Salyersville Nursing and 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.

44.3% 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: 15.4% 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% 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 142 beds and averages 107.2 residents a day — about 75% occupied, or roughly 35 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 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 3.64 hrs/resident/day on weekends vs 4.19 on weekdays — 13% thinner on weekends. RN hours go from 0.71 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as 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.

39 citations, most serious first. The 28 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-05-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two of 37 sampled residents Resident (R) 26 and R110. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR §483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are…

  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 · Kcited before2025-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for one of 37 sampled residents (Resident (R) 26). Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-05-17 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, the facility failed to utilize its resources effectively to ensure that its policies related to nutrition/hydration were implemented and failed to ensure that an effective system was in place to obtain accurate weights for each resident. In addition, the facility did not identify significant/severe weight changes and failed to implement interventions to ensure adequate nutrition/hydration and prevent serious adverse outcomes for 79 of 87 sampled residents (R1-R79).Immediate Jeopardy (IJ) was identified on 07/14/2025. It was determined to exist on 06/11/2025 in the areas of 42 CFR 483.25, Nutrition/Hydration Status Maintenance (F692) at the highest scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F692). The facility was notified of the Immediate Jeopardy on 07/14/2025.The facility presented an acceptable plan for removal of the IJ on 07/18/2025 at 1:00 PM. The survey team…

  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 · Kcited before2025-05-17 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's Administrator and Director of Nursing's Position Descriptions, review of the facility's policies and procedures, and review of the facility's abuse investigations, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's failure to have an effective system in place to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F610) at the highest scope and severity (S/S) of a J; 42…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-05-17 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based upon interview, review of medical records, review of the facility's policy/procedures, the facility failed to ensure that its Quality Assurance and Performance Improvement Plan (QAPI) provided overall guidance to the facility; to provide excellence in quality of care and support quality of life through patient-centered care. The facility failed to implement an effective QAPI program to guide its operations and ensure the appropriate allocation of resources. As a result, the facility did not operate effectively or efficiently to achieve the highest practicable level of physical, mental, and psychosocial well-being for residents. This systemic failure caused or was likely to cause serious injury, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on 07/14/2005. IJ was determined to exist on 06/11/2025 at 9:30 PM in the areas of 42 CFR S483.75 Quality Assurance and Performance Improvement (F865) at the highest S/S of J. 42 CFR S483.25 Nutrition/Hydration Status Maintenance (F692) at the highest S/S of K and 42 CFR S483.70 Administration (F835) at 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for three (3) of thirty-seven sampled residents (Residents (R) R12, R73, and R98.) Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and (F610), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600, and F610). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revised 07/2022 revealed in the event an alleged or actual violation occurs, the resident 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 investigation and policy, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated to prevent further potential abuse for 2 of 37 sampled residents, (Residents (R)73 and R98). The facility's failure to ensure allegations of sexual and verbal abuse were thoroughly investigated to protect residents has caused or is likely to cause serious injury, impairment, or death to a resident if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and ( F610), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600 and F610). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. (Refer to F600) 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-17 · 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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of thirty-seven sampled residents (R) R26. Review of R26's Care Plan for Impaired Skin Integrity, dated 02/10/2025, indicated that R26 would have a weekly skin assessment performed. However, the facility failed to provide evidence of weekly skin assessments. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were to be ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of R26's admission Face Sheet revealed 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 · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-05-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, the facility failed to ensure its residents received the necessary care and treatment by professional standards of practice and as required by the comprehensive person-centered care plan for one (Resident (R) 320) of 37 sampled residents. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care (F684) at the highest scope and severity S/S of a J and (F697), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684, and F697). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the facility's policy, Skin Care Standard of Practice, dated 07/2020, revealed the facility was required to assess the resident on admission, readmission, and with each change of condition that may compromise the skin. The facility's nurse was required 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-05-17 · 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 review of the facility's policies, it was determined the facility failed to ensure that pain management was provided to residents who required services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25(k), Pain Management (F697) at the highest scope and severity S/S of a J and (F684), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 42 CFR 483.25(k), (F697, and F684). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. (Refer to F684) The findings include: Review of the facility's policy titled, Pain Management, dated 07/2020, revealed the facility must ensure pain management was provided to residents who required such services, consistent with professional standards of practice, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-17 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview, review of medical records, and review of the facility's policy/procedures, the facility failed to maintain complete and accurately documented clinical records. The facility failed to maintain complete and accurately documented clinical records for 79 of 116 residents (R1 - R79). Staff documented weights that had been falsified (made up). The fabricated and inaccurate weight records were used in clinical assessments related to residents' nutritional status, monitoring of weight changes, and care planning. These inaccurate records compromised the facility's ability to appropriately monitor residents' nutritional status and respond to weight changes. Documentation inconsistencies were found between recorded weights and residents' actual physical condition and intake records.This widespread and systemic failure to ensure reliable clinical documentation created an Immediate Jeopardy to resident health and safety, as the falsified data directly impacted critical clinical decisions.Immediate…

