her femur after the resident rolled off of his/her low air loss mattress while only one (1) staff provided his/her care. The resident was care planned to require the extensive assistance of two (2) staff for bed mobility. 3. The 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-29 · 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, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #10). On [DATE], the facility admitted Resident #10 and on [DATE], Registered Nurse (RN) #4 discovered Resident #10's admission orders had been transcribed incorrectly. Therefore, Resident #10 was administered the wrong medications from [DATE] to [DATE]. The facility's failure to have an effective system to ensure residents were free of significant medication errors is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR §483.45 (F760) Pharmacy Services at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.45 (F760) Pharmacy Services. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and IJ is…

  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
• Immediate jeopardy · Jcited before2023-09-29 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to maintain clean and sanitary conditions in the facility's kitchen; failed to ensure proper setup of the three-compartment sink; and failed to not have personal items in the food handling area. This had the potential to affect all residents who received nutrition from the kitchen.Findings included: An initial tour of the kitchen was done on 07/15/2025 beginning at 9:20 AM with the Intern Dietary Manager (IDM) and revealed the following:-The floors of the walk-in refrigerator located inside the kitchen were sticky with a black substance on the floor. The IDM agreed the floors were dirty.-Debris and a black substance were visible on the kitchen floor between the dish station and the wall. The IDM agreed the floor was dirty.-Debris and a black substance were visible on the floor between the coffee station and the wall.-Personal sunglasses were observed on the second shelf of the cart that held the coffee, creamer, and sugar.-The tube light above the stove was observed covered with dust, and the light fixture had spots of…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 45 resident rooms had a homelike environment. Specifically, room [ROOM NUMBER] was observed with ceiling tiles bulging downward and with brown stains.Findings included: An observation on 07/16/2025 at 8:38 AM revealed ceiling tiles in room [ROOM NUMBER] were bulging downward, and other ceiling tiles were noted with brown stains. An observation on 07/17/2025 at 10:55 AM revealed ceiling tiles in room [ROOM NUMBER] were bulging downward, and other ceiling tiles were noted with brown stains. An additional ceiling tile in the bathroom of room [ROOM NUMBER] was also noted with brown stains. A facility document titled, Work Order #856, dated 04/29/2025, revealed staff reported that room [ROOM NUMBER] had one tile by the bathroom door that needed to be popped back up and one tile near the window had cracks. The Work Order indicated the Maintenance Director updated the status of the Work Order to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure supplemental oxygen tubing was dated when changed and the physician-prescribed supplemental oxygen flow rate was followed for 1 (Resident #1) of 2 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled, Oxygen Administration, revealed, 5. Turn on the oxygen at the number of liters / [per] minute as ordered by the physician/practitioner. 6. Place appropriate oxygen device on the resident (i.e., [id est, that is] mask, nasal cannula and/or nasal catheter). 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered. An admission Record indicated the facility admitted Resident #1 on 05/28/2025. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), chronic pulmonary edema, and obstructive sleep apnea. An admission Minimum Data Set (MDS), with an Assessment…

  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 · Fcited before2024-06-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, it was determined the facility failed to follow professional standards for proper sanitation practices and maintaining equipment to prevent cross contamination. Observation on 06/10/2024 revealed an ice scoop stored uncovered by an ice machine in the kitchen which is used to provide ice to all residents. Additionally, observations on 06/11/2024, revealed dietary staff towel drying plate covers which were then used to cover the residents lunch meal. The findings include: Review of the 2017 United States Food and Drug Administration Food Code Section 4-903.11 (B)(1) Equipment, Utensils, Linens, and Single-Service and Single-Use Articles revealed Clean Equipment and Utensils shall be stored in a self-draining positron that allows air drying. Further review of the food code revealed ice scoops may be stored handles up in an ice bin except for an ice machine. Observation during initial kitchen tour on 06/10/2024 at 3:20 PM revealed an ice scooper stored in an uncovered bin by the ice machine which was used for all residents. Observation during lunch…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-06-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility policy review and facility job descriptions review, it was determined the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for four of 46 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The findings include: Review of facility's policy titled Homelike Environment Guidance, revised 06/20/2024, revealed it was the policy of the facility to ensure the environment provided for residents was safe, sanitary, functional, and comfortable. Continued review of the facility policy revealed as part of daily guardian angel rounds, as well as, whenever it was noticed, institutional odors will be addressed and eliminated. Additionally, all room contents to include clothes, furniture, devices, linens, bedspreads, privacy curtains, window coverings, wall hangings, wallpaper, and floors should be clean and in good repair. Review of facility's housekeeping job description, undated, revealed…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-12 · tag F0727 — failed to provide required RN coverage — isolated
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, it was determined the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for four days (03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024) out of 104 days from 03/01/2024 through 06/12/2024. The findings include: During an interview with the Administrator on 06/12/2024 at 3:27 PM, she stated the facility did not have a staffing policy. Additionally, the Administrator stated the facility did not have an RN staffing waiver. Review of the facility's daily schedules dated 03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024, revealed the facility did not have a Registered Nurse (RN) scheduled to work on these dates. Review of the facility's timecards for all nursing staff, dated 03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024, revealed the facility did not have an RN working on those dates. During an interview with Certified Nursing Assistant (CNA) 1 on 06/11/2024 at 10:27 AM, he stated he was picking up more shifts in the facility due to either call ins or just short on staff. CNA1 stated he had noticed 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-06-12 · tag F0761 — failed to label and store drugs safely — isolated
  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

