Allen Oaks Nursing and Rehab 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.

45.6% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 51.9% 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% 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 91 beds and averages 75.5 residents a day — about 83% occupied, or roughly 16 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.28 hrs/resident/day on weekends vs 3.92 on weekdays — 16% thinner on weekends. RN hours go from 0.38 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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.

36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · J2024-08-19 · 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, observations, and interviews, the facility failed to ensure a cognitively impaired resident who had a history of wandering, was adequately supervised and not allowed to exit the building without staff knowledge, for 1 Resident (#R7) of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m., when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024. S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m. The Immediate Jeopardy was removed on 08/19/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-19 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on 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 (#R7), of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). The facility failed to: 1. Have an effective system in place to ensure Resident #R7 was adequately supervised to prevent her from exiting the building unsupervised on 06/25/2024 and 08/03/2024; 2. Complete an incident report and/or thoroughly investigate Resident #R7's elopements on 06/25/2024 and 08/03/2024; and 3. Update Resident #R7's care plan to include new interventions to prevent the resident from exiting the building unsupervised after two previous elopements. This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m. when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a resident's right to be free from verbal and mental abuse by staff for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents. This failed practice resulted in an actual harm situation for Resident #1 on 07/23/2024 on the 6:00 p.m. to 6:00 a.m. shift when Resident #1, who was severely impaired cognitively, and had diagnoses of Dementia and Major Depressive Disorder, was verbally and mentally abused by S3 CNA. Review of Resident #1's video camera footage revealed on 07/23/2024 at 7:54 p.m., S3 CNA while in Resident #1's room stated to Resident #1 You old meanie. At 11:00 p.m., while S3 CNA and S4 CNA were providing ADL assistance to Resident #1, S3 CNA stated to Resident #1 Why you gotta be like that man? Resident #1 replied I love Jesus. S3 CNA stated If you loved Jesus, you wouldn't be ugly every time someone came in here. That's not loving Jesus, that's loving the Devil. At 11:07 p.m., S3 CNA and S4 CNA were in Resident #1's room. S3 CNA…

