Southern Hills Healthcare And Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

44.6% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 27.0% 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 37 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 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 101 beds and averages 78.7 residents a day — about 78% occupied, or roughly 22 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.46 hrs/resident/day on weekends vs 3.92 on weekdays — 12% thinner on weekends. RN hours go from 0.31 to 0.14 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.

19 citations, most serious first. The 14 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · J2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision during incontinent care for 1 (#2) of 3 (#1, #2, #3) residents reviewed for falls. The deficient practice resulted in an immediate jeopardy for Resident #2 on 04/26/2025 at approximately 5:00 a.m. when Resident #2 fell out on the left side of the bed during incontinent care when S4CNA (Certified Nursing Assistant) failed to ensure the resident was secured and safe in the bed to prevent her from falling before she turned away to retrieve an adult brief from the over bed table leaving Resident #2 unsupervised causing Resident #2's fall resulting in a fractured right femur. Resident #2 was transferred to a local ER (Emergency Room) on 04/26/2025. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · L2025-02-07 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5RN (Registered Nurse) asked Resident #36, who was cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that 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 date of correction
• Immediate jeopardy · L2025-02-07 · tag F0609 — failed to report abuse allegations — widespread
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator, to the appropriate state agency within 2 hours after the allegations were made and to local law enforcement for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2025-02-07 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. protect Resident #36 from sexual abuse by Resident #2 and ensure all residents were free from abuse; 2. report abuse to the appropriate state agency and law enforcement. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's glassed-in, unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-15 · tag F0644 — pattern
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to refer 1 (#70) of 1 resident with a new diagnosis of bipolar disorder for a level II PASARR. Findings:Review of Resident #70's medical record revealed an admit date of 10/09/2020 with the following diagnoses, including in part: generalized anxiety disorder, dementia, bipolar disorder current episode mixed severe with psychotic features (01/13/2026) and insomnia.Review of Resident #70's quarterly MDS assessment dated [DATE] revealed an active diagnosis of bipolar disorder. Review of Resident #70's medical record failed to reveal a level II PASARR referral was completed for a new diagnosis of bipolar disorder.During an interview on 04/14/2026 at 2:45 p.m. S2 Social Services reported Resident #70 had a permanent level II PASARR but was unable to produce documentation.During an interview on 04/15/2026 at 8:25 a.m. S1 DON confirmed a level II PASRR referral was not completed on Resident #70 following a new diagnosis of bipolar disorder.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-15 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#33) of 2 total residents reviewed for anticoagulant medications. The facility failed to develop a care plan for Resident #33's cerebral infarction and anticoagulant therapy. Findings: Review of Resident #33's medical record revealed an admit date of 02/12/2026 with the following diagnoses, including in part: cerebral infarction and chronic obstructive pulmonary disease. Review of Resident #33's Physician's orders revealed an order dated 02/13/2026: Xarelto (anticoagulant) oral tablet 10 mg give 1 tablet by mouth in the evening related to cerebral infarction. Review of Resident #33's Comprehensive Care Plan failed to reveal a problem and approach for cerebral infarction and anticoagulant therapy. During an interview on 04/14/2026 at 12:40 p.m., S3MDS Nurse acknowledged Resident #33 had not been care planned for cerebral infarction and the use of an anticoagulant and should have been.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-15 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit an assessment within 14 days after completion for 1 (#56) of 1 resident reviewed for resident assessments. Findings:Review of Resident #56's medical record revealed an admit date of 08/19/2024 with the following diagnoses, including in part: type 2 diabetes with hyperglycemia, heart failure unspecified and paranoid schizophrenia. Review of Resident #56's MDS Assessments revealed a quarterly assessment dated [DATE] with a status of inactivated. Further review revealed an assessment dated [DATE] with a status of annual is export ready. During an interview on 04/14/2026 at 1:30 p.m. S3 MDS Nurse reported Resident #56's assessment dated [DATE] was entered as a quarterly assessment and should have been an annual assessment. S3 MDS Nurse acknowledged the 02/24/2026 assessment had not been transmitted.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-07 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  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 notify the resident's representative and physician after an incident of sexual abuse for 1 (#36) of 2 (#2 and #36) residents reviewed for abuse. Findings: Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of Resident #36's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #36 had a BIMS (Brief Interview of Mental Status) score of 03 out of 15 indicating severely impaired cognition. Review of Resident #36's medical record revealed, a nurse's note by S5 RN (Registered Nurse) dated 09/08/2024 at 9:24 p.m. which read in part, S4 CNA (Certified Nursing Assistant) reported to S5 RN that Resident #36 was being felt on in dining room by a male resident (Resident #2). Further review Resident #36'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-07 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#22, #326) out of 18 sampled residents reviewed. The facility failed to ensure a physician's order was in place for Resident #22's wander guard alarm device and for the maintenance/monitoring and/or discontinuation of Resident #326's PICC (Peripherally Inserted Central Catheter) line. Findings: Resident #22 Review of Resident #22's medical record revealed an admit date of 12/12/2022 with diagnoses that included, in part, Alzheimer's disease, anxiety disorder, and chronic kidney disease. Review of Resident #22's physician orders failed to reveal an order for wander guard alarm device. Review of Resident #22's annual MDS (minimum data set) assessment dated [DATE] revealed in part, Resident #22 had a BIMS (brief interview for mental status) score of 03, indicating severely impaired cognition. Review of Resident #22's current care plan revealed Resident #22 was 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-07 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 correct use and maintenance of bed rails by ensuring 3 (#13, #50, #51) out of 3 residents reviewed for bed rails were assessed for the risk of entrapment from bed rails and 1 (#51) out of 3 residents nurse data collection and screening for bed rails was completed correctly. Findings: Review of facility's Physical Restraints/Devices Policy (revision date 03/2024) revealed: Purpose: to ensure that the resident is given the least restrictive options to care. To ensure resident safety and promote wellbeing. Potential reasons for using a physical restraint: 1. to improve the resident's mobility and independent function. 2. to treat resident's medical symptoms 3. in an emergency to restrict movement to protect the resident during treatment and diagnostic procedures. 4. to prevent the resident from injuring himself or others. Side rails: 4. Ensure that there is not a gap between the mattress and the side rail, as per facility policy.…

