Lyndon Crossing, LLC

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.

Met the expected recovery: 57.7% 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 26 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 145 beds and averages 125.6 residents a day — about 87% occupied, or roughly 19 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 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 3.22 hrs/resident/day on weekends vs 3.68 on weekdays — 12% thinner on weekends. RN hours go from 0.75 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-14 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of the clinical record, and review of the facility policy, the facility failed to implement the resident(s) care plan interventions for 1 out of 9 resident(s) sampled for elopement risk, Resident (R)1.The facility admitted R1 on 07/08/2025 and was assessed to be a risk for elopement. The resident was required to reside on the secured memory care unit, which required supervision while on the unit. Per the policy and the resident's care plan, this was for the resident's safety. Additionally, the resident's care plan interventions included providing structured activities. On 09/15/2025, R1 left the facility unsupervised and without staff knowledge. Interviews with staff revealed the resident's care plan was not implemented due to staff providing care to other residents on the unit. Immediate Jeopardy (IJ) was identified on 10/24/2025 and was determined to exist on 09/15/2025 in 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 at a Scope and Severity (S/S) of a J. The facility…

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

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-12-14 · 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, interviews, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision for 1 out of 9 sampled residents. Resident (R)1.On 07/08/2025, the facility admitted R1 and assessed the resident to require the need to reside on its memory care [secure] unit with supervision provided while on the unit. According to the facility's policy and R1's care plan, this was for the safety of the resident. However, on 09/15/2025 the resident left the facility unsupervised. The resident was found at the park, approximately .4 miles away from the facility, by concerned citizens who called 911 to alert the police of the missing resident. When the [NAME] Officer questioned staff about the resident, staff stated they were unaware the resident had left the facility. Immediate Jeopardy (IJ) was identified on 10/24/2025 and was determined to exist on 09/15/2025, in 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of a J. The facility…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-02-13 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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, review of the clinical record, and review of the facility policy the facility failed to develop the baseline care plan for 1 of 4 residents sampled for elopement and care plans out of the 33 total sampled residents, (Resident (R)401). The facility admitted R401 on 01/21/2025 and assessed the resident as at risk for elopement on that date. However, the facility failed to develop a baseline care plan with necessary interventions to address the resident's risk for elopement. R401 left the facility without staffs' knowledge on 01/24/2025. Immediate Jeopardy (IJ) was identified on 02/12/2025 and was determined to exist on 01/24/2025 in the area of 42 CFR §483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 02/12/2025 at 4:23 PM. On 02/12/2025 at 4:23 PM, the facility's Administrator, Regional [NAME] President of Clinical (RVPC), and Regional [NAME] President (RVP) were provided a copy of the IJ Template and notified that the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-02-13 · 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 facility policy, the facility failed to ensure each resident received adequate supervision for two of 12 sampled residents, Residents (R) 400 and R401. On 01/21/2025, the facility admitted R401 and assessed the resident as at risk for elopement; however, failed to address that risk in the baseline care plan. Therefore, on 01/24/2025 at approximately 10:30 PM, R401 left the facility without facility knowledge (which could be considered an elopement) and was not located until the next morning (of 01/25/2025) at a local hospital. Additionally, the facility failed to assess R400 for smoking safety and falls in its initial assessment of the resident upon admission. Immediate Jeopardy (IJ) was identified on 02/12/2025 and was determined to exist on 01/21/2025, in the area of 42 CFR §483.25 Accidents, F689 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 02/12/2025 at 4:23 PM. On 02/12/2025 at 4:23 PM, the facility's Executive…

  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 · E2026-01-12 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure a comfortable, sanitary environment free from odors. The Men's Unit of the facility had ongoing, unpleasant odors of stale urine on all four days of the survey. In additions, feces and/or blood was observed to be smeared on different surfaces on one of the four days of the survey. The failure to maintain a comfortable, sanitary environment which was free from odors, had the potential to affect any of the 23 residents living on this locked unit, as well as staff and the public/visitors in the area.The findings include:Review of the facility policy titled, Safe and Homelike Environment, reviewed/revised 02/16/2024, revealed The facility will provide a safe, clean, comfortable and homelike environment. Per the policy, Environment refers to any environment in the facility that is frequented by residents including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas .and activity areas. The policy…

  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 · D2026-01-12 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one (Resident (R) 3) of 26 sampled residents had an admission Minimum Data Set (MDS) assessment completed within 14 days of admission. R3 was admitted on [DATE], and the MDS V200B date, signifying completion of the assessment, was not completed until 11/05/2025.The findings include:Review of R3's Census tab in the electronic medical record (EMR) revealed the resident was admitted on [DATE]. The review of the admission MDS, with an Assessment Reference Date (ARD) of 10/21/2025, revealed that V200B date, signifying completion of the Care Area Assessment (CAA) Process, was not signed by the MDS Coordinator until 11/05/2025, the 22nd day of admission.Interview with the MDS Coordinator on 01/09/2026 at 3:30 PM revealed that she was the Registered Nurse (RN) responsible for signing R3's admission MDS as complete. She confirmed that R3's admission MDS was due to be completed no later than 10/28/2025, the 14th day of admission to the facility. She…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  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 that one (Resident (R) 38) of 26 sampled residents had a thorough, complete medical record which reflected the care that was provided. R38 had no documentation of medication administration or multiple contacts with the physician in accordance with physician orders.The findings include:Review of the facility policy, titled, Timely Administration of Insulin, reviewed/revised 02/14/2024, revealed the procedures included, Document on the medication administration record the time and location of the insulin injection. Review of the facility policy, titled, Medication [sic] Administration, reviewed/revised 02/14/2024, revealed staff are to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Sign MAR [Medication Administration Record] after administered. For those medications requiring vital signs, record the vital signs on the MAR.Review of the facility policy, titled,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-17 · 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, and record review, the facility failed to store medications in a secure manner. Observations revealed medications on top of a medication cart, with no staff in view of the cart. The findings include:Review of the facility policy, Medication Storage, dated 02/01/2024, revealed under the General Guidelines that all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.Review of policy review records revealed the medication storage policy was reviewed and acknowledged by Licensed Practical Nurse 4 and dated 09/24/2025.During observation and interview on12/17/2025 at 8:50 AM, revealed Medication Cart C was unattended, positioned to the right of the nurse's station and locked. On top of the cart was a container of medication labeled with a resident's name. Additionally, a capped syringe was lying on the cart along with a glucometer (device used to measure blood glucose) with a test strip sticking out of the glucometer. Licensed Practical…

