Clifton Heights

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 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 110 beds and averages 91.8 residents a day — about 83% occupied, or roughly 18 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.28 hrs/resident/day on weekends vs 3.75 on weekdays — 12% thinner on weekends. RN hours go from 0.77 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 79% is well above the national median of 45%. 1 administrator has left in the past year.

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.

35 citations, most serious first. The 20 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · J2025-11-22 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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, interview, and review of the facility's policies, it was determined the facility failed to ensure an effective pain management regimen, based on a thorough assessment and a person-centered care plan, was implemented for 1 of 11 sampled residents receiving scheduled pain medications (Resident (R) 1). The facility failed to administer pain medication as ordered to R1, who had a history of chronic pain and required multiple daily doses of a potent opioid analgesic. The failure created ongoing, severe pain, and R1 also experienced withdrawal symptoms which he described as, The only way the pain was going away was if I died.The findings include:Review of the facility's policy titled Pain Management, dated [DATE], revealed the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy states that, in order to help 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
• Immediate jeopardy · K2023-08-11 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for six (6) out of thirty-nine (39) sampled residents. (Resident #7, Resident #4, Resident #70, Resident #15, Resident #89, and Resident 46). 1. The facility failed to protect Resident #7 from abuse. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. The facility, however, failed to protect the resident from abuse and continued to allow the staff member to work, gaining access to the resident to potentially abuse the resident further. Subsequently, on 07/26/2023, Resident #7 reported to the facility staff allegations of sexual abuse when Certified Nursing Assistant (CNA) #24, would come into his/her shower room while he/she was undressed, which made him/her feel uncomfortable and harassed. 2. On 07/24/2023, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-08-11 · tag F0835 — failed to run the facility competently — pattern
  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

  Based on interview, record review, review of the facility's policies, documents, Job Descriptions, and Plan of Correction (PoC) submitted for the 06/10/2023 and 09/13/2021 it was determined the facility failed to have an effective system to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the facility's Standard Recertification and Abbreviated Plan of Correction (POC) for the 06/11/2023 survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) failure to report allegations of abuse to State Agencies. During an Abbreviated/Partial Extended Survey initiated on 07/12/2023, the State Survey Agency (SSA) identified continued non-compliance in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) on 07/29/2023. The facility's Administration failed to report an allegation received on 07/20/2023 of sexual abuse of a resident by a Certified Nursing Assistant…

  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 · K2023-08-11 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, review of the Administrator's Job Description, review of the Statement of Deficiencies (SoD) submitted for the 06/11/2023 and the Plan of Correction (POC) submitted for the 09/17/2021 survey and review of the facility's policy, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure they developed, implemented, and maintained an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. The facility was aware of potential allegations of abuse; however, failed to report to the State Survey Agency (SSA); conduct thorough investigations; develop and implement policies; monitor and audit identified non-compliance; and ensure the QAPI program comprehensively developed, implemented, and monitored its plan to ensure effectiveness in addressing repeat noncompliance and allegations of abuse to maintain substantial…

  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 · J2023-08-11 · 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 interview, record review, 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, ensuring staff reported without fear of retaliation, 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 thirty-nine (39) sampled residents, Resident #7. Review of the facility's Alleged Abuse Incident Nursing Description Note, dated 07/20/2023, revealed an anonymous call was received by the Executive Director (ED) during which the caller reported a relationship involving texting and sending inappropriate pictures via text messages to a resident (Resident #7) by a facility staff Certified Nurse Aide (CNA #24). Interview with Resident #7 and with facility staff revealed they were afraid to report allegations of abuse, out of fear of retaliation. Therefore, the allegation of sexual abuse 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-08-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure allegations of sexual and physical abuse were reported to State Agencies and local law authorities immediately, but no later than two (2) hours after the allegations were made for two (2) of thirty-nine (39) sampled residents ( Residents #7 and #1). 1. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. Review of the facility's documentation; however, revealed the facility failed to notify/report the allegations of potential abuse to the state agencies and law enforcement, to protect its resident, even though staff had been trained on abuse to include reporting requirements. 2. On 12/10/2022 Resident #1 ran into the hallway yelling help me, she is hitting me. However, LPN #11 failed to report the allegation as abuse. The facility's failure 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-08-11 · 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 interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, that would meet the resident's physical, mental, and psychosocial needs for one (1) of thirty-eight (38) sampled residents (Resident #48). On 05/29/2023, Resident #48 was found by the driver of a transportation company seated in the lobby of the facility in his/her wheelchair, alone and unresponsive. The driver of the transportation company attempted to locate the facility staff but was unable to locate staff to assist the resident, and he attempted to call the facility several times and no one answered the phone. Subsequently, the driver of the transportation company drove the resident to his/her dialysis appointment, which was approximately eight (8) minutes away from the facility. Once the resident arrived at the dialysis clinic, the transportation driver alerted the dialysis staff to assist…