  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 · E2026-06-17 · tag F0605 — failed to not use drugs as a restraint — pattern
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based interview and record review, the facility failed to ensure a resident was free of chemical restraints for 1 (Resident #8) of 5 residents reviewed for unnecessary medications by failing to ensure: 1. A new order was obtained for an as-needed (PRN) psychotropic drug after 14 days; and2. Indications of use were documented for the administration of a PRN psychotropic drug Review of the facility's undated policy titled, Antipsychotic Medication Use revealed in part . Antipsychotic medications may be considered for residents with dementia, but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosages for the shortest period of time and are subject to gradual dose reduction and re-review. 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · Ecited before2025-07-02 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  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 meet the nutritional needs for residents in accordance with established national guidelines. The facility failed to follow the menu for all residents receiving puree diet. 5 residents in the facility received a puree diet. Findings: On 06/30/2025 at 3:25 p.m., review of facility undated policy titled, Puree Diet, revealed in part . the puree diet is based on the regular diet, therefore, all the same guidelines apply with alterations being made only to allow for ease and chewing and swallowing. On 07/01/2025 at 9:15 a.m., review of facility policy titled, Menus, with revision date of October 2017 revealed in part, Menus meet the nutritional needs of residents in accordance with recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. On 06/30/2025 at 10:00 a.m., observation of the menu posted 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 before2025-07-02 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 72 residents who resided in the facility. The facility failed to ensure: 1. Food items in the refrigerators and freezers were labeled and dated; 2. Dry food items were labeled with an open date and stored in a sealed container; 3. Dishware was clean and stored under sanitary conditions; 4. Staff were wearing hair restraints, including beard restraints, to prevent hair from contacting food. Findings: On 07/01/2025 at 9:50 a.m., review of facility policy titled, Food Receiving and Storage, with revision date of July 2014, revealed in part . Food shall be received and stored in a manner that complies with safe food handling and practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated. 1. On 06/30/2025 at 8:47 a.m.,…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-02 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from flies. The deficient practice had the potential to affect 72 residents who resided in the facility. Findings: On 07/01/2025 11:00 a.m., review of facility policy titled Pest Control with revision date of May 2008 revealed in part . Our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Observation of the facility's kitchen on 06/30/2025 at 9:06 a.m., accompanied by S3 Dietary Manager, revealed multiple flies observed throughout the kitchen area, with flies landing on the food being prepared and the food prep area. On 06/30/2025 at 10:25 a.m., during a return trip to the kitchen, multiple flies were observed in the kitchen food prep area. On 06/30/2025 at 3:50 p.m., during a return trip to the kitchen area for an interview with S3 Dietary Manager, multiple flies were observed in the kitchen area. S3 Dietary…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-02 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observations, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#61) of 1 residents reviewed for dignity. Findings: Review of Resident #61's medical record revealed an admission date of 04/04/2025, with diagnoses that included in part . Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct; Hypospadias, Penile; Encounter for Palliative Care; Presence of Urogenital Implants; Neuromuscular Dysfunction of Bladder; and Retention of Urine. Review of Resident #61's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/25/2025 revealed a BIMS score of 14, which indicated intact cognition. Resident #61 used an indwelling urinary catheter for urine elimination. Review of Resident #61's current clinical physician's orders revealed an order date of 04/24/2025-catheter care every shift: to keep…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  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 resident received reasonable accommodation of needs by failing to have an assistive device accessible to 1 (Resident #45) of 26 sampled residents. Findings: On 07/2/2025 at 1:50 p.m., review of the facility policy titled. Assistive Devices and Equipment, with a revision date of July 2017, revealed in part . Our facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These include, but are not limited to, walkers. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' plan of care. Review of Resident #45's electronic medical record revealed an admit date of 12/26/2024 with diagnoses that included but not limited to: Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Head, Neck, and face, Heart Failure, Acquired Absence of…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-02 · 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, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure a resident received enteral feedings as ordered by the physician for 1 (#65) of 1 residents reviewed for tube feeding. Total sample size 26. Findings: Review of Resident #65's Clinical Record revealed an admit date of 07/10/2024 with diagnoses which included: Pneumonitis due to Inhalation of Food and Vomit; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Heart Failure; Anxiety; Cerebral Infarction; Hyperlipidemia; Aphasia; Hypertension; Dysarthria and Anarthria. Review of Resident #65's Annual MDS with an ARD of 05/24/2025 revealed a BIMS score of 0 indicating Resident #65 rarely/never understood. Resident #65 was dependent for bed mobility, transfers, eating, and toileting. Review of Resident #65's Physician Orders revealed the following, in part: 06/27/2025-Enteral feedings: Osmolite 1.2 at 40 milliliters (ml) /hour via pump Review of Resident #65's Care Plan dated 04/28/2025 read in part: Resident #65…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#55) of 2 (#14 and #55) residents reviewed for respiratory care. Findings: Review of the facility's policy titled Oxygen Administration, with a revised date of 10/2010 revealed the following in part, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 4. All assessment data obtained before, during, and after the procedure. Review of Resident #55's medical record revealed an admission date of 10/15/2024 with diagnoses that included in part, Chronic Obstructive Pulmonary Disease with (Acute)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · 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, interview, and record review the facility failed to provide pharmaceutical services that assured accurate disposition and/or administration of medications to meet the needs of each resident. The facility failed to: 1. Ensure proper nursing procedures and documentation were completed at the time of wasting/destroying narcotics on 1 (Med Cart 1) of 2 (Med Cart 1 and Med Cart 2) medication carts for Resident #26. 2. Ensure proper nursing procedures for wasting of controlled substances were completed when Resident #60's controlled medication was not administered. Findings: Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Discarding and Destroying Medications revised on 10/2014 revealed the following part . Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 6. for unused, non-hazardous controlled substances that are not disposed of by an authorized collector, c. dispose with the solid waste in the presence of two…

  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 · D2025-07-02 · tag F0761 — failed to label and store drugs safely — isolated
  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 — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. This deficient practice has the potential to affect all 72 residents residing in the facility. The facility failed to: 1. Ensure expired medications were not available for administration to residents in 1 (Med Room B) of 2 (Med Room A and Med Room B) medication rooms. 2. Ensure controlled substances were properly stored in a permanently affixed compartment and had restricted access until destroyed appropriately. Findings: Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Controlled Substances revised on 12/2012 revealed the following in part .The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Storage of Medications revised on 04/2007 revealed the following in part .the facility shall store all drugs and…

  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

“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

$133,224 in federal fines across 1 penalty.

• $133,224 — penalty dated 2024-08-19

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.

Who owns this facility

CMS files one row per role, so the 33 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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 75% 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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