Autumnwood of McBain

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.

44.2% 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 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 13.0% 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 23 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% 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 95 beds and averages 89.7 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.10 hrs/resident/day on weekends vs 3.51 on weekdays — 12% thinner on weekends. RN hours go from 0.91 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below 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.

34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.

• Actual harm · G2025-05-27 · tag F0711 — isolated
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  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 ensure the physician reviewed medication orders for accuracy for one Resident (#3) of three residents reviewed for physician visits. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive…

  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
• Actual harm · G2025-05-27 · tag F0760 — failed to prevent significant medication errors — isolated
  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 interview and record review, the facility failed to accurately transcribe and double check admission medications per standards of practice for one Resident (#3) of three residents reviewed for new admissions. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine. R3 was supposed to receive Carbidopa/Levodopa five times a…

  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
• Actual harm · H2025-03-26 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00150419 and MI00151063. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 19 residents (#37, #51, #7, #87, #35, #36, #42, #48, #65, #81 and nine confidential residents) reviewed for staffing. This deficient practice resulted in actual harm for Residents #37, #7, #35, #42, and #48 who were forced to lay in their own excrement or urine for extended periods of time or delay a bowel movement due to insufficient staffing, resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept. Findings include: Resident #37 (R37) Review of the Minimum Data Set (MDS) assessment, dated 2/10/2025, revealed R37 was admitted to the facility on [DATE]. R37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for ADLs (activities of daily…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-27 · tag F0726 — failed to have competent, trained nursing staff — isolated
  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 Based on interview and record review, the facility failed to identify harmful dosing parameters and recognize the resulting side effects for an incorrectly prescribed thyroid medication for one Resident (#3) of 3 residents reviewed for .three residents reviewed for new admissions. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 observation and interview, the facility failed to store food in accordance with professional standards for food service safety as evidenced by: A. Failure to ensure expired food was discarded. B. Failure to ensure adequate labeling of potentially hazardous food. C. Failure to ensure cabinetry surrounding an ice machine was maintained in good repair. This deficient practice had the potential to result in food borne illness among any or all of the 89 residents in the facility. Findings include: The following were observed during the initial tour of the kitchen: 1. On 3/23/25 at 10:06 AM, undated heads of wilted cabbage were observed in a cardboard box in dry storage. An undated cardboard box of raw potatoes was observed next to the cabbage with numerous rotten potatoes scattered throughout the box. 2. On 03/23/25 at 10:07 AM, a broken raw egg was observed next to intact eggs inside a carton in the reach-in refrigerator. 3. On 3/23/25 at 10:08 AM, four pints of undated, moldy, cherry tomatoes were observed in the reach-in refrigerator. 4. On 3/23/25 at 10:10 AM, undated…

  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 · F2025-03-26 · tag F0923 — widespread
  Have enough outside ventilation via a window or mechanical ventilation, or both.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms on one hall, serving 19 of a total 89 residents. This deficient practice resulted in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable. Findings include: On 3/23/25 at 10:30 AM, noxious odors were noted throughout the 300 Hall. On 3/24/25 at 7:20 AM, noxious odors were noted throughout the 300 Hall. On 3/24/25 at 8:45 AM, in response to the presence of continued noxious odors on the 300 Hall, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the cling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place was deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-26 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00150419. Based on observation, interview and record review, the facility failed to ensure residents were cared for in a dignified and respectful manner for five residents (#37, #51, #7, #38 and #2) of five residents reviewed for dignity, resulting in feelings of frustration, humiliation and low self-worth based on a reasonable person standard. Findings include: Resident #37 (R37) Review of the Minimum Data Set (MDS) assessment, dated 2/10/2025, revealed R37 was admitted to the facility on [DATE] and had diagnoses including diabetes, colocutaneous fistula (abnormal tract leading from the intestine to an opening in the abdomen), history of MRSA (Methicillin Resistant Staphylococcus Areus) infection, and major depressive disorder. Further review revealed R37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for ADLs (activities of daily living), including toileting hygiene, bathing and all mobility. A review of the Brief…