  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 · J2019-02-06 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure prompt efforts were made to resolve grievances for one (1) of forty-seven (47) sampled residents (Resident #117). On 01/09/19, Resident #117's family member voiced concerns to the Administrator and Director of Nursing (DON) that staff were not adequately suctioning secretions from Resident #117's tracheostomy (an opening in the neck to the windpipe). Resident #117 had been treated in the Emergency Department (ED) on 01/08/19 and diagnosed with Respiratory secretion[s] in [the] tracheostomy tube. According to the family member, the ED Physician who treated the resident on 01/08/19 stated the resident was not receiving appropriate tracheal suctioning. However, the facility failed to take any action to investigate the concerns regarding Resident #117's respiratory care to ensure the resident was receiving appropriate respiratory care. Staff failed to provide tracheostomy care/suctioning 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2019-02-06 · 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 policy, it was determined the facility failed to develop/implement comprehensive, person-centered care plans for four (4) of forty-seven (47) sampled residents (Resident #117, #21, #98, and #106). The facility failed to implement Resident #117's care plan, which stated staff were required to provide tracheostomy (an opening in the neck to the windpipe) care and administer insulin as ordered. On [DATE], at 7:00 PM staff failed to provide tracheostomy care (which includes suctioning) and at 11:00 PM, when the resident indicated he/she needed to be suctioned, staff only suctioned the resident's oral cavity but did not suction the resident's tracheostomy. Further, the facility failed to follow Resident #117's Physician's Orders for administration of Humulin R Insulin (regular, fast acting). On [DATE], staff did not administer the resident's insulin that was due at 12:00 AM, until 2:00 AM, two hours late. In addition, staff documented…

  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 before2019-02-06 · 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 interview, closed record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of forty-seven (47) sampled residents (Resident #117) received adequate supervision to prevent accidents. A review of Resident #117's admission assessment and a Physical Therapy Note dated [DATE], revealed the resident required assistance with transfers to/from bed/chair. The admission assessment revealed the resident also required extensive assistance with ambulation and toileting. However, on [DATE], at approximately 5:30 AM, staff observed Resident #117 transfer from bed to the bedside commode alone without offering to assist the resident. In addition, staff left the resident on the bedside commode unassisted. At approximately 6:30 AM, one hour later, staff found the resident on the floor, face down, unresponsive and not breathing. The facility initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital where the resident was pronounced dead 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2019-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 that three (3) of four (4) residents who required tracheostomy care and tracheal suctioning were provided such care, in accordance with physician's orders. Resident #117 had a tracheostomy (an opening in the neck to the windpipe) and had physician's orders for tracheostomy (trach) care every shift and suctioning as needed. On [DATE], the facility transferred Resident #117 to the hospital due to a low oxygen saturation and the resident returned to the facility on [DATE] at 4:23 AM, with a diagnosis of Respiratory secretion[s] in [the] tracheostomy tube. The resident's family member reported to the facility that the hospital physician stated staff were not suctioning the resident adequately. However, during the night of 01/09-10/19, the facility failed to ensure tracheostomy care/suctioning was provided for the resident. At 6:40 AM on [DATE], staff found the resident on the floor, unresponsive, and not breathing.…

