Eastway 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.

51.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 252 beds and averages 169.7 residents a day — about 67% occupied, or roughly 82 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.10 hrs/resident/day on weekends vs 3.85 on weekdays — 19% thinner on weekends. RN hours go from 0.49 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

41 citations, most serious first. The 20 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · J2021-07-03 · 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 [NAME] Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure residents were free from abuse for seven (7) of one hundred-thirteen (113) sampled residents (Residents #161, #47, #74, #344, #345, #90 and 136). Resident #161 and Resident #47 related to resident to resident sexual abuse; Resident #74 related to verbal abuse; and, Resident #344, Resident #345, Resident #90 and Resident 136 related to resident to resident physical abuse. 1. On 03/19/2021, after the dinner meal, around 7:30 PM, Certified Nurse Aide (CNA) #36 left the unit to go on break. The CNA left Resident #161 in the dining room/dayroom unsupervised. CNA #35 was at the nurse's station and watched the camera monitor. However, the CNA left the nurse's station to assist another resident, and was gone from the monitor for about five (5) minutes. Upon CNA #35's return to the nurse's station, she observed on the camera monitor, Resident #47 next to Resident #161 in the dayroom.…

  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 · J2021-07-03 · 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 observation, interview, record review, and facility policy review it was determined the facility failed to develop or implement their policy related to facility abuse and neglect for two (2) of one hundred-thirteen (113) sampled residents (Residents #47 and #161) . The facility failed to develop a policy related to assessment for capacity to consent to sexual contact for Resident #47 and Resident #161. On 03/19/2021, Resident #47 and Resident #161 had sexual contact with each other. The facility assessed the resident Brief Interview for Mental Status (BIMS) scores after the incident, and used the BIMS' score results as a determination of capacity to consent to the contact. However, the facility did not have a policy to reference how to determine resident capacity, or when BIMS scores were used as the sole assessment for resident capacity. Immediate Jeopardy was identified on 06/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600…

  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 · J2021-07-03 · 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 observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the care plan was revised to incorporate behaviors, increased supervision and monitoring for one (1) of one-hundred and nineteen (119) sampled residents, Resident #87. Review of Resident #87's Comprehensive Care Plan last reviewed on 09/01/2021 revealed the behavior care plan was last revised on 07/10/2019. With the exception of one intervention updated on 04/02/2021, to check on resident frequently and to meet resident needs in a timely manner. The findings include: Review of the facility's policy Baseline Care Plan Assessments/Comprehensive Care Plans, undated, revealed the Minimum Data Set (MDS) and/or Care Plan Coordinator would lead the care plan conference. Other disciplines would review and discuss their specific department care plans established for the resident. Changes to the care plan would be made at meeting as warranted. An Interdisciplinary Team (IDT) not would be…

  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 · J2021-07-03 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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 it was determined the facility failed to ensure two (2) of one hundred thirteen (113) residents received medically related social services related to assessment for a resident's capacity to consent to sexual contact with others. On 03/19/2021, Resident #47 and Resident #161 engaged in sexual contact with each other. At the time of the incident, the facility did not have a full time Social Worker to ensure Resident #47 and Resident #161 were assessed to determine his/her capacity to consent. The facility utilized a contracted social worker approximately one (1) day per week. Additionally, the facility failed to inform the contracted social worker of the sexual contact that occurred between Resident #47 and Resident #161. Immediate Jeopardy was identified on 05/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at S/S of J and F607 Develop/Implement…

  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 · J2021-07-03 · 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

  Based on interview, record review, review of the facility's policy, and review of repeated deficient practice citations, it was determined the facility failed to have effective administration responsible for establishing and implementing policies regarding the management and operation of the facility. This was evidenced by the facility being cited on 12/06/2019 for F584, F600, F656, F657, F689, F761, and F880; on 11/08/2020 for F656, and F689; and current citations including F584, F600, F656, F657, F689, F761, and F880. Record review and interview revealed the facility failed to ensure residents were free from abuse and ensure resident behaviors were addressed; failed to ensure residents' care plans were developed, revised and implemented; failed to ensure the facility was safe, comfortable, and supervised for residents, and medications were labeled and stored accordingly. The facility's failure to provide an effective administration responsible for establishing and implementing policies regarding the management and operation of the facility has caused or is likely to cause serious…