  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 · Jcited before2023-06-11 · 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 observation, interview, record review, review of the facility's policies and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for four (4) of twenty-four (24) sampled residents (Residents #160, #310, #359, and #161). 1. Resident #160 expressed to staff his/her desire to be discharged home and he/she was anxious about his/her upcoming court hearing. The resident reported his/her concerns to staff on [DATE]; the week of [DATE], and on [DATE]; however, the facility failed to develop the resident's individualized person-centered care plan to include adequate supervision and monitoring. Therefore, on [DATE], the resident exited his/her window, climbed on a table with a chair stacked on top of the table and climbed across the facility's six (6) foot fence. The facility was unaware of the resident's whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes. 2. Review of Resident #310's Comprehensive Care…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-06-11 · 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 observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for three (3) of twenty-four (24) sampled residents (Residents #160, #161, and #359). 1. On 04/22/2022 at approximately 12:30 AM, Resident #160 exited the facility through his/her window without staff's knowledge. The facility was unaware of Resident #160's whereabouts until a local shelter notified staff by telephone on 04/23/2022 at 11:15 AM of the resident's location. The resident was last seen on 04/21/2022 at 10:30 PM by Licensed Practical Nurse (LPN) #13, who checked his/her blood sugar and administered insulin as ordered at that time. Review of the local weather for 04/22/2022, per historical data, showed a low temperature of fifty-nine (59) degrees Fahrenheit with high temperature around…

  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 · G2025-11-22 · tag F0776 — isolated
  Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
  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, interview, and review of the facility's policies, it was determined the facility failed to ensure that 1 of 11 (Resident (R)1) sampled residents received diagnostic x-ray services in a timely manner, which created a delay in reporting any abnormal results to the physician and/or Nurse Practitioner, who had ordered the x-ray. After R1 sustained a fall, the facility failed to ensure that the resident received necessary follow-up, including implementation of physician orders for bilateral lower extremity (BLE) X-rays. R1 reported having severe leg pain and displayed swelling, changes in condition, and was eventually found to have a displaced tibia and fibula fracture that remained undiagnosed for approximately three days after his fall. R1 ultimately required surgery and 10 days of hospitalization in response. The findings include:Review of the facility's policy titled Verbal Orders, revised 02/14/2024, revealed that Physician orders may be received by telephone, by a licensed nurse or other…

  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 · E2025-12-04 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain a sanitary and safe physical environment to help prevent the presence of pests within resident care areas. interviews and observations during survey revealed concerns with the presence of pests.The findings include:Review of facility policy, Pest Control Program, implemented, 02/01/2024, revealed a local contractor provided preventative treatment monthly and as needed. Further review revealed the most recent treatment provided by the contractor was on 09/19/2025. Observations revealed insect/pest activity/residue in resident rooms and/or resident care areas during environmental rounds. Evidence of ongoing pest (insect) presence observed with pest residue recurring in reports noted upon re-entry after prior treatment last documented pest control entry 09/18/2025.Observations during survey, on 09/18/2025 at approximately 9:00AM and 09/19/2025, approximately 9:00 AM revealed insect carcasses (appeared to be cockroaches) in 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · 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, and record review, the facility failed to ensure that a resident requiring tracheotomy care received treatment and services in accordance with professional standards of practice, the resident's care plan, and facility policy. The failure had the potential to result in respiratory complications, infections, and compromised airway safety for 1 of 3 sampled residents, Resident(R)32.The findings include:Review of facility policy, Tracheostomy Care Education, dated 2013, revealed tracheostomy care is the process of aseptically cleaning the tracheostomy tube and stoma site. Additionally, the policy indicated to follow relevant infection control procedures as appropriate.Review of facility record revealed the facility admitted R32 on 05/16/2025 with diagnoses including tracheostomy status, epilepsy unspecified, dysphagia, gastrostomy status. The facility assessed R32 on 06/14/2025 with a Brief Interview for Mental Status (BIMS) score of 5, indicating impaired cognition. During observation of tracheostomy care on 10/02/2025 at approximately 11:06 AM for R32,…

  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 · E2023-08-11 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 there was a system in place to prevent the diversion of the resident's-controlled drugs for eight (8) out of thirty-nine (39) sampled residents (Resident #6, Resident #11, Resident #10, Resident #16, Resident #21, Resident #23, Resident #25, and Resident #42). On 05/24/2023, the Narcotic count at 3:00 PM revealed Resident #6 was missing five (5) Gabapentin; Resident #11 was missing one (1) Gabapentin; and Resident #10 was missing one (1) Tramadol. The facility's investigation determined the Licensed Practical Nurse (LPN) #13 had signed out too many pills that could not be accounted for. On 07/12/2022 Residents #16, #21, #23, #25, and #42 had Hydrocodone that was signed out by Licensed Practical Nurse (LPN) #14. Record review revealed the LPN documented the residents received their medications. However, review of the facility's investigation revealed the residents stated they did not 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-08-11 · 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 interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident had communication with and access to persons and services inside and outside the facility for one (1) out of thirty-nine (39) sampled residents, Resident #48. On 05/29/2023 the transport driver arrived at the facility to pick up Resident #48 for transport to the Dialysis Center and found Resident #48 alone in the lobby and unable to answer the phone to allow the driver into the facility. The driver attempted to call the facility several times and no one answered the phone to let the driver in. The driver stated he had to wait several minutes outside the facility until a staff member reporting for their shift arrived and opened the door so he could transport Resident #48 to the Dialysis Center. In addition, Resident #48 arrived to the Dialysis Center unresponsive the Dialysis Center attempted to call the facility several times to communicate a change in Resident #48's condition upon arrival to the center. The first time a call was attempted, the center…