  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 before2019-02-06 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to ensure that one (1) of forty-seven (47) sampled residents (Resident #117) was free of significant medication errors. Resident #117 had a Physician's order for Humulin R insulin (regular, fast acting insulin that starts lowering your blood sugar within 30 minutes of being injected) to be administered every six (6) hours, but to hold the insulin for blood sugar results below 140 mg/dl (milligrams per deciliter). According to the resident's medication record, Humulin R insulin was due at 12:00 AM on [DATE]; however, interview with staff revealed the medication was not administered until 2:00 AM. Further review of the resident's medication record revealed staff administered another dose of Humulin R insulin four (4) hours later at 6:00 AM on [DATE], when the resident's blood sugar was 111 mg/dl, even though the resident had a Physician's Order to hold the medication if 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2019-02-06 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility Administrator failed to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being for Resident #117. The facility failed to develop respiratory policies and procedures to ensure Resident #117 received respiratory care as needed. The Administrator also failed to investigate and respond to a grievance presented by a family member of Resident #117 on [DATE], regarding the resident's respiratory care. On [DATE], staff failed to provide respiratory care as ordered by the resident's physician and the resident was found not breathing on [DATE]. The resident was transferred to a hospital where he/she was pronounced dead as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility's failure to ensure the facility was administered in a manner that enables it to use resources effectively and efficiently 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 before2025-05-17 · 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

  Based on interviews, review of the facility's documents, and policy, it was determined the facility failed to ensure allegations of sexual and verbal abuse were reported to State Agencies and local law authorities immediately, but no later than two hours after the allegations were made for two of 37 sampled residents. (Resident (R) R73, and R98). The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revision date 07/2022 revealed in the event an alleged or actual violation occurs, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law including the state survey agency within five working days of the incident. Continued review of the facility's policy revealed the policy did not cover 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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, the facility failed to immediately inform the resident's physician and/or Responsible Party (RP) as required for one (Resident (R) 1) of nine residents reviewed for medication administration. R1's Vimpat (an anti-convulsant medication used to treat seizures) was unavailable and not administered from 01/29/2026 until 02/01/2026. When the evening dose of Vimpat was administered on 02/01/2026, R1 received twice the ordered dose. The facility failed to immediately notify the resident's physician and representative of these medication errors. In addition, the facility failed to immediately notify the resident's RP when the resident was transferred to the hospital for evaluation after the 02/01/2026 medication overdose resulted in a change of condition.The findings include:Review of the facility's protocol, Medication Error Standard of Practice, dated 04/2025, revealed the purpose was to provide a timely response to identified medication administration…

  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 before2026-02-13 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 1) of nine residents reviewed for medication administration was free from significant medication errors. The facility failed to administer Vimpat (an anti-convulsant medication used to treat seizures) from 01/29/2026 until 02/01/2026, due to unavailability. When Licensed Practical Nurse (LPN) 1 administered the first (evening) dose of Vimpat on 02/01/2026, the resident received 200 milligrams (mg), rather than the 100 mg which was ordered. These errors are considered significant, as Vimpat has a narrow therapeutic window for safety, with high doses or incorrect administration having the potential to lead to increased seizures and/or severe, life-threatening events. After receiving twice the ordered dose, the resident became lethargic, displayed a change in condition, and required transfer to the hospital for evaluation in response to medication overdose. The findings include:Review of the facility's…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-01 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 observation, interview, record review and facility policy, the facility failed to notify the Responsible Party (RP) when) a decision was made to transfer or discharge the resident from the facility to the hospital for one of 14 sampled residents. (Resident (R) 3). The findings include:Review of the facility policy titled Admission, Discharge, and Transfer Standard of Practice dated 10/2020 revealed before the facility transfers a resident, the facility shall notify the resident and resident's representative to include the reason in a language and manner they understand.On 06/18/2025, R3 was transferred to the hospital from the facility. The RP was not informed of the transfer by the facility. Review of R3's admission Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses of Diastolic Heart Failure; Vascular Dementia, severe; and Diabetes.Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2025 revealed a Brief Interview for Mental Status…

