Spring Creek Post-Acute Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

43.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 176 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 71.3% 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 94 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 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 226 beds and averages 130.9 residents a day — about 58% occupied, or roughly 95 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 4.59 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.53 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 4 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.

21 citations, most serious first. The 15 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-05-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 26 sampled residents (Resident (R)529). Immediate Jeopardy (IJ) was identified on 05/09/2025 and was determined to exist on 04/18/2025 in the area of §483.25(d) Accidents Hazards, F689. On 05/09/2025, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25, Quality of Care. The IJ was determined to exist on 04/18/2025, when the facility discovered R529 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on…

  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 before2023-10-27 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and a review of the facility's policy, it was determined the facility failed to implement the resident's Person-Centered Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #5), who required a specific diet. On 10/10/2023, the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids, as the resident had difficulty chewing and swallowing his/her foods. The resident's care plan was revised on the same day, to reflect the change in the resident's diet. Staff failed to implement the resident's care plan. Subsequently, on 10/13/2023, Certified Nursing Assistant (CNA) # 6 gave Resident #5 a piece of her cheeseburger, causing the resident to choke. The resident was transported to the emergency room (ER) where he/she was intubated. Review of the physician's ER…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-27 · tag F0803 — failed to meet residents' dietary needs — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident with Dysphagia (difficulty swallowing food or liquid) and at risk for choking, received food that was appropriate for the residents assessed diet for one (1) of three (3) sampled residents (Resident #5) who were at risk for aspiration and/or choking. On 10/10/2023, the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids as the resident had difficulty chewing and swallowing his/her foods. On 10/13/2023; however, at approximately 12:50 AM, Certified Nursing Assistant (CNA) # 6 gave Resident #5 a piece of her cheeseburger, causing the resident to choke. Staff initiated the Heimlich maneuver on the resident and was able to dislodge some of the food the resident had consumed; however,…

  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
• Actual harm · Gcited before2024-03-08 · 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, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-eight (28) sampled residents (Resident #61). Resident #61's Comprehensive Care Plan, revised 01/05/2024, revealed an intervention to utilize the mechanical lift with two (2) staff members for transfers. However, on 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf which required a transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Additionally, on 02/21/2024, CNA #13 failed to implement Resident #61's Comprehensive Care Plan related 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-08 · 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 policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-eight (28) sampled residents (Resident #61 and Resident #74). 1. On 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a Hoyer mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf and required transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Subsequently, on 02/21/2024, CNA #13 transferred Resident #61 from the bed to the wheelchair, without the assistance of another staff member and without using the mechanical lift and caused a skin tear to 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 · Dcited before2026-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, closed record review, and review of the facility's policy, the facility failed to ensure residents were adequately assisted to prevent accidents for 1 of 4 residents sampled for falls, out of the total sample of 26 residents, (Resident (R)134). The findings include: Review of the facility policy titled, Fall Prevention Program, undated, revealed each resident was to be assessed for fall risk. Further review revealed each resident was also to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the facility policy titled, Incidents and Accidents, undated, revealed it was the facility's policy for staff to report, investigate, and review any accidents or incidents that occurred or were alleged to occur on facility property which might involve or was alleged to involve a resident. Record review revealed the facility admitted R134 on 12/26/2025, with diagnoses that included Pneumonia, Altered Mental Status, and need for assistance with personal care. Further record review 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-10 · 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 facility policy, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety for 4 of 26 sampled residents (Resident (R)111, R106, R32, and R122). The findings include: Review of the facility's policy, Serving a Meal, undated, revealed it was the facility's policy to serve meals that met the nutritional needs of residents. Continued review revealed the Policy Explanation and Compliance Guidelines included: Avoid handling actual unwrapped food items with bare hands. Observation of the dinner meal service on 05/06/2025 at 5:15 PM, revealed Licensed Practical Nurse (LPN)14 touched four residents' (R111, R106, R32, and R122's) buns with her bare hands while cutting the residents' sandwiches in half. Further observation revealed LPN14 also touched the residents' straws with her bare hands when placing the straws in the residents' drinks. During interview with LPN14 on 05/09/2025 at 12:15 PM, she stated she honestly should have had gloves on. She stated 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-10 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, it was determined the facility failed to review and update the facilitys assessment which had the potential to affect 131 residents. The findings include: Review of the facility's policy titled, Facility Assessment, not dated, revealed the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for their residents competently during both day-to-day operations and emergencies. Further review revealed the Administrator was responsible for ensuring the completion of the facility's assessment and that it would be reviewed and updated as necessary and at least annually. Review of the Facility Assessment, dated 06//26/2023, revealed a review date of 07/11/2023 and it would be reviewed every third Tuesday of every month. The assessment identified it had the capacity to meet the needs of 226 residents. Further review revealed the census at that time averaged 115 residents. During an interview with the Director of Nursing (DON) on 05/10/2025 at 3:38 PM, she stated she had…