  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 before2023-08-11 · 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 observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for two (2) out of thirty-nine (39) sampled residents (Residents #12 and Resident #74). 1. On the 06/11/2023 Standard Extended/Recertification/ Abbreviated Survey, Immediate Jeopardy was identified in the area of 42 CFR 483.25 Quality of Care ( F689). The State Survey Agency (SSA) exited the facility with Immediate Jeopardy (IJ) onging. The SSA concluded the first (1st) revisit, to remove the IJ, on 06/29/2023 and the facility had implemented corrective actions to remove the IJ, prior to the SSA exit. On 08/11/2023, the SSA concluded the Abbreviated Survey and found continued non-compliance related to complaint number, KY #39861 with Resident #74, in the area of F689. The complaint was identified as…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-06-11 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 policy review, it was determined the facility failed to ensure a safe, clean, comfortable, and homelike environment. Observations of the linen storage revealed linens were not available to provide resident grooming, hygiene, and a comfortable bed for five (5) of twenty-four (24) sampled residents (Residents #6, #14, #25, #53 and #78). Observation of residents' pillows on their beds were not in good condition. The pillows were covered with a pillowcase, but the condition of the pillows exposed the resident to the potential unsanitary environment as the barrier on the pillowcase was no longer intact. The facility failed to ensure the residents were provided the necessary linens to provide for proper grooming, hygiene, and clean, sanitary, and comfortable beds. The findings include: Review of Resident #65's admission Record revealed the facility admitted the resident on 01/04/2023 with diagnoses of Unspecified Spina Bifida with Hydrocephalus, Neuromuscular Dysfunction…

  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 · Ecited before2023-06-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, and interview, it was determined the facility failed to store and serve food under sanitary conditions. Observations, during the lunch tray line on 06/06/2023, revealed the dish covers and bowls being used were wet. The Dietary Director was observed drying dishware with a paper towel. Further observation revealed the kitchen ingredient bins were not labeled or dated. The findings include: 1. Observations, on 06/06/2023 at 11:55 AM, during the kitchen tour revealed three (3) ingredient bins were not labeled and dated. In an interview, on 06/09/2023 at 3:38 PM, Cook/Night Supervisor #2 stated ingredients bins which contained sugar, flour, and rice were to be labeled and dated. The Cook/Night Supervisor #2 stated the bins were washed before adding more products. The Cook/Night Supervisor #2 further stated if the bins were not labeled the product inside could be out of date and staff would not know the last date the bin was cleaned. In an interview, on 06/09/2023 at 3:40 PM, Cook/Diet Aide Floater #3 stated the ingredients bins were to be labeled for safe use. 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of facility policy review, it was determined the facility failed to ensure that residents' right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of twenty-four (24) sampled residents (Resident #65). Observation of Resident #65's mobility was limited to his/her wheelchair. The resident was unable to get to the bathroom sink for personal hygiene due to his/her wheelchair not fitting through the bathroom door. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). Record review revealed the facility admitted Resident #65 on 01/04/2023 with diagnoses of Unspecified Spina Bifida with Hydrocephalus,…

  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 before2023-06-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, it was determined the facility failed to report allegations of abuse within two (2) hours for one of twenty-four (24) sampled residents (Resident #34). On 05/05/2023, Certified Nurse Assistant (CNA) #18 heard an allegation from Resident #82 that Resident #312 groped Resident #34's genitals. However, CNA #18 stated she reported this to Registered Nurse (RN) #5 on 05/05/2023. However, staff failed to report this allegation to the Executive Director until four (4) days later on 05/09/2023. The findings include: Review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 09/2022, revealed the facility's staff reported allegations of abuse to the abuse coordinator immediately. Further review revealed that immediately was defined as within two (2) hours for an allegation involving abuse. Review of the facility's investigation revealed CNA #18 was in the dining room at lunch on 05/05/2023 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-11 · tag F0641 — isolated
  Ensure 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 interview, record review, and facility policy review, it was determined the facility failed to ensure all assessments accurately reflected the resident's status for one (1) of twenty-four (24) sampled residents (Resident #359). Review of the admission Minimum Data Set (MDS) Assessment, dated 02/20/2023, revealed the resident was not assessed accurately for pressure. The MDS coded Resident #359 as having no pressure ulcer upon admission, however, it was documented by the Advanced Practice Nurse Practitioner (APRN) that the resident had a pressure wound present on his/her right buttock. The findings include: Review of the Resident Assessment Instrument (RAI) MDS 3.0 Manual revealed the steps for skin assessments included: (1) Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments; (2) Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review 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.

  Resident Assessment and Care Planning 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to JOURNEY HEALTHCARE — 32 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 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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 91% 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 $1.2M 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 KY