Lakeshore Manor Nursing & Rehab

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.

28.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 110 beds and averages 82.0 residents a day — about 75% occupied, or roughly 28 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 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.19 hrs/resident/day on weekends vs 3.18 on weekdays — 31% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above 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 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.

49 citations, most serious first. The 19 most serious are shown; the remaining 30 are one tap away and print in full.

• Immediate jeopardy · L2026-03-14 · tag F0607 — failed to have anti-abuse policies — widespread
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement its written abuse policy to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure employment screening was completed for 1 (S12) of 1 unknown alleged agency staff. On [DATE], S12, who was not employed by the facility or staffing agency, was assigned to provide direct care to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10 without being screened for a history of abuse, neglect, exploitation or misappropriation of property. An Immediate Jeopardy situation began on [DATE] at 8:00 a.m. when S12, who was not employed by the facility or staffing agency, presented herself to S10LPN, S11LPN, and S13LPN stating she was a staffing agency CNA arriving to cover an open shift. Facility staff failed to ensure S12 was sent by the staffing agency and screened prior to being assigned direct care of residents. From approximately 8:30 a.m. to 10:30 a.m. S12 was assigned to provide direct care…

  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 · Lcited before2026-03-14 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to ensure an effective screening and onboarding system was developed and implemented to prevent 1(S12) of 1 unknown alleged agency staff from being assigned to provide direct resident to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10. This deficient practice had the potential to affect any of the 83 residents residing in the facility that received direct care from nursing personnel. An Immediate Jeopardy situation began on 03/12/2026 at 8:00 a.m. when S12, who was not employed by the facility or staffing agency, presented herself to S10LPN, S11LPN, and S13LPN stating she was a staffing agency CNA arriving to cover an open shift. Facility staff failed to ensure S12 was sent 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-02-24 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 provide appropriate treatment and services for 1 (#1) of 3 (#1, #2, and #3) newly admitted or readmitted residents who needed physician orders for immediate care and/or follow up for surgery and for implanted devices. For 26 days, the facility failed to ensure the admission Nurse, Charge Nurses, Wound Care Nurses, Licensed Practical Nurses and Registered Nurses: 1. Had accurately transcribed and clarified Resident #1's 01/24/2025 hospital discharge recommendations, wound care and dressing orders, cardiology follow up for surgical incision care, and monitoring equipment instructions; 2. Understood and acted as needed on their responsibilities for Resident #1's cardiac loop recorder and; 3. Assessed, monitored, documented, and treated Resident #1's surgical incision site, loop recorder, and loop recorder monitoring equipment. This deficient practice resulted in an Immediate Jeopardy situation on 01/24/2025, when Resident #1 was readmitted…

  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 · J2025-01-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual and psychosocial abuse for 1(#33) of 12 (#13, #14, #24, #31, #33, #61, #74, #77, #190, #191, #192, and #193) residents reviewed for sexual and psychosocial abuse. The facility failed to ensure Resident #33 was not sexually abused by S5MAIN. This deficient practice resulted in an Immediate Jeopardy (IJ) situation for Resident #33, a cognitively impaired blind resident, on 01/08/2025, when it was discovered that during the Christmas/New Year Holiday Season, S8CNA witnessed S5MAIN sitting on Resident #33's bed, rubbing the resident's shoulder, and kissed her on the cheek. S8CNA failed to report the sexual abuse and S5MAIN continued to work in the facility until 01/02/2025 at 5:00 p.m. On 01/05/2025, #R1 reported S5MAIN sat down next to Resident #33 on her bed, rubbed Resident #33's back and arm, kissed her cheek and neck and said he wanted to see her beautiful cat again. As a result of the investigation,…

  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 · Jcited before2025-01-12 · tag F0609 — failed to report abuse allegations — isolated
  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 interviews and record reviews, the facility failed to ensure allegations of sexual abuse were reported immediately to the facility's administrator and to law enforcement authorities in an appropriate timeframe for 1 (#33) of 12 (#13, #14, #24, #31, #33, #61, #74, #77, #190, #191, #192, and #193) residents reviewed for sexual abuse. The facility failed to ensure: 1. Staff immediately reported allegations of sexual abuse to the administrator; and 2. The Administrator reported allegations of sexual abuse to local law enforcement This deficient practice resulted in an Immediate Jeopardy (IJ) situation for Resident #33, a cognitively impaired blind resident, on 01/08/2025, when it was discovered that during the Christmas/New Year Holiday Season, S8CNA witnessed S5MAIN sitting on Resident #33's bed, rubbing the resident's shoulder, and kissed her on the cheek. S8CNA failed to report the sexual abuse and S5MAIN continued to work in the facility until 01/02/2025 at 5:00 p.m. On 01/05/2025, #R1 reported to S6CNA…