  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 · E2025-05-10 · 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 observations, interviews, and review of facility policy, it was determined the facility failed to maintain a safe, clean, comfortable and homelike environment for twenty-six (26) sampled residents. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, not dated, revealed it is the facility's policy to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The policy stated routine surface cleaning and disinfection will be conducted with detailed focus on visibly soiled surfaces and high touch areas to include but not limited to toilet flush handles, bed rails, tray tables, call buttons, IV poles, television remotes, and telephones. Review of the facility's policy titled, Resident Environmental Quality,not dated, revealed it was the facility's policy to ensure the facility was designed, constructed, equipped, and maintained to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-10 · 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 facility policy review, 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 the development and transmission of communicable diseases and infections for 6 of 26 sampled residents, (Resident (R)32, R65, R106, R111, R122, and R229) The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, undated, revealed the facility was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Per review, all staff should assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Continued review revealed hand hygiene should be performed in accordance with 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility policy review, the facility failed to ensure residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility related to residents with eating difficulties for four (4) of 26 sampled residents (Resident (R) 32, 106, R122, , R111) and one (1) unsampled resident (R2). The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, undated, revealed the facility would protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintained or enhanced the resident's quality of life by recognizing each resident's individuality. Further review of the policy revealed all staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 1. Review of Resident R32's…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-10 · 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 Director of Nursing (DON) and Administrator's Job Descriptions, and policy review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to the facility's Administrator and/or DON failed to notify the state regulatory office on the elopement on 04/18/2025 of R529. The findings include: On 04/18/2025 at approximately 2:58 PM, R529 walked 71 yards from her room through two sets of double doors, into a staff meeting/break room, out a single storage room door and then through a door outside onto the loading dock. R529 was found on the dock, where she found a lift and was raised 81 inches from the pavement below. Review of the facility's policy titled, Governing Body, undated, revealed the facility was to have a governing body or designated persons functioning as a governing body that were legally responsible for establishing and implementing…

  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 · D2024-03-08 · 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 review of facility policy, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the resident's status for three (3) of twenty-eight (28) sampled residents (Residents #21, #112 and #141). Resident #21's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/08/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. Additionally, review of Resident #112's MDS Assessment with an ARD date of 03/12/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. Moreover, Resident #141's Discharge MDS Assessment, with an Assessment Reference Date (ARD) date of 12/30/2023 was coded under Section A2105 as the resident being discharged to a Short-term General Hospital…

  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 · D2024-03-08 · 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 facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (2) of twenty-eight (28) sampled residents (Resident #48 for and Resident #74). On 01/10/2024, staff transferred Resident #74 from the bed to the chair using a Hoyer lift (mechanical body lift). After the transfer, it was observed by staff the Hoyer lift pad was poor-fitting in size, resulting in skin-shear injury to the resident's left gluteal fold. After the incident, the resident's lift pad was changed to the green Hoyer lift pad with the blue stripe manufactured by Liko. However, the resident's CCP was not revised to reflect the change in lift pads. Additionally, Resident #48 sustained a 16.2 pound weight loss from 01/19/2024 until 03/04/2024, indicating a 16.2 pound weight loss in less than two (2) months which…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-27 · tag F0568 — isolated
  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 interview, record review, and review of the facility's policy, it was determined the facility failed to maintain a system that accepted accounting principles and proper bookkeeping techniques, in order to maintain the ongoing balance for each resident's personal funds entrusted to the facility on the resident's behalf for two (2) of eighteen (18) sampled residents (Resident #6 and Resident #8). Additionally, the facility failed to refund the resident's representative upon the death or discharge of a resident (Resident #8). The findings include: Review of the facility's policy titled, Resident Funds Policy and Procedure, not dated, revealed the purpose of the policy was to ensure the facility's residents had access to and were able to manage their personal funds. The facility would keep track of such funds through an established system in order to document the date, time, and the amount of funds received from or dispersed. The policy further stated the facility would ensure through established systems in place that it would safeguard against misappropriation of 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$52,540 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $26,685 — penalty dated 2025-05-10
• $5,666 — penalty dated 2024-03-08
• $5,667 — penalty dated 2024-03-08
• $7,261 — penalty dated 2023-10-27
• $7,261 — penalty dated 2023-10-27
• Medicare payment denial — starting 2023-11-01 for 9 days

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

Who owns this facility

CMS files one row per role, so the 7 rows in the source record cover these 4 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.

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