Pilgrim Manor 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.

42.2% 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 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 62.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 59 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 0.64 therapist hours per resident per day in 2026Q1 — more than 90% 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 155 beds and averages 121.4 residents a day — about 78% 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.99 hrs/resident/day on weekends vs 3.57 on weekdays — 16% thinner on weekends. RN hours go from 0.24 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% 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.

22 citations, most serious first. The 16 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-12-04 · 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 record review, video footage review, and interviews, the facility failed to protect the resident's right to be free from deprivation of goods and services by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents when staff failed to utilize a Hoyer lift during a transfer. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-12-04 · 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 record review, video footage review, and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 (#1, #2, #3) residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings:…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Lcited before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
  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 record review, video review, and interviews the facility failed to supervise a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m., when the search began and local police and Resident #1's RP (Responsible Party) were notified. Resident #1 was found with no injuries on 07/23/2024 at approximately 8:25 p.m. by Resident #1's RP. Resident #1 was located at a local restaurant approximately one mile from 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 · L2024-08-01 · tag F0835 — failed to run the facility competently — widespread
  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, video review, an interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure a process was in place to prevent a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 (#1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. and 2. Ensure the nursing staff possessed the competency to accurately assess a resident for an elopement risk. The lack of administrative oversight resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized…

  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 · K2024-08-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 the nursing staff possessed the competency to accurately assess a resident for elopement risk for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m. Resident #1 had been inaccurately assessed upon admission to the facility on [DATE] by S4ADON (Assistant Director of Nursing) as not at risk for elopement. S4ADON failed to interview Resident #1's family or RP (Responsible Party) at the time of the initial…

  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
• Actual harm · Gcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to use a Hoyer lift, as determined necessary by the resident's comprehensive care plan, during a transfer from the resident's bed to wheelchair for 1 (#1) of 3 (#1, #2, #3) sampled residents which resulted in a right humeral neck fracture.The deficient practice resulted in harm for Resident #1 on 07/14/2025 at approximately 10:30 a.m. when S6 agency CNA (Certified Nursing Assistant) transferred Resident #1 from the bed to a wheelchair with a stand and pivot method without utilization of a Hoyer lift. Resident #1 had an onset of acute pain to her right arm/shoulder and reported her right arm hit the wheelchair armrest during transfer. Resident #1 was care planned for activities of daily living self-care deficit with intervention of dependent in transferring with the use of Hoyer lift. S7 agency LPN (Licensed Practical Nurse), Hospice and Resident #1's Responsible Party were notified. Resident #1's right shoulder x-ray results dated 07/14/2025 revealed an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-25 · 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 review and interviews, the facility failed to follow physician's orders for 1 (Resident #47) of 1 (Resident #47) resident reviewed for UTI. Findings: Review of Resident #47's medical record revealed an admit date of 09/26/2017 with a re-entry date of 11/22/2021. Resident #47 had diagnoses which included in part type 2 diabetes, postmenopausal atrophic vaginitis, unilateral primary osteoarthritis of the right hip and polyneuropathy. Review of Resident #47's Quarterly MDS dated [DATE] revealed in part a BIMS score of 15, indicating intact cognition. Review of Resident #47's comprehensive care plan revealed in part, Resident #47 was frequently to always incontinent of bowel and bladder with interventions initiated on 05/07/2024 to monitor for s/sx of UTI: pain, burning, and urinary frequency. Review of Resident #47's physician orders revealed an order dated 07/23/2025 for estradiol vaginal cream 0.1 mg/gm 1 application vaginally q day for vaginal irritation related to postmenopausal atrophic…

  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 · E2026-02-25 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on medication administration observations, record reviews, and interviews, the facility failed to ensure the facility was free from a medication error rate of 5% or greater. The facility had a 14.29% medication error rate with 4 medication errors out of 28 opportunities.Findings: Resident #19 Observation of the medication pass for Resident #19 on 02/23/2026 at 8:15 a.m. revealed S2LPN administered 13 oral medications to Resident #19. Review of Resident #19's current physician orders and MAR revealed Resident #19 had not received the following medications during medication pass, which were due on 02/23/2026 at 9:00 a.m.: Fluticasone propionate 50 mcg/at 1 spray in each nostril bidOlopatadine hcl solution 0.1% 1 drop in right eye q dayCyclosporine emulsion 0.05% 1 drop in both eyes bid During an interview on 02/23/2026 at 11:10 a.m. S2LPN acknowledged she administered fluticasone propionate, olopatadine hcl and cyclosporine emulsion to Resident #19 after medication pass observations had been completed. S2LPN acknowledged she should have notified surveyor to observe 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
• Potential for harm · Dcited before2026-02-25 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 2 (#38, #96) of the 48 sampled residents. Findings:Review of facility's policy titled Advance Directives with revision date of 05/31/2023 revealed in part:Policy StatementAdvance directives will be respected in accordance with state law and facility policy.Policy Interpretation and Implementation1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Resident #38 Review of Resident #38's medical record revealed an date of 02/17/2025. Further review of Resident #38's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. During an interview on 02/24/2026 at 2:53 p.m., S3admission Coordinator reported it was the facility's policy to provide printed…

