Colonial Oaks Skilled Nursing and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

30.6% 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 55 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.3% 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 44 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 0.79 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 120 beds and averages 85.8 residents a day — about 72% occupied, or roughly 34 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.36 on weekdays — 13% thinner on weekends. RN hours go from 0.10 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · K2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to ensure Resident #331 received needed services and treatment for pain management of a right fractured hip by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol…

  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 · K2025-06-05 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to provide pain management consistent with professional standards of practice for a resident, following a fractured right hip, for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. Nursing staff failed to ensure severe pain was managed for Resident #331 by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after…

  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 · K2025-06-05 · 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 record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to have an effective system in place to obtain and provide pain management for Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain…

  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 · E2025-06-05 · tag F0554 — pattern
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 and interviews, the facility failed to provide services that met professional standards for 1 (#51) of 36 sampled residents. The facility failed to ensure safe medication administration practices by leaving medication at the bedside. Findings: Review of facility's Self-Administration of Medications policy revised December 2016 revealed in part: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of their overall evaluation the staff with the assistance from the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity the interdisciplinary team will perform an assessment of Self-Administration of Medications Form, or equivalent including (but not…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-05 · tag F0568 — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure quarterly statements were provided for 2 residents (#35, #54) of 2 (#35, #54) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and or their responsible parties. Findings: Review of the facility's Resident Trust Fund Agreement included in the facility's admission packet revealed on page 13 the statement: I will receive a statement of any account at least quarterly. Resident #35 Review of Resident #35's medical record revealed an admit date of 02/16/2018 with diagnoses of but not limited to cerebral infarction, chronic obstructive pulmonary disease, polyneuropathy, abnormalities of gait and mobility and anxiety disorder. Review of Resident #35's Quarterly MDS (Minimum Data Set) dated 04/12/2025 revealed a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. During an interview on 06/02/2025 at 3:47 p.m. Resident #35 reported she did not receive…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-05 · tag F0656 — failed to write and follow a full care plan — pattern
  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 record reviews and interviews the facility failed to develop resident's comprehensive person-centered care plans with a focus and appropriate approaches on bed rails/side rails for 3 (#8, #12, and #27 ) of 3 (#8, #12, and #27) residents reviewed for physical restraints. Findings: Resident #8 Review of Resident #8's face sheet revealed an admission date of 05/01/2020 with diagnoses of fusion of lumbar spine, sequelae of cerebral infarction, rheumatoid arthritis, muscle wasting to multiple sites, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility. Review of Resident #8's June 2025 physician orders revealed an order dated 04/04/2025: may have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning. Review of Resident #8's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed bed rails not in use. Review of Resident #8's care plan failed to reveal a focus with appropriate interventions on bed rails/side rails. Observation 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-05 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide pharmaceutical services that assure the accurate administering of medications for 2 (#44 and #331) of 2 (#44 and #331) residents whose medications were reviewed. The facility failed to ensure administration of pain medication was accurately documented. Findings: Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Document the following in the resident's medical record: 1. Results of the pain assessment 2. Medication 3. Dose 4. Route of administration; and 5. Results of the medication (adverse or desired). Review of Resident #44's medical record revealed an admit date of 07/22/2023 with diagnoses of but not limited to muscle wasting and atrophy, Parkinson's disease without dyskinesia, Crohn's disease, and primary generalized osteoarthritis. Review of Resident #44's Quarterly MDS (Minimum Data Set) dated 03/27/2025 revealed Resident #44 was assessed to have a BIMS (brief interview mental…

  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 · Ecited before2025-06-05 · tag F0851 — pattern
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required. Findings: Review of PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 1 2025 (October 1-December 31) revealed triggers for the following: star staffing rating equals 1 and excessively low weekend staffing. Review of the facility's weekend staffing patterns for FY Quarter 1 2025 (October 5, 2024-Decemeber 29, 2024) revealed the facility had adequate amount of staffing hours. During an interview on 06/04/2025 at 11:50 a.m. S1 Administrator reported payroll was completed in the facility and ultimately sent to CMS by the Corporate Office. S1 Administrator reported the facility had above the required staffing hours for FY Quarter 1 2025. S1 Administrator reported the discrepancy with the staffing hours occurred when agency staff do not clock in on the facility clocking system and agency staffing hours have to be manually added to the payroll and/or facility employees…