  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
• Actual harm · Gcited before2025-08-27 · 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

  Based on interview, record review, and facility policy review, the facility failed to fully develop and implement the comprehensive person-centered care plan for one of 49 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned for staff to place the Resident in a common area when she became restless. The care plan, however, was not fully developed with interventions to include supervision and monitoring while in the common area. While staff were in the nurses' station, the Resident was left unattended and fell in the common area, fracturing her hip. This caused actual harm to the Resident. The findings include: Review of the facility's policy titled, Care planning – Comprehensive Person – Centered, undated, revealed the comprehensive care plan was to promote patient (resident) safety, and reflect currently recognized standards of practice. Review of R17's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/18/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision to prevent injury for 1 out of 29 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned to place the resident in a common area when she became restless. Staff implemented the resident's care plan by placing the resident in the common area; however, failed to ensure the resident was supervised while in the area. While staff were in the nurses' station, the Resident fell while in the common area unsupervised and sustained a fractured hip, which caused actual harm to the resident. The findings include: During an interview with the Director of Nursing (DON) on 08/05/2025 at 3:57 PM, she stated it was her expectation that staff would provide supervision to the residents. Review of Resident (R)17's medical record revealed the facility admitted the resident on 03/04/2025, with diagnoses that included Congestive Heart Failure, Alzheimer's unspecified, chronic obstructive pulmonary disease, and repeated falls. Review…

  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 · G2021-07-03 · 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 2. Review of the facility's policy, Resident Rights, undated, revealed residents had the right to be free from verbal, sexual, physical or mental abuse. In addition, the facility implemented procedures to protect residents from abuse, neglect or mistreatment. In the event of an alleged violation, the facility is required to report to the appropriate officials and promptly and thoroughly investigated. Through interview, State Survey Agency (SSA) revealed Certified Nurse Assistant (CNA) #18 was sent home on [DATE] due to sleeping and related behaviors in front of residents. However, the facility had no report or documentation related to incident. Record review of time punches on 04/23/2021 revealed CNA #18 clocked in at 7:15 PM and clocked out 9:00 PM. Interview with CNA #18 on 05/27/2021 at 12:42 AM, revealed a Certified Medication Technician (CMT), unknown name, accused her of being on drugs about a month prior to SSA interview. The CMT reported CNA #18 was asleep at the sink and acting weird. Interview with CMT…

  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
• Actual harm · Gcited before2021-07-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide adequate supervision for one (1) out of one-hundred and nineteen (119) residents sampled, Resident #87. Observation on 09/29/2021 at 4:00 PM, revealed Resident #87 wandering the Seventh (7th) Floor without supervision. Resident #87 was entered room [ROOM NUMBER], walked about ten (10) steps in, turned around and walked out. Resident #87 walked into room [ROOM NUMBER], went to the empty bed near the window, got in bed, under the covers and then got back up. Resident #87 went across the hall and entered the shower room and remained in there for three (3) minutes. Resident #87 came out of the shower room and went back to room [ROOM NUMBER] and got back in the same empty bed, under the covers and laid his/her head on the pillow as if to go to sleep. Continued observation on 09/29/2021 at 4:22 PM, further revealed Resident #87 continued to wander unsupervised on the Seventh (7th) floor. Resident had been at the common…

