OC Milford Gardens LLC

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.

49.2% 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 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.5% 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 99 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% 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 135 beds and averages 111.6 residents a day — about 83% occupied, or roughly 23 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.17 hrs/resident/day on weekends vs 3.45 on weekdays — 8% thinner on weekends. RN hours go from 0.53 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 81% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

28 citations, most serious first. The 13 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Hcited before2024-12-09 · 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 interview and record review, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#65), out of a total sample of 18 residents. Specifically, the facility failed to implement treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum. Findings include: Resident #65 was admitted to the facility in June 2024 with diagnoses including C. diff, pressure ulcer of sacral region, and chronic…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-12-09 · tag F0580 — failed to tell family and doctor about changes — isolated
  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 observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for four Residents (#65, #13, #58, and #70), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #65, to notify the Physician of treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting in a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; 2. For Resident #58, to notify the Physician of his/her significant weight loss; 3. For Resident #70, to notify the Physician of his/her significant weight loss; and 4. For Resident #13, to notify…

  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
• Actual harm · G2024-12-09 · 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 review, the facility failed to ensure two Residents (#65, #68), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #65, to implement wound care orders per physician recommendations for a stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; and 2. For Resident #68, to implement orders for a change in treatment for the care of an unstageable pressure ulcer injury (full thickness tissue loss that is covered by a layer of dead tissue that prevents the stage from being determined) to the left heel. Findings include: Review of the facility's policy titled Prevention of Pressure Injuries, undated, included but was not limited to: - The purpose of this procedure is to provide information regarding identification of pressure injury risk factors 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-17 · tag F0656 — failed to write and follow a full care plan — isolated
  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

  Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who had limited mobility and required staff assistance to complete Activities of Daily Living (ADLs), the facility failed to ensure their ADL Care Plans were individualized, with interventions that clearly identified the necessary number of staff assistance required to adequately and safely meet their needs.Findings include:Review of the facility's policy, titled Care Plans-Comprehensive, with a revision date of 07/2023, included the following:-An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident.-The comprehensive care plan is based on thorough assessment that includes but is not limited to the Minimum Data Set (MDS) assessment.-Each resident's comprehensive care plan is designed to:*Incorporate identified problem areas*Incorporate risk factors associated with identified problems*Reflect treatment goals, timetables and objectives in…

  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 · E2026-05-19 · 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 reviews and interviews for one of three sampled residents (Resident #1), who was newly admitted to the facility, the Facility failed to ensure he/she was free from a significant medication error, when medications from his/her Hospital Discharge Summary were not accurately reconciled by Nursing and he/she was administered Buspirone (anxiolytic medication) and Benzonatate (cough suppressant) in error.Findings include:Review of the Facility Policy titled, Reconciliation of Medications on Admission, dated as revised 04/2025, indicated the following:-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care;-obtain a medication history from the resident or family, complete this first;-gather 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-19 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews for one of three sampled residents (Resident #1), who was alert, oriented and newly admitted to the facility, the Facility failed to ensure that they obtained signed written informed consent for the administration of psychotropic medication, Buspirone, which include providing the resident with information related to the risks and benefits of the medication, prior to it being administered.Findings include:Review of the Facility Policy Psychotropic Consent, dated as last revised 02/2021, indicated the following:-the facility will obtain informed written consent prior to administration of any psychotropic medication;-psychotropic medications include: antipsychotic, antidepressant, antianxiety and hypnotic medications;-prior to the administration of a psychotropic medication, the prescribe must discuss the purpose for administering the psychotropic drug, the prescribed dosage and any known effect or side effect of the psychotropic medication with the resident;-prior to administration of a psychotropic medication, the facility representative must…

  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 before2026-03-04 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of Resident Council Minutes, a resident group meeting, interviews, and document review, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely.Findings include:Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following:-the purpose of resident council is to provide a forum for residents to have input into the facility operation, discuss concerns, communication and dissemination of information-a resident council response form will be utilized to track issues, and their resolution will be discussed at the next meeting Review of the facility's policy titled: Grievances/Complaints, dated as revised 7/2025, indicated but was not limited to the following:-the resident or persons filing a grievance will be informed of findings of the investigation and actions taken to correct identified problems, by the Administrator within 10 working days of filing the grievance; a written summary will be…

  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 before2026-03-04 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to ensure one Resident (#28), out of a total sample of 23 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to obtain a physician's order and/or include a left heel boot in the plan of care. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion, undated, indicated the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. And the care plan will include type, frequency, and duration of interventions. Review of the facility's policy titled Charting and Documentation, undated, indicated but was not limited to the following:-All services provided to the resident, progress toward care plan goals, or any changes on the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-04 · 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 observation, record review, and interview, the facility failed to ensure one Resident (#59), out of a total sample of 23 residents, was provided an environment as free of accident hazards as possible and received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure person-centered interventions were developed and implemented related to the root cause of the falls to mitigate the risk of future falls and/or injury resulting in five falls in three months after he/she had sustained a fall with fracture and had a change in mobility and continence. Findings include: Review of the facility's policy titled Falls-Clinical Protocol, undated, indicated but was not limited to the following:-While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.-Examples of risk factors include musculoskeletal abnormalities, gait and balance disorders, weakness, environmental hazards, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#63), in a total sample of 23 residents. Specifically, the facility failed to ensure nail care was performed for Resident #63. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), undated, indicated residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene. Resident #63 was admitted to the facility in January 2026 with diagnoses which included intervertebral disc degeneration and weakness. Review of the Minimum Data Set (MDS) Assessment, dated 2/16/26, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment, indicating he/she was cognitively intact and was dependent on staff for assistance with ADLs. Review of the Comprehensive Care Plan indicated Resident #63 had an ADL self-care performance deficit due to weakness and degenerative disc…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#12) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 23 sampled residents. Specifically, the facility failed to ensure enteral feedings (provide nutrition directly into gastrointestinal tract) were administered via G-tube in accordance with physician's orders.Findings include:Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, dated as revised 7/2025, included but was not limited to:- The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.- Preparation: Verify that there is a physician's order for this procedure.- General Guidelines: Check the enteral nutrition label against the order before administration. Check the following information: Resident name, ID, and room number; type of formula; date and time formula was prepared; route 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 record review and interviews, the facility failed to ensure staff maintained accurate medical records for one Resident (#5), out of a total sample of 23 residents. Specifically, the facility failed to ensure nursing staff accurately documented the use of an as needed (PRN) medication on the medication administration record (MAR).Findings include:Review of the facility's policy titled Administering Medications, last revised 7/2025, indicated but was not limited to:-The individual administering the medication initials the resident's Medical Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.-As required or indicated for a medication, the individual administering the medication records [sic] in the resident's medical record: -the date and time the medication was administered. Resident #5 was admitted to the facility in January 2026 with diagnoses including osteoarthritis and pressure ulcer of the sacral (base of the spine) region. Review…

  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 · D2026-01-13 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensures staff consistently implemented and followed their abuse policy, when on 12/13/25 after Nurse #1 was made aware of an allegation that Resident #1 was abused by a staff member, and the following day the Nursing Supervisor was also made aware of the same allegation, however neither of them immediately reported it to facility administration, as required.Findings include: Review of the Facility's Policy titled, Abuse, dated as revised March 2023, indicated that;- the Facility must ensure that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the administrator and Director of Nurses of the facility utilizing the chain of command,-staff will follow [Facility Name] Policy 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.

  Freedom from Abuse, Neglect, and Exploitation 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

$148,051 in federal fines across 1 penalty.

• $148,051 — penalty dated 2024-12-09

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 AZURE HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 MA