  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 · E2025-06-05 · tag F0868 — pattern
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview the facility failed to have the six required staff members present for quarterly QAA (Quarterly Assessment Assurance) Committee meetings. Findings: Review of the facility's Quality Assessment and Assurance Committee Summary meetings 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025 sign-in sheets revealed the DON (director of nursing), IP (infection preventionist), MD (medical director), and Administrator were present. Further review failed to reveal the required two additional staff members were present for QAA meetings on 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025. During an interview on 06/05/2025 5:30 p.m. S1 Administrator confirmed the required two additional facility staff members were not present for QAA meetings on 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-05 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations, and interview the facility failed to provide appropriate treatment and services for 1(#52) resident of 1(#52) resident reviewed for tube feedings. The facility failed to ensure Resident #52's tube feeding bag was changed every 24 hours. Findings: Review of the facility's Enteral Feedings-Safety Precautions policy with a revision date of November 2018 revealed in part: 1. Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer. Review of Resident #52's Physician Orders revealed an order dated 02/01/2024 to enteral feed every shift; Isosource 1.5. 45 ml (milliliter) per hour for 22 hours via feeding pump. Observation on 06/02/2025 at 8:15 a.m. revealed Resident #52's tube feeding bag infusing at 45 ml per hour dated 06/01/2025 at 4:00 a.m Observation on 06/02/2025 at 9:20 a.m. with S5 LPN (Licensed Practical Nurse) MDS (Minimum Data Set) Nurse revealed Resident #52's tube feeding bag infusing at 45 ml per hour and dated 06/01/2025 4:00 a.m During an interview on 06/02/2025 9:20 a.m.…

  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 · D2025-06-05 · tag F0732 — isolated
  Post nurse staffing information every day.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews the facility failed to ensure facility's daily census and nurse/CNA (Certified Nurse Assistant) staffing information was clearly displayed in a visible place for residents and visitors to view at any given time. Findings: Observation of the facility on 06/02/2025 at 2:00 p.m. failed to reveal the facility's daily census/staffing information was posted. Observation of the facility on 06/03/2025 at 10:30 a.m. failed to reveal the facility's daily census/staffing information was posted. Observation of the facility on 06/04/2025 at 2:30 p.m. failed to reveal facility's daily census/staffing information was posted. During an interview on 06/04/2025 at 2:30 p.m. S17 CNA/Ward Clerk reported daily census, nurse/ CNA staffing information should be posted in a locked bulletin board in the facility breezeway. S17 CNA/Ward Clerk reported S1 Administrator had a key to the locked bulletin board and nurse/CNA staffing information was not posted on the weekend and have not been posted this week. During an interview on 06/04/2025 2:30 p.m. S1 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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 record review, observation and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure: 1. Kitchen staff properly monitored the chemical levels in the third compartment sanitization sink 2. the chest freezer remained free from ice buildup 3. expired/outdated food was removed from the chest freezer and 4. The chest freezer was free of spilled food items. This had the potential to affect any of the 77 residents who received trays out of the kitchen on 06/02/2025. Findings: Review of the facility policy titled Manual Cleaning and Sanitizing Utensils and Portable Equipment dated 10/01/2018 revealed in part: 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75 degrees Fahrenheit. 9. Test and record the parts per million…

  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 · Dcited before2024-12-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews, the facility failed to ensure a resident fall was reported according to facility policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents for falls. Findings: Review of facility's policy Accidents and Incidents- Investigating and Reporting dated November 2024 revealed, in part: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident. 3. The Charge Nurse or designee shall complete an Incident Report form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of Resident #1's medical record revealed in part, an admit date of 07/24/2020 with diagnoses including muscle wasting and atrophy not elsewhere classified multiple sites, other specified disorders of bone…

  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

“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

$66,170 in federal fines across 1 penalty.

• $66,170 — penalty dated 2025-06-05

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 PRIORITY MANAGEMENT — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 LA