  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 · E2025-02-07 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on review of personnel records and an interview the facility failed to ensure an annual performance review was completed for 1 (S11) of 5 (S11, S12, S13, S14, & S15) CNAs (Certified Nurse Assistant) at least once every 12 months. Findings: Review of S11 CNA's personnel record revealed a hire date 02/03/2017 and a re-hire date 10/28/2021. Review of S11 CNA's personnel record failed to reveal a 2024 annual performance review was completed. During an interview on 02/06/2025 at 8:40 a.m. S9 Human Resources reviewed S11 CNA's personnel file and confirmed an annual performance review had not been completed for 2024.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 1 (#326) of 1 (#326) resident reviewed for antibiotic use. Findings: Review of the facility's Enhanced Barrier Precautions policy with a revision date of 03/2024 revealed in part: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBPs (Enhanced barrier precautions) involve gown and glove use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). EBPs are indicated for residents with any of the following: Wounds and/or…

  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 · D2025-02-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the care plan had been revised for 1 (Resident #2) of 18 sampled residents. The facility failed to update Resident #2's care plan to include increased monitoring/supervision after an incident of resident to resident abuse. Findings Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part bipolar disorder, major depressive disorder-single episode severe with psychotic features, anxiety disorder, intellectual disabilities and delusional disorders. Review of Resident #2's most recent quarterly MDS (Minimum data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview of Mental Status) score of 09 out of 15 indicating moderate cognitive impairment. Resident #2 used antipsychotic medication on a routine basis. Review of Resident #2's comprehensive care plan failed to reveal Resident #2's care plan had been updated to include increased monitoring/supervision after a resident to resident…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor for 1 (#70) of 1 (#70) resident reviewed for urinary catheters. Findings: Review of Resident #70's medical record revealed an admit date of 10/14/2024 with diagnoses that include in part cerebral infarction, essential hypertension, symbolic dysfunctions, dementia with behavioral disturbance, benign prostatic hyperplasia with lower urinary tract symptoms and delusional disorders. Review of Resident #70's physician orders revealed an order dated 10/29/2024; catheter type 16; French 5 bulb size. Review of Resident #70's Minimum Data Set assessment dated [DATE] revealed the resident #70 is rarely or never understood. Resident #70 is totally dependent for toileting, has an indwelling catheter, and is frequently incontinent of bowel. Observation on 02/03/2025 at 8:30 a.m.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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

$61,584 in federal fines across 2 penalties.

• $17,345 — penalty dated 2025-05-14
• $44,239 — penalty dated 2025-02-07

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 THE BEEBE FAMILY — 48 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 37 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

14 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 74% 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 $790K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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