Oak Haven Rehabilitation and Healthcare 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.

46.7% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.8% 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 42 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 104 beds and averages 93.1 residents a day — about 90% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.31 hrs/resident/day on weekends vs 4.08 on weekdays — 19% thinner on weekends. RN hours go from 0.42 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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 fewer than at the previous inspection — improving. 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.

37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, The facility failed to ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision; and failed to ensure the resident's (#61) environment remained as free of accident hazards as possible for 1 (#61) of 5 sampled residents reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. Resident #61 was found by S6CNA standing on the side of a busy two-lane highway that runs in front of the facility, with a posted speed limit of 55 miles per hour. Facility administration were made aware of a door wanderguard system malfunction since 02/13/2026 and did not implement appropriate interventions…

  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 · K2026-04-16 · 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

  Based on observation and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#61) of 5 sampled residents reviewed for elopement. The facility failed to ensure staff were knowledgeable and able to identify residents at risk for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. Resident #61 was found by S6CNA standing on the side of a busy two-lane highway that runs in front of the facility, with a posted speed limit of 55 miles per hour. Facility administration were made aware of a door wanderguard system malfunction since 02/13/2026 and did 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2026-04-16 · 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

  Based on observation, record review, and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #61) of 5 sampled residents reviewed for elopement. The facility failed to:1. Ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision;2. Ensure staff were knowledgeable and able to identify residents at risk for elopement;3. Implement appropriate interventions and/or increase supervision after identifying the wanderguard security system was not functioning properly; and4. Ensure the resident's environment remained as free of accident hazards as possible. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was…

  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 · J2024-03-21 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders, and the resident's advance directives for 1 (Resident #76) of 2 (Resident #76 and Resident #77) closed records reviewed out of a total sample of 23. The facility failed to: 1. Ensure S4 LPN acted in accordance with Resident #76's Advanced Directives and Physician Orders, and initiated CPR when the resident was found unresponsive and without a pulse; and 2. Ensure EMS and the physician were notified when Resident #76 was found unresponsive, without a pulse. This deficient practice resulted in an Immediate Jeopardy for Resident #76 that began on [DATE] at approximately 6:00 a.m., when S6 CNA found Resident #76 in bed, unresponsive, and not looking right. S6 CNA notified S4 LPN, who failed to initiate CPR when she found Resident #76 unresponsive and without a pulse.…

  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
• Actual harm · Gcited before2024-12-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for 1 (#1) of 2 (#1 and #2) residents reviewed for falls. This failed practice resulted in an actual harm situation on 11/07/2024 at 9:35 a.m., when Resident #1, who was severely impaired cognitively; had diagnoses that included Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side; Unspecified Dementia; and required substantial/ maximal assistance for shower/ bathing and rolling left and right; rolled out of bed while receiving a bed bath by S4 CNA. Resident #1 fell onto the floor, and sustained a Closed Right Hip Fracture. Findings: Review of the facility's policy and procedure with revision date of March 2018, and titled Activities of Daily Living (ADLs), Supporting read in part . Policy Interpretation and Implementation 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement…

  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 · F2026-04-16 · tag F0732 — widespread
  Post nurse staffing information every day.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to post nurse staffing information on a daily basis that included in part the total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 93.Findings:Observation on 04/13/2026 at 7:30 a.m. revealed a Staffing Reporting Form dated 04/10/2026 on display at the front desk. There was no updated Actual Hours Worked for the date at the top of the form, nor another form dated today's date.Observation on 04/14/2026 at 9:45 a.m. revealed a Staffing Reporting Form dated 04/14/2026. There was no posted form with actual hours worked from the previous day (04/13/2026). There was also no binder available at the front desk with the previous forms available.Interview on 04/15/2026 at 11:10 a.m. with S1Admin and S2DON confirmed that they were unaware that Actual Hours Worked on the Staffing Reporting Form were required to be updated and posted or kept where the public could access the forms.Interview on 04/15/2026 at 11:30 a.m. with S15 AdminAsst confirmed that she…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure pureed foods were prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 12 residents on a puree diet. Total facility census was 93. Findings:Review of facility policy titled Puree Food Preparation revised 2025, revealed in part. It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 6. Resident receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per policy and procedure. Observation of S12 Dietary [NAME] on 04/13/2026 at 5:38 a.m. revealed the following:1. There was no recipe being followed to prepare pureed ham. S12 Dietary Cook, stated I judge the amount of ham to use.2. S12 Dietary [NAME] used a glass to pour chicken broth on the pureed ham. S12 Dietary Cook,…

  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 before2026-04-16 · 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 — the official record, unedited, may be distressing