  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 · F2025-07-25 · 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, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, it was determined the facility failed to store and serve food in a safe manner which had the potential to affect 126 residents who received food from the kitchen.The findings include:Review of the USDA web site https://www.fsis.usda.gov, undated, revealed when checking food temperatures, a food thermometer was to be placed in the thickest part of the food, away from bone, fat or gristle. Continued review revealed for thin foods, the food thermometer was to be inserted through the side until it reached the center of the food. Further review revealed always check each piece of food to ensure it reached the safe internal temperature.Observation of the [NAME] on 07/22/2025 at 11:25 AM, during the lunch meal tray line, revealed the [NAME] pushed the food thermometers through the plastic wrap of the creamed corn, pureed enchilada casserole and kernel corn on the steam table.In interview with the Interim Dietary Manager on 07/24/2025 at 10:05 AM,…

  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 · F2025-02-13 · tag F0568 — widespread
  Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
  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 policy, the facility failed to provide residents and/or guardians with resident personal funds account quarterly statements for 5 of 5 residents sampled for personal funds accounts, (Residents (R) 1, R6, R8, R22, and R49). The findings include: Review of the facility's policy, Resident Rights, dated 02/15/2024, revealed the facility must furnish to each resident a written description of (their) legal rights which included a description of a manner in protecting personal funds. Review of the facility's policy, Resident Personal Funds, dated 01/09/2024, revealed the facility was to ensure individual financial records were available to the resident through quarterly statements and upon request. 1. Review of R1's, Resident Statement dated 02/10/2025, revealed the resident had a credit of $1,344.00 at the end of the business day on 02/01/2025. Review of the facility's Surety Bond Certification dated 08/30/2024, revealed the facility was licensed and certified for $145,000.00. In interview with Representative 1…

  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 · F2025-02-13 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure the residents' environment was safe, clean, comfortable, and homelike. The facility failed to provide a functional and comfortable environment for residents related to cold water temperatures for 14 out of 19 resident rooms. (Rooms 101, 102, 103, 105, 106, 107, 108, 109, 110, 121, 122, 124, 125, and 126). The findings include: Review of the facility's policy titled, Resident Rights, revised 02/15/2024, revealed the residents had a right to a safe, clean, comfortable, homelike environment, including but not limited to receiving treatment and support for daily living. Review of the facility's policy titled, Safe and Homelike Environment, revised 03/09/2024, revealed housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable environment. Further review of the policy revealed under General Considerations to report any unresolved environmental concerns to the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-13 · tag F0730 — widespread
  Observe each nurse aide's job performance and give regular training.
  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 a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12-months for five out of five CNAs' personnel records reviewed, CNA #2, #18, #20, #31, and #32. Additionally, the facility failed to provide evidence of regular in-service education based on the outcome of these reviews for three of five records reviewed, CNA #18, #31, and #32. The findings include: The State Survey Agency requested a staffing policy on 02/11/2025 at 3:05 PM; however, the facility did not provide a policy. During an interview, at that time, with the Executive Director he stated the facility did not have a staffing policy. He stated they based staffing off the facility's assessment. Review of the facility's policy titled, Job Description; Certified Nursing Assistant, dated 02/01/2024, revealed CNAs were to attend a minimum of 12 hours of continuing education programs provided by the center in order to maintain certification. Review of CNA2's personnel file revealed…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-13 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record review the facility failed to ensure it electronically submitted complete and accurate direct care staffing information, to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters in 2024. The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September 2024. The findings include: Review of the facility's provided CMS Payroll Based Journal (PBJ) report which was based on the staffing data submitted by the facility revealed excessively low weekend staffing, no RN hours, and a failure to have licensed nursing coverage 24 Hours/Day triggered for August and September 2024. A request for the facility's staffing data submitted for the third quarter (July, August, September) PBJ was requested but no verification that it had been reported successfully was provided. The facility provided an Excel…

  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 · E2025-02-13 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's documentation and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections for 2 of 3 sampled residents (Resident (R) 20 and R67). Observations of Licensed Practical Nurse (LPN)6 of R20 and R67 during wound care revealed the LPN failed to perform hand hygiene when moving from a dirty task to a clean task. Additionally, the LPN failed to ensure a barrier was in place before placing supplies on the table. In an interview with the Wound Doctor, she stated this practice could contaminate the wound and cause an infection. The findings include: Review of the facility's policy titled, Wound Treatment and Management, with a date implemented of 02/01/2024 and a date revised of 02/14/2024, revealed the purpose of the policy was to promote wound healing of various types of wounds by providing evidence-based…

  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

$20,563 in federal fines across 3 penalties.

• $3,218 — penalty dated 2025-02-13
• $6,500 — penalty dated 2025-02-13
• $10,845 — penalty dated 2025-02-13

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.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

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. This home reported $1.6M 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