  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 · D2025-08-01 · 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 a care plan was developed and implemented for four of 14 sampled residents (Resident #1 (R1), R3, #6, and R8. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 04/06/2015 and revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Closed record review of R1's face sheet revealed the facility admitted the resident on 04/22/2024. R1 was readmitted to the facility on [DATE] included diagnoses of: subsequent encounter for closed fracture with routine healing; personal history of Transient Ischemic Attack (TIA/stroke); and cerebral infarction without residual deficits, and difficulty in walking,…

  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 before2025-08-01 · 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 and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents. On 07/28/2025, Resident (R)8 was in the dining room and hit R6; only one staff member, out of three scheduled, was present during the altercation.The findings include:Review of facility policy titled, Resident Rights Standard of Practice, review date 04/2025, revealed residents have the right to have a safe, clean, comfortable, and homelike environment.Review of facility policy titled, Abuse Prohibition Standard of Practice, review date 04/2025, revealed neglect was the failure of the center, its team members or service providers to provide services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect included cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could result in physical harm, pain, mental anguish, or emotional distress.Review of a mealtime staffing sheet, undated, revealed three staff members were required to be present for…

  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 · D2025-08-01 · tag F0836 — isolated
  Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of state law, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Review of employee medical records revealed facility staff had not received tuberculosis (TB) testing within the required timeframe.Review of 902 [NAME] 20:205 revealed the administrative regulation established requirements for TB testing of healthcare workers in healthcare facilities or settings. The procedures were necessary to minimize the transmission of infectious TB disease among staff, patients, and residents of health facilities. Continued review revealed healthcare workers consisted of physicians, nurses, nurse aides, therapists, housekeeping, laundry, maintenance, and billing. Healthcare workers were required to have annual TB screening risk assessments and annual education about the signs and symptoms of active TB disease.The facility did not provide facility-specific policies for TB testing when…

  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 · Dcited before2025-07-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to protect residents from abuse for 2 of 84 sampled residents, (Residents (R)11 and R43). The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, last revised 07/2022, revealed the facility's definition of sexual abuse was, Non-consensual sexual contact of ANY type with a resident/patient. Per review, prevention of abuse included an ongoing assessment of resident behaviors was to be performed with care planning to include appropriate interventions. Continued review revealed for the reporting of abuse, the policy stated, alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames, and appropriate steps shall be taken to prevent recurrence of the incident.Review of the facility's internal Grievance/Concern Form, completed by the Social Services Director (SSD) on 06/24/2025,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-19 · 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

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement the facility's abuse policy for 2 of 84 sampled residents. (Residents (R)11 and R43).The findings include:Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revised 07/2022, revealed the facility's definition of sexual abuse was, Non-consensual sexual contact of ANY type with a resident/patient. Per review, prevention of abuse included an ongoing assessment of resident behaviors was to be performed with care planning to include appropriate interventions, Continued review revealed for the reporting of abuse, the policy stated, alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames, and appropriate steps shall be taken to prevent recurrence of the incident.Review of the facility's internal Grievance/Concern Form, completed by the SSD on 06/24/2025, revealed R11 reported to the SSD that another resident was making inappropriate comments to…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record reviews, and review of the facility's policy, the facility failed to implement its policies and procedures to ensure 2 of 84 sampled residents (R11) and (R12) were thoroughly investigated for abuse. The findings include:Review of the facility's policy titled Abuse Prohibition Standard of Practice, last revised 07/2022, revealed that in the event an alleged or actual violation occurs, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law, including the state survey agency within five working days of the incident. Continued review of the abuse policy revealed the facility's definition of sexual abuse was Non-consensual sexual contact of ANY type with a resident/patient. Additionally, the facility's policy, last…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-19 · 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 develop and implement a comprehensive person-centered care plan for 2 of 87 sampled residents (Residents (R) 45, and 81). The findings include:Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were to be ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of the Facility Investigation dated 05/17/2025 around 7:25 PM revealed Registered Nurse (RN) 2 observed R45 throw an ashtray at R81, during smoke break outside the facility.(a) Review of R45's Face Sheet revealed the facility admitted 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$447,485 in federal fines across 2 penalties.

• $12,740 — penalty dated 2025-05-17
• $434,745 — penalty dated 2025-05-17

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 BENJAMIN LANDA — 48 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

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

Follow the money — this home’s finances

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

About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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