  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 · D2026-02-25 · 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 record review and interview the facility failed to revise the care plan to reflect changes of a resident refusing medication/treatment for 1 (#31) of 1 sampled resident reviewed for care planning.Findings:Review of Resident #31's record revealed an admission date of 09/02/2020 with the following diagnoses which included but not limited to: Muscle wasting atrophy, Chronic Obstructive Pulmonary Disease, Mild protein-calorie malnutrition; and unspecified dementia.Review of Resident #31's Quarterly MDS dated [DATE] revealed a BIMS of 13 indicating intact cognition. Further review revealed under Section E: Rejection of Care was coded 0 indicating the behavior was not exhibited.Review of Resident #31's Discharge MDS dated [DATE] revealed under Section E: Rejection of Care was coded a 0 indicating the behavior was not exhibited. Review of Resident #31's Physician Order dated 06/18/2024 revealed an order for Estrace Vaginal Cream 0.1 milligram/gram, insert 1 application vaginally at bedtime.Review of 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
• Potential for harm · D2026-02-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  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 observations, interview and record review the facility failed to provide nutritional and hydration care and services for 1(#57) of 5 (#4, #7, #13, #14 and 57) resident reviewed for nutrition. The facility failed to provide care and services for resident #7 consistent with the resident's comprehensive assessment resulting in weight loss.Findings: Review of Resident #57's Comprehensive Plan of Care dated 05/17//2025 revealed Resident #57 had an ADL self-care performance deficit related to cerebral vascular accident times two, other symptoms and signs involving cognitive functions following cerebral infarction, vision loss. Eating, resident requires supervision to touch assistance with eating due to blindness, CVA.Review of Resident #57's record revealed diagnoses which included visuospatial deficit and spatial neglect following cerebral infarction, need for assistance with personal care, other lack of coordination and transient cerebral ischemic attack.Review of Resident #57's most recent Quarterly MDS…

  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 · D2026-02-25 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to use infection control standards of practice for 1(#7) of 5 (#4, #7, #13, #14 and 57) residents reviewed for nutrition by not providing proper placement of a resident's gastrostomy tubing to prevent an increased risk of contamination and infection. Resident #7's gastrostomy tubing with the cap or cover was attached to the feeding pump tubing laying on the floor.Observation on 02/23/2026 at 12:50 p.m. with S4 LPN revealed Resident #7's PEG tube was disconnected. The gastrostomy tubing extended from Resident #7's abdomen did not have a cap or cover; it was opened. The cap or cover attached to the feeding pump tubing laying on the floor. S4 LPN removed the cap or cover from the floor and attached it to Resident #7's gastrostomy tube.During an interview on 02/23/2026 at 12:50 p.m. S4 LPN reported she would have to change the tubing later.Review of Resident #7's record revealed diagnoses which included gastrostomy status, dysphagia, right…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to ensure a resident remained free from neglect when nursing staff failed to use a Hoyer lift to transfer 1 (Resident #F3) of 4 (Residents #F1, #F2, #F3, and #F4) sampled residents who required a mechanical lift for transfers.Findings:Review of the facility's Abuse and Neglect - Clinical Protocol policy with a revision date of 10/15/2025 revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Definitions. Neglect, as defined by S483.5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of goods or services that a…

  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 · E2024-12-17 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  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, observations and interviews, the facility failed to provide services that met professional standards for 2 (#102, #105) of 26 sampled residents. The facility failed to ensure safe oral medication administration practices by leaving medication at the bedside. Findings: Review of the facility's policy Administering Oral Medications with a revision date of October 2010 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation: 21. Remain with the resident until all medications have been taken. Resident #102 Review of Resident #102's medical record revealed an admit date of 07 /11/2023 with a diagnosis including, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #102's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 15 indicating intact cognition. An 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 · E2024-12-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  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

  Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#27, #224) out of 2 (#27, #224) residents reviewed for respiratory services. The facility failed to: 1. Change the humidification bottle and nasal cannula weekly as ordered for Resident #27, and 2. Ensure oxygen tubing was dated, and humidification was administered with oxygen for Resident #224. Findings: Review of facility policies related to oxygen therapy revealed in part: Department (Respiratory Therapy)-Prevention of Infection (revised November 2011): Use distilled water for humidification per facility protocol. [NAME] bottle with date and initials upon opening . Oxygen Administration (Revised October 2010)-The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .The following equipment and supplies will be necessary when performing this procedure. 1)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-12-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 observations and interviews, the facility failed to ensure dietary services were provided in a safe, sanitary environment to prevent contamination and food borne illness for the 121 residents served a meal tray from the kitchen per the Dietary Manager. The facility failed to ensure frozen meat was thawed following accepted practices. Findings: Observation in the facility kitchen on 12/15/2024 at 7:50 a.m. revealed 2 large tube shaped chubs of ground beef in plastic packing and 3 large tube shaped pork tenderloins in plastic packing submerged in standing water in the sink. During an interview on 12/15/2024 at 7:58 a.m. S7 [NAME] confirmed the meat should be thawing under running water, and should not be submerged in standing water. S7 [NAME] further reported the pork tenderloin was for the day's lunch, and the ground beef was for spaghetti for supper. During an interview on 12/15/2024 at 8:32 a.m. S6 Dietary Manager confirmed meat should be thawed under running, not standing, water. Observation in the facility kitchen on 12/16/2024 at 8:13 a.m. revealed multiple loose pork…

  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

“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

$186,253 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $12,425 — penalty dated 2025-09-03
• $52,855 — penalty dated 2024-12-04
• $120,973 — penalty dated 2024-08-01
• Medicare payment denial — starting 2025-10-16 for 13 days

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

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 13 rows in the source record cover these 10 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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