  Based on observation and interview the facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Total facility census was 93. Findings:Observation on 04/13/2026 at 5:10 a.m. accompanied by S13 Dietary Manager revealed:1. A box of biscuits open to air in the freezer.2. A box of steak fingers open to air in the freezer. Interview at the time of observation with S13 Dietary Manager confirmed the above listed items were open to air, and should not have been.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-03 · tag F0802 — failed to prepare enough nourishing food — pattern
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to ensure that dietary support personnel were competent to safely and effectively perform the functions of the food and nutrition service. This deficient practice had the potential to affect the 89 residents who were prepared and served meals from the kitchen.During the initial tour of the kitchen on 12/01/2025 at 09:00 a.m., revealed no documentation reflecting dishwasher temperatures and sanitation checks were being performed routinely in the kitchen.In an interview on 12/01/2025 at 10:45 a.m., S6Dietary revealed he had been employed at the facility for about 3 months and is a dietary aide in the kitchen. S6Dietary revealed he was not trained on how to properly wash and sanitize dishes. S6Dietary revealed he did not know how to set up a 3-compartment sink. S6Dietary confirmed he had never checked the dishwasher temperature or sanitizer level when using the dishwasher; therefore, he had never recorded dishwasher temperatures or sanitizer levels.In an interview on 12/01/2025 at 10:50 a.m., S5Dietary revealed…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 and interviews, the facility failed to ensure that pureed food was prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 7 residents on a puree diet.Review of facility policy titled Puree Food Preparation revised 09/01/2024, revealed in part. It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 6. Resident receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per policy and procedure. 7. Puree Food Preparation Guidelines per serving: Vegetables (leaf, stem, or flower): Add 2 tablespoons mashed potato flakes.Review of facility approved recipe: Lemon Broccoli (#36865-P.[NAME] Broccoli Lemon 1/2 Cup) Week 1 revealed in part. 1 serving size…

  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 · Ecited before2025-12-03 · 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 observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 89 residents who received meals from the kitchen. The facility failed to ensure:1. Dish washing machine temperature and sanitizer status are monitored and logged daily.2. Coolers and freezer temperatures are monitored and logged daily.3. Food temperatures are recorded daily to ensure food is at the proper temperature before trays are assembled.4. Dietary staff wore hair restraints while preparing food.Review of facility policy titled Dietary Personal Hygiene, revised 09/1/2024, revealed in part. It is the policy of this facility to utilize the following guidelines for employee personal hygiene to prevent contamination of food by food service employees. 4. All dietary staff must wear hair restraints (e.g. hairnet, hat, and or beard restraint) to prevent hair from contacting food.Review of facility policy titled Record of Food…

  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 before2025-12-03 · tag F0658 — failed to meet professional standards of care — isolated
  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

  Based on observation, interview, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure Resident #4's physician's orders for a dietary supplement was carried out.Review of facility policy titled, Nutritional and Dietary Supplements, revised 09/01/2024, revealed in part. It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and the resident's highest practicable level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the residents' assessed needs.Review of Resident #4's medical record revealed an admission date of 05/31/2022, with diagnoses that included, in part. Unspecified Dementia, Severe, with Agitation, Bipolar Disorder, Major Depressive Disorder, Generalized Muscle Weakness, and Dysphagia.Review of Resident #4's quarterly MDS with ARD…

  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 · E2025-05-07 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings. Findings: Review of the facility's record of the Resident Council meeting held on 02/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. Review of the facility's record of the Resident Council meeting held on 03/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. Review of the facility's record of the Resident Council meeting held on 04/30/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. During the facility's Resident Council meeting on 05/05/2025 at 1:30 p.m., residents complained that staff continued to talk loudly down the hallways and on their phones, and that…

  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 before2025-05-07 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview, the facility failed to ensure controlled medications were stored in separately locked compartments in 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) medication rooms observed. Findings: Observation on 05/06/2025 at 09:45 a.m. of Medication Room A revealed one bottle of Lorazepam oral concentrate (controlled medication) in medication refrigerator placed next to medication lockbox. Interview on 05/06/2025 at 09:46 a.m. with S5 LPN (Licensed Practical Nurse) confirmed the above findings. S5 LPN confirmed the bottle of Lorazepam oral concentrate should have been in the medication refrigerator lockbox and was not because the key to the lockbox would not unlock the lockbox. S5 LPN stated she did not notify anyone of her inability to open medication lockbox. On 05/06/2025 at 09:46 a.m. S2 DON arrived to Medication Room A during above interview with S5 LPN. S2 DON confirmed Lorazepam and any other controlled medications that require refrigeration should be locked securely in medication refrigerator in lockbox.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#4) of 1 Residents reviewed for advance directives. The facility failed to ensure all medical records regarding advance directives consistently reflected Resident #4's wishes to be a DNI (Do not intubate). The total sample size was 29. Findings: Review of Resident #4's EHR (Electronic Health Record) revealed an admit date of [DATE] with a re-entry date of [DATE] with diagnosis which included: Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Respiratory Failure, Type 2 Diabetes Mellitus without Complications, Morbid Obesity, Non-rheumatic Aortic Valve Stenosis, Atherosclerosis Heart Disease, Hypertension, Depressive Disorder, Chronic Kidney disease. Further review of Resident #4's EHR's bed board revealed a code status of Full Code. Review of Resident #4's Significant Change MDS with ARD of [DATE] revealed 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 Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$44,606 in federal fines across 3 penalties.

• $11,004 — penalty dated 2024-12-05
• $16,801 — penalty dated 2024-03-21
• $16,801 — penalty dated 2024-03-21

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 VENZA CARE MANAGEMENT — 25 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 24 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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 $769K 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.

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