  Based on observation, interviews, and facility policy review it was determined the facility failed to implement procedures that address and monitor the safe storage and handling of medications for one of three medication storage refrigerators. Observation of the medication storage refrigerator on the A Hall on 06/11/2024 at 10:00 AM revealed the refrigerator was unplugged and the temperature inside the refrigerator registered at 62 degrees Fahrenheit (F). The findings include: Review of facility policy titled, Medication Storage in the Facility, revised 11/21/2022, revealed medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy stated medications shall be stored at temperatures between 36 degrees F and 46 degrees F. On 06/11/2024 at 10:00 AM, a review of the Medication Storage Refrigerator temperature log located on the A Hall revealed it was last…

  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 · D2024-06-12 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 35 sampled residents (R) R8. The findings include: Review of the facility's policy, titled Infection Prevention and Control Guideline, revised 02/25/2022, revealed it was the policy of the facility to ensure a comprehensive system was in place which prevents, identifies, investigates reports, records and controls infections and prevent the development and transmission of communicable disease processes for residents/care providers, staff, visitors, and others within the facility to include those providing contractual services in an effort to provide a safe, sanitary, and comfortable environment. Continue review of the facility policy revealed the facility would determine the most…

  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 · Dcited before2024-01-12 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure 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

  Based on observation, interview, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to provide or arrange for services or care that adhered to accepted standards of practice for three (3) of twenty-three (23) sampled residents (Residents #59, #14, and #58). The residents' nurse and/or Kentucky Medication Aide (KMA) dispensed the medications from the blister pack into their (nurse/KMA) ungloved hand and then into the medicine cup. The findings include: Review of the facility's policy, Policy and Procedure, Medication Administration, undated, outlined timeframes for medication administration. However, there was no information on medication distribution. Review of the facility's policy, Medication Administration Competency, dated 06/2011, revealed it provided instruction on dispensing of medication from blister packs into medication cup. However, it did not instruct staff on how to handle the medication and avoid using the bare hand. Review of the facility's document, Landmark-Clinical Standard and Guideline: Medication…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-10-21 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  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 review of the facility's policies, it was determined the facility failed to ensure the security and confidentiality of residents' medical records for two (2) of four (4) medication carts in the facility. Observation on [DATE] of Medication Cart #1 on the B Hall and on [DATE] of Medication Cart #2 on the B Hall revealed unattended computers were open with resident information displayed on the computer screen located on the cart. The findings include: Review of the facility's policy titled, Medical Records Health Insurance Portability and Accountability Act (HIPAA) Guideline, dated [DATE], revealed Personal Health Information (PHI) would be used and disclosed in accordance with the HIPAA Privacy Standards and other applicable laws. Further review revealed PHI included oral, written, or otherwise recorded information that was created or received by the facility and might relate to an individual's physical or mental health, payment, or health care services provided to 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$350,786 in federal fines across 16 penalties. 1 Medicare payment denial on record.

• $4,017 — penalty dated 2024-06-12
• $5,346 — penalty dated 2024-06-12
• $5,346 — penalty dated 2024-06-12
• $4,545 — penalty dated 2023-11-06
• $4,587 — penalty dated 2023-10-30
• $4,587 — penalty dated 2023-10-23
• $3,638 — penalty dated 2023-10-17
• $4,587 — penalty dated 2023-10-10
• $4,587 — penalty dated 2023-10-02
• $283,081 — penalty dated 2023-09-29
• $4,587 — penalty dated 2023-09-25
• $4,587 — penalty dated 2023-09-18
• $4,587 — penalty dated 2023-09-11
• $4,587 — penalty dated 2023-09-05
• $4,235 — penalty dated 2023-08-28
• $3,882 — penalty dated 2023-08-21
• Medicare payment denial — starting 2023-10-04 for 109 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 LYON HEALTHCARE — 11 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 30 rows in the source record cover these 23 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.

14 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.

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 KY