  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 · G2021-07-03 · 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 interview, record review, and facility policy review, it was determined the facility failed to provide pain management for one (1) of one hundred thirteen (113) sampled residents (Resident #146). Interview with Resident #146 revealed he/she experienced pain and notified staff. Resident #146 stated the pain was so bad he/she cried himself/herself to sleep. However, staff did not administer the resident's ordered pain medication. The findings include: Review of the facility's policy, Management of Pain, undated, revealed as part of a comprehensive approach to pain assessment and management, pain would be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. The policy defined pain as whatever the experiencing person said it was, existing whenever the experiencing person said it did. Further review revealed staff assessed and managed pain in a timely fashion, especially if it was of recent onset. Staff notified the physician of the resident's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-27 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  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

  Based on observation, interview, record review, and review of facility policies, the facility failed to provide a safe, clean, comfortable and homelike environment. This had the potential to affect all residents residing in the facility. The findings include: Review of the facility's undated policy titled, Pests Control, revealed the facility should maintain an effective pests control program to ensure the building was kept free of insects and rodents. Review of the facility's policy titled, Environmental Services Quality Control, dated 10/01/2021, revealed housekeeping and laundry departments had developed a quality control program that measured the level of the quality of services provided by those departments.1) Observation on 07/29/2025 at 10:27 AM, revealed R170's side of the room was cluttered with clothing, books, a couple of boxes, and magazines. Continued observation revealed R170's overbed table was also cluttered with cups. a. Observation on 07/29/2025 at 10:40 AM, revealed R153's and R115's room floor was sticky and dirty looking. Additional observation on 07/30/2025 at…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-27 · tag F0800 — widespread
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDEDBased on observation, interview, record review, and review of facility policies, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional needs, taking into consideration the preferences of each resident. Resident (R)44 had a known allergy to watermelon; however, staff continued to serve the Resident watermelon during her meal service. Additionally, R150's dietary order documented the resident should have no pork; however, this was not documented on the Resident's meal ticket and interview with R150 revealed staff continued to serve her pork which made her feel terrible. Further, the facility failed to ensure the Residents with allergies or specialized diets were care planned with appropriate interventions to address their needs. Lastly, interview with the Resident Council and R143 revealed the facility did not provide substitutes or alternatives to their meals or offer enough to eat which caused the Residents emotional distress…

  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 · Fcited before2025-08-27 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  AMENDEDBased on observation, interview, and review of the facility's policy, the facility failed to ensure menus were prepared to meet the nutritional needs of residents in accordance with established national guidelines for 8 of 15 sampled residents of the total sample of 49 residents, (Resident (R)67, R88, R118, R115, R43, R70, R143, and R170). Interviews with the residents revealed they were often hungry and anxious as they were served small portions of food. Additionally, facility staff stated they did not have enough snacks to give to all the residents. The findings include:Review of the facility's policy titled, Kitchen Weights and Measures, dated 10/01/2021 revealed Food Services staff were to be trained in proper use of cooking and serving measurements to maintain portion control. Further review revealed the Food Service Supervisor was to ensure cooks prepared the appropriate amount of food for the number of servings required. 1) Observation of the lunch meal on 07/29/2025 at 12:10 PM revealed residents' portions were small. Per review of R88's meal ticket the resident was…

