Waldon Health Care 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.

Met the expected recovery: 44.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 205 beds and averages 90.0 residents a day — about 44% occupied, or roughly 115 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.480 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.21 hrs/resident/day on weekends vs 3.59 on weekdays — 10% thinner on weekends. RN hours go from 0.21 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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.

38 citations, most serious first. The 14 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · K2024-09-05 · 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 interviews and record review, the facility failed to deliver care per professional standards by failing to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); and, 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-09-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate. S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented 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
• Immediate jeopardy · K2024-09-05 · 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

  Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents; and, 3. Staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision; 4. The facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024,…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-04-17 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer pain medication when a nonverbal resident showed signs and symptoms of pain for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in actual harm for Resident #2 beginning on 04/09/2024 when S4Occupational Therapist (OT) reported to S3Licensed Practical Nurse (LPN) Resident #2 had facial grimacing with movement of the right lower extremity with no intervention to manage Resident #2's pain. Findings: Review of the facility's policy titled, Pain Management dated January 2024 revealed, in part, identifying pain in a non-verbal resident was observing for facial grimacing and being resistive to movement and care. Further review revealed pain can be managed by pharmacological interventions such as prescribed medication. Further review revealed interventions for pain would need to be reassessed and if it has not been adequately controlled, the multidisciplinary team, including 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
• Potential for harm · D2026-01-14 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to:1. Ensure the Minimum Data Set (MDS) accurately reflected the diagnosis of 1(Resident #8) of 1 resident reviewed for active diagnoses;2. Ensure the MDS accurately reflected high-risk medications for 1(Resident #8) of 1 resident reviewed for medications;3. Ensure the MDS accurately reflected a Pre-admission Screening and Resident Review (PASRR) Level II for 2 (Resident #9, Resident #67) of 2 residents reviewed for PASRR Level II; and,4. Ensure the MDS accurately reflected the tobacco status of 1(Resident #67) of 1 resident reviewed for tobacco use.Findings: 1. Review of Resident #8's medical record revealed, in part, Resident #8 was admitted to the facility on [DATE], with a diagnosis of obstructive and reflux uropathy.Review of Resident #8's admission MDS with an Assessment Reference Date (ARD) of 12/10/2025 revealed, in part, Resident #8 was assessed as having no diagnosis of obstructive and reflux uropathy. Review of Resident #8's care plan, dated…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-14 · 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, interviews, and record review, the facility failed to ensure the total number and the actual hours worked for licensed and unlicensed nursing personnel was posted daily during review of nurse staffing requirements.Findings:Observation on 01/12/2026 at 8:35AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/12/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.Observation on 01/13/2026 at 10:32AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/13/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.In an interview on 01/13/2026 at 10:35AM, S5Ward Clerk indicated she entered the total number of licensed and unlicensed personnel that worked on the Daily Nursing Staffing…

  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 before2026-01-14 · 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, interviews, and record review, the facility failed to ensure food stored in the facility's walk-in refrigerator was properly labelled and contained with an opened date and was unavailable for resident use. Findings: Review of the facility's policy, dated 01/2026 and titled Food Receiving and Storage revealed, in part, all food stored in the refrigerator will be labeled and dated.Observation on 01/12/2026 at 9:28AM revealed the facility's walk-in refrigerator had the following opened, undated and unlabeled food items:-1 package of smoked sausage; and, -2 packages of smoked sliced turkey breast.In an interview on 01/12/2026 at 9:29AM, S8Cook confirmed the above-mentioned opened food items were not dated and labeled, and should have not been available for resident use.In an interview on 01/12/2025 at 1:55PM, S1Administrator indicated the above-mentioned undated and unlabeled opened food items should have been labeled appropriately and not available for resident use.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-26 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to implement facility policy to ensure all witness statements received verbally were titled, and signed by both the person making the statement and the witness. Findings: Review of the facility's Abuse, Neglect, and Misappropriation of Funds Policy and Procedure, with revised date of March 2025, if only oral information can be obtained about an allegation of abuse, the following is required, in part: A statement must be documented signed and date; and, The recorder and the witness to the statement must sign, date, and title statement. Review of the facility's investigation related to an allegation of sexual abuse dated 12/04/2024, revealed S1Administrator had documented S13Housekeeper's statement regarding alleged sexual abuse; however, S13Housekeeper had not signed and dated the statement, and S1Administrator had not titled the statement. Review of S5LPN's Sexual Abuse Allegation Statement dated 03/15/2025 revealed the statement was not signed by S5LPN, nor any witness. Review of S12CNA's Sexual Abuse Allegation Statement…