  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 · Lcited before2023-08-08 · tag F0684 — failed to provide proper treatment and quality of care — widespread
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, # 5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2023-08-08 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure licensed nurses and other nursing personnel had the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed multiple doses of 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2023-08-08 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident. The facility failed to ensure a functional system was in place to acquire, receive, transcribe, and implement accurate physician orders for 7 ( #1,#2,#3,#4, #R1, #R2, #R3) out of 8 ( #1, #2, #3, #4, #5, #R1, #R2, #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed 7 of the 10 doses ordered of intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound…

  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 · Gcited before2023-10-16 · 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 observations, record reviews and interviews, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#1) of 8 (#1, #2, #3, #R1, #R2, #R3, #R4, and #R5) residents reviewed for accidents. The facility failed to secure Resident #1's safety (belt) during transport as recommended by manufacturer guidelines. This failed practice resulted in an actual harm for Resident #1 on 09/20/2023 when S2VD failed to properly restrain Resident #1 into the facility van. During transport, Resident #1 slid out of her wheelchair onto the van floor. Resident #1 was transferred to a local hospital on [DATE] where x-ray revealed a Left Tibia Plateau Fracture extending to the Proximal Tibial Metaphysis. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the manufacture's user…

  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
• Potential for harm · Ecited before2026-07-01 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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, record review and interviews, the facility failed to ensure staff:Provided residents with a clean, comfortable and homelike environment for 6 of 6 (Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6) hallway floors; Provided a clean, comfortable and homelike environment for resident's room floor for 1 (#3) of 4 sampled residents reviewed for environmental concerns; andMaintained a resident's mattress in a sanitary manner and good condition for 1 (#3) of 4 sampled residents reviewed for environmental concerns. Findings: Review of the facility's policy dated 03/2026 and titled Resident Rights Safe, Clean and Comfortable Environment revealed the following, in part:The resident has a right to a safe, clean and comfortable environment. The facility will provide a safe, clean and comfortable environment.The facility will provide housekeeping and maintenance service necessary to maintain a sanitary, orderly and comfortable interior.The facility will provide a bed in good condition.1.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 Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-07-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review the facility failed to provide the necessary treatment and services, consistent with professional standards, to promote healing and prevent the development of new pressure ulcers by failing to ensure resident's wound care was implemented as ordered for 3 (#R1, #R2, and #R3) of 8 residents reviewed for wound care management.Findings: #R1Review of Resident #R1's clinical record revealed an admission date of 08/21/2024 with diagnoses which included the following in part, Peripheral Vascular Disease, Atopic Dermatitis and Inflammatory Disorders of Scrotum. Review of Resident #R1's current physician orders revealed in part, the following:Start Date: 04/24/2025- MedCentris to evaluate and treatStart Date: 03/20/2026- Calcium Alginate-Silver External Pad 4-Apply to left groin topically every day shift every Monday, Wednesday, Friday for Abscess. Clean wound bed with wound cleaner, apply silver alginate and cover with Optilock absorbent padStart Date: 06/23/2026- Wound care steps-1-evalaute patients back and skin tears 2- cleanse wound site 3- Apply…

  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 plan of correction
• Potential for harm · Ecited before2026-07-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews the facility failed to ensure 4 (S7LPN, S8LPN, S9LPN and S10LPN) of 4 LPNs reviewed for wound care had the competencies and skill sets to provide wound care to residents. Findings: On 06/30/2026 at 9:30 a.m., an interview was conducted with S10LPN. S10LPN stated he provided wound care to his assigned Residents who required wound care management services. S10LPN stated the provider had not assessed his competencies or provided training prior to assigning residents with wound care. On 07/01/2026 at 11:15 a.m., an interview was conducted with S8LPN. She stated she had limited clinical experience due to being a recent graduate. She denied having any certifications or educational background in wound care management. She stated she did not feel comfortable providing wound care without the proper education and training. She stated the provider had not assessed her competencies or provided training prior to assigning her to complete wound care management for residents. She voiced concern that if she provided wound care incorrectly and had an adverse outcome she could…

  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 plan of correction
• Potential for harm · E2026-07-01 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident was free of significant medication errors by not providing medication administration in accordance with accepted professional nursing standards for 1 (#1) of 4 residents' MARs reviewed.Findings: Review of the facility's undated policy titled Job Description Licensed Practical Nurse revealed the following, in part:Pharmacy knowledge:Demonstrate a knowledge of drug reactions and sensitivities and nursing interventions. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Further review revealed Resident #1's allergies included Amoxicillin. Review of Resident #1's current Physician Orders, as of 06/29/2026, revealed the following antibiotic:Start date 06/28/2026. Amoxicillin-Pot Clavulanate tab 875-125mg, 1 tab via PEG tube every 12 hours for dental infection for 7 days.…