  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 · F2025-08-27 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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, the facility failed to ensure each resident was provided a nourishing snack at bedtime. This had the potential to affect all residents receiving snacks from the facility's kitchen. The findings include:Review of the facility's policy titled, Between Meal and Bedtime Snacks, dated 10/01/2021 revealed, the purpose of this procedure is to provide the resident with adequate nutrition. This policy further stated, review the resident's care plan and provide for any special needs of the resident, check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. It also stated, the person performing this procedure should record the following information in the resident's medical record: date and time the snack was served, name and title of the individual who served the snack, amount of snack eaten by the resident (i.e. 50%m 75%, etc.). Finally, this policy stated, notify the licensed nurse if the 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-27 · 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, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety which had the potential to affect all residents consuming meals from the kitchen. The findings include:Review of facility policy titled, Dishwashing Machine Use, undated, revealed high temperature sanitation dishwashing machines hot water sanitation rinse temperatures may not be more than 194 degrees ( ) Fahrenheit (F), or less than 165 F for stationary rack, single temperature machines and 180 for all other machines. Review of the instructions provided on the facility's document titled, Dish Machine Log - Low Temp, dated 2019, revealed staff were to, Record wash temperature and sanitizer PPM (Parts Per Million) provide initials, three times per day.Review of the facility's May 2025 dishwashing records revealed staff were documenting on a form titled, Dish Machine Log - Low Temp, dated 2019, which instructed staff to record wash temperature and sanitizer PPM three times per day 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-27 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review and record review, the facility failed to provide a bed hold notification for 2 out of 5 sampled residents (Resident (R)46 and R18) when an emergent transfer to the hospital was necessary.The findings include:Review of the facility's policy titled, Bed Hold undated, revealed that if it is an emergency transfer, a written bed hold notice must be given to patient or patient representative within 24 hours. Per the policy, the each family is provided information on the bed hold policy at the time of admission as well for transfers planned or emergent.1. Review of Resident (R)46 Electronic Medical Record (EMR) revealed the resident was sent to the emergency room on [DATE] and 07/11/2025 and there was no documentation of a bed hold notification given to the resident or her representative in the electronic or paper chart. The facility was unable to produce copies of the bed hold notifications for these hospital visits.During an interview with R46 on 08/01/2025, she stated she does 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · 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, interview, record review, and facility policy review, the facility failed to ensure all drugs and medical supplies were stored in accordance with professional standards including expired medications and products. This affected 1 of 3 treatment carts.The findings include:Review of the facility's policy titled, Medication Storage, not dated, revealed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologics. All such drugs shall be returned to the dispensing pharmacy or destroyed. In addition, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. As well as Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologics shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policies and procedures, the facility failed to implement appropriate transmission-based precautions for 3 of 49 sampled residents, Resident (R)183, R184, and R70. This failure had the potential to result in the transmission of a communicable disease to other residents, staff, and visitors.The findings include:Review of the facility's policy titled, Infection Control Program, no revision date listed, revealed the facility was responsible for, Development isolation precaution protocols for when control of an infectious or communicable disease or disease risk is required in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations.Review of the facility's policy titled, Infection Prevention and Control Committee, no revision date listed, revealed duties of the Infection Preventionist and/or committee included, Review, and revise, if necessary, isolation precaution techniques and procedures to help ensure personnel, residents, and visitors follow established…

  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 · Fcited before2024-07-12 · 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, interview, record review, and review of facility policy, it was determined the facility to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation revealed multiple food items in the pantry, refrigerator and freezer that were opened but not dated. Further observation revealed kitchen staff were not properly wearing hair restraints to prevent hair from contacting food. The findings include: The facility did not provide any policies requested by the survey team related to labeling and dating food items, food storage, or hairnets. Observation of the facility kitchen's dry storage pantry, on 07/08/2024 at 11:00 AM, revealed a country style gravy package opened, re-sealed and undated. A package of turkey gravy wrapped in plastic wrap but was not dated. A package of brownie mix wrapped in plastic wrap and sealed but not dated. A package of pasta noodles was sealed but not dated. A bottle of worcestershire sauce was opened, and had an original label, but no date. Continued observations included…

  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 · Fcited before2024-07-12 · tag F0880 — failed to prevent and control infections — widespread
  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 facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Observations revealed staff entering resident rooms marked with precaution signage without donning (putting on) protective equipment. Additionally, observations of the facility laundry room revealed concerns including incorrect ventilation, lack of defined sorting areas, and no personal protective equipment available for staff use. The findings include: Review of facility policy Guidelines for Infection Prevention Control, revised 04/05/2022, revealed the purpose of the policy included to establish, maintain, and manage an effective infection prevention and control program. Added review revealed the program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable…

  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

“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

$10,868 in federal fines across 2 penalties.

• $5,434 — penalty dated 2025-08-27
• $5,434 — penalty dated 2025-08-27

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

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

Follow the money — this home’s finances

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

About 84% 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. 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