  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 · D2025-03-26 · tag F0741 — failed to have staff trained for behavioral health — isolated
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors for 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) of 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) sampled staff reviewed for behavior training. Findings: Review of the facility's Facility Assessment Tool updated on 10/16/2024 revealed, in part, the facility was able to accept residents with psychiatric/mood disorders and psychiatric symptoms and behaviors would be identified and interventions implemented to help support the residents. Review of Resident #2's Minimum Data Set Assessment Reference Date 12/24/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 8 (score of 08-12 indicated moderate cognitive impairment). Review of Resident #2's care plan revealed, in part, Resident #2 had the potential to touch female peers inappropriately (touching a resident's arm without permission) initiated on 03/16/2025 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-26 · tag F0755 — failed to provide safe pharmacy services — isolated
  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

  Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (Resident #R1) of 7 (Resident #2, Resident #3, Resident #4, Resident #R1, Resident #R2, Resident #R3, Resident #R4) sampled residents observed during medication administration. Findings: Review of Resident #R1's record revealed, in part, Resident #R1 had diagnoses which included chronic diastolic congestive heart failure (condition in which the heart was unable to pump blood proficiently) and sinusitis. Review of Resident #R1's March 2025 Physician Orders revealed, in part, Lasix (medication used to remove excess fluid from the body) 20 milligrams (mg) administer three tablets by mouth daily. Further review revealed an order for Flonase (medication used to treat allergies) 50 micrograms (mcg) per actuation one spray in both nostrils one time a day. Observation on 03/21/2025 at 8:15AM revealed S4Licensed Practical Nurse (LPN) was unable to locate Resident #R1's Flonase and Lasix to administer. In an interview on 03/21/2025 at 8:15AM, S4LPN indicated…

  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 · E2025-01-16 · tag F0801 — pattern
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interviews, the facility failed to ensure the dietary manager had completed an approved food safety program and passed the accompanying test for 1 (S13Dietary Manager) of 1 (S13Dietary Manager) sampled dietary managers employed by the facility. Findings: In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated she had been the facility's dietary manager for 2 years. S13Dietary Manager further indicated she had not taken the exam for the ServSafe course. In an interview on 01/14/2025 at 3:50 p.m., S1Administrator indicated the facility was not aware S13Dietary Manager had not completed the examination for her ServSafe course, and therefore did not have ServSafe certification. At time of exit the facility had not presented any evidence S13Dietary Manager had passed the ServSafe examination.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-16 · 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, record review, and interviews, the facility failed to ensure: 1. Food items were not placed in areas in which water had accumulated on food packaging; 2. Food items were covered in the refrigerator; 3. Expired food items were discarded and not available for use; 4. Damaged food items were not stored amongst other food items; 5. Staff had all hair restrained when in the food preparation areas; 6. Chemicals were not stored in food preparation areas; 7. Food items were labeled with an opened date and labeled with the contents of the container/bag; and, 8. Staff did not store their food items with residents' food items; Findings: Review of the facility's policy titled, Food Receiving and Storage Policy and Procedure, last reviewed in 01/2025 revealed, in part: -staff were to ensure refrigerated foods were labeled, dated, and monitored so they are used by their use by date, frozen, or discarded; and, -food may not be stored under leaking water lines, or under lines on which water has condensed. Observation on 01/13/2025 at 9:46 a.m. with S13Dietary Manager…

  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 · E2025-01-16 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, the facility failed to ensure: 1. A facility-wide surveillance of resident's infections were maintained (Resident #7, Resident #12, Resident #27, and Resident #84); and, 2. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care (Resident #21). This deficient practice was identified for 4 (Resident #7, Resident #12, Resident #27, and Resident #84) of 13 (Resident #1, Resident #7, Resident #12, Resident #27, Resident #39, Resident #55, Resident #56, Resident #63, Resident #73, Resident #76, Resident #79, Resident #84, and Resident #88) sampled residents reviewed for infection surveillance; and, for 1 (Resident #21) of 2 (Resident #21 and Resident #27) residents observed during incontinence care. Findings: 1. Review of the facility's Antibiotic Stewardship- Review of and Surveillance of Antibiotic Use and Outcomes, with revised date of February 2024, revealed, in part: -as part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-16 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record reviews, and interviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #21) of 2 (Resident #21 and Resident #27) sampled residents observed during incontinence care. Findings: Review of the facility's undated Resident [NAME] of Rights revealed, in part, staff shall protect the right to privacy of the resident's body during toileting, bathing, and other activities of personal hygiene. Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated Resident #21 had severe cognitive impairment. Further review revealed Resident #21 was dependent on staff assistance for toileting hygiene. Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care while Resident #21's roommate, Resident #46, remained in the room. Further observation revealed S11CNA and S12CNA did not close…

  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

$120,279 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $88,656 — penalty dated 2024-09-05
• $31,623 — penalty dated 2024-04-17
• Medicare payment denial — starting 2024-10-18 for 28 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 INSPIRED HEALTHCARE MANAGEMENT — 6 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 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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