  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 plan of correction
• Potential for harm · Dcited before2026-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident received ADL care in accordance with professional standards of practice and the comprehensive person-centered care plan for Resident 1 (#4) of 4 residents reviewed for ADL care.Findings: Review of the facility's policy dated 03/2026 and titled Quality of Life Activities of Daily Living/ Maintain Abilities revealed the following, in part:Facility provides necessary care and services to support the resident's needs. Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Generalized Muscle Weakness, Lack of Coordination, and Difficulty in Walking. Review of Resident #4's current MDS revealed she had a BIMS of 14, which indicated she was cognitively intact. Review of Resident #4's most recent Care Plan revealed the following, in part:Problem: Self-care Deficit Approaches: Toileting- totally dependent An interview was conducted on 06/30/2026 at 5:00 p.m. with Resident #4.…

  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 plan of correction
• Potential for harm · Dcited before2026-05-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 residents received care, consistent with professional standards of practice, to prevent pressure ulcers. The facility failed to ensure heel protectors were placed on a resident per Physician's Orders for 1 (#3) of 3 sampled residents. Findings: Review of the facility's Skin Integrity Policy dated 05/2026 revealed the following, in part:Policy Statement:The facility, based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical condition demonstrates that they were unavoidable. Policy Components:5. A resident identified as at risk of developing impaired skin integrity will have individualized interventions implemented to attempt to prevent areas of skin integrity impairment from developing. Review of Resident #3's Clinical Record 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-10 · 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 review the facility failed to ensure an effective system was in place for staff to identify residents assessed as unsafe smokers and to provide supervision and interventions during smoking for 1 (#50) of 3 residents reviewed for smoking. Review of the facility's policy, Physical Environment- Facility with Independent and Supervised Smokers, revised 03/2025, revealed the following in part:Purpose: To provide a safe environment for residents.Guidelines:Smoking blankets or aprons will be furnished for residents who are assessed to require a smoking blanket or apron.Residents who are independent smokers are instructed not to share smoking paraphernalia with other residents or staff.Residents who are deemed unsafe to smoke independently will be supervised by staff members while smoking.Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following: Cerebral Infarction due to Embolism of Left Middle…

  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 · Ecited before2025-12-10 · 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, interviews, and policy review, the facility failed to store food under sanitary conditions by failing to ensure food was properly dated, labeled, and sealed in the walk-in refrigerator and freezer. This deficient practice had the potential to affect 72 residents who ate from the facility's kitchen.Findings: Review of the facility's policy dated 03/2023 and titled, Food Safety, revealed the following, in part:9. Refrigerated foods:f. Food, including leftovers, will be labeled and dated in the refrigerator. On 12/08/2025 at 8:14 a.m., an initial tour was conducted of the facility's kitchen with S4CK. The following observations were made with S4CK: Walk-in refrigerator:1 metal pan of mustard greens covered with plastic wrap with no date or label; and 3 pork loins with no date or label. Walk-in freezer: 1 metal pan of green beans with no date or label; 1 clear bag of hamburger patties, not sealed, open to air, with no open date. On 12/08/2025 at 8:22 a.m., an interview was conducted with S4CK. She confirmed the above observations. S4CK confirmed the refrigerator…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment 1 (#74) of 24 sampled residents. Findings: Review of Resident #74's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #74's MDS with an ARD of 11/11/2025 revealed the facility assessed him to have a BIMS of 15, which indicated he was cognitively intact. On 12/08/2025 at 9:05 a.m., an interview was conducted with Resident #74. Resident #74 stated his toilet was clogged with feces and toilet paper. He stated it had been clogged for at least 3 days. Resident #74 stated he could not use the toilet in his room and had to use a restroom at the end of his hall. He stated he reported the clogged toilet to a CNA 2 days ago and nothing had been done. On 12/08/2025 at 9:10 a.m., an observation was conducted of Resident #74's restroom. The toilet was observed with multiple layers of feces and toilet paper. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 residents with an identified mental health diagnosis were referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required for 1 of 1 (#12) resident reviewed for PASARR.Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis. Further review revealed an additional medical diagnosis of Unspecified Psychosis with an onset date of 09/30/2019.Review of Resident #12's PASARR Level I dated 09/27/2019 revealed no mental health diagnoses were selected. Further review revealed no review for a Level II evaluation and determination had been submitted for Resident #12 to include his diagnosis of Unspecified Psychosis.An interview was conducted on 12/09/2025 at 2:30 p.m. with S9SS. She reviewed Resident #12's PASARR pre-admission Level I and resident review dated 09/27/2019. She confirmed Resident #12 had a diagnosis of Unspecified…

  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

“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

$249,106 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $19,868 — penalty dated 2026-03-14
• $224,275 — penalty dated 2025-01-12
• $4,963 — penalty dated 2023-12-04
• Medicare payment denial — starting 2025-02-13 for 55 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 VOLARE HEALTH — 16 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 20 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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 77% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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