  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 · E2025-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficient practice pertains to intake MI00151063. Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for six dependent Residents (#35, #36, #42, #48, #65, and #81) out of 19 residents reviewed for personal hygiene and incontinence care. Findings include: Resident #35 (R35) Review of R35's annual Minimum Data Set (MDS) assessment, dated 12/12/24, revealed R35 required substantial/maximal assistance, indicating the helper completed more than half the effort and R35 was occasionally incontinent. R35 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:56 AM, an observation was made of R35 in their room lying in bed. R35 reached out in an attempt for help. Certified Nurse Aide (CNA) H was made aware of R35 needing assistance. CNA H was asked if R35 was incontinent and the last time they were checked on. CNA replied, Yes, I was in here around 8:00 AM this…

  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 · E2025-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1. Obtain physician orders and administer oxygen at the prescribed flow rate, and; 2. Ensure respiratory equipment was changed, labeled, stored, and cleaned appropriately; for eight Residents (#243, #43, #3, #240, #245, #88, #44, and #18) of eight residents reviewed for oxygen and respiratory equipment services. Findings include: Resident #243 (R243) On 3/23/25 at 11:51 AM, R243 was observed with supplemental oxygen being delivered via nasal cannula (tube that delivers supplemental oxygen). The oxygen tubing was dated 3/15/25. The oxygen was set to be administered at 3 LPM (liters per minute). R243 said the oxygen should be set at 2 LPM. During an interview with Family Member (FM) II on 3/23/25 at 11:55 AM, concern was verbalized regarding the oxygen required by R243. FM II said R243 should always be on oxygen, but the facility had repeatedly failed to ensure the portable oxygen tank was turned on. FM II stated the facility would also…

  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 · E2025-03-26 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a medication error rate below 5% for two Resident (#11 & #26) of nine residents reviewed for medication administration. This deficient practice resulted in 2 medication errors out of 31 opportunities for error with a medication error rate of 6.4%. Findings Include: Resident #11 (R11) R11 was admitted to the facility on [DATE] with a primary diagnosis of osteoarthritis (a degenerative disease of the joints). Review of R11's physician orders revealed an order dated 10/13/24 that read: Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 mg (milligrams): Give 1 tablet by mouth three times a day for Arthritis pain. On 3/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) O was observed preparing medications to administer to R11. LPN O removed a tablet of Tylenol 8-Hour Arthritis Pain Extended Release and broke the tablet in half before placing both halves into a medication cup. LPN O was asked if extended-release tablets…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-26 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to dispose of expired medications and ensure required medications were dated when opened on two medication carts of three medication carts reviewed for medication storage and labeling. Findings include: Maple Lane medication cart: On 3/24/25 at 1:04 PM, the 200-unit (Maple Lane) medication cart was reviewed with Licensed Practical Nurse (LPN) O. The cart was noted to contain a Novolin R FlexPen (insulin). The FlexPen contained an illegible date. LPN O said the FlexPen was dated as opened on 2/16/25 and said the FlexPen needed to be disposed 30 days after opening. LPN O said the FlexPen was expired and disposed of the FlexPen in a biohazard container. A bottle of ciprofloxacin (antibiotic) eye drops in the medication cart was dated as opened 3/12/25. The box containing the bottle of ciprofloxacin eye drops contained a pharmacy-generated label indicating the medication was dispensed from pharmacy on 3/19/25. LPN O said, That doesn't make any sense - that's concerning. The medication cart contained a bottle 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 and interview, the facility failed to ensure meals were served at a palatable and appetizing temperature for two Residents (#51, #71) of two residents reviewed for food palatability, and nine out of 10 residents from the confidential group meeting, resulting in decreased meal satisfaction and the potential for decreased food acceptance and nutritional decline. Findings include: An observation of morning meal service in the [NAME] Unit dining room on 3/24/2025 revealed meals trays were delivered in an insulated cart from the main kitchen at 7:50 a.m. Temperatures taken from the first two trays off the cart revealed the following: pancakes temped at 106 degrees Fahrenheit (F); scrambled eggs temped at 102 degrees F. The last meal from the cart was observed to be delivered at 8:09 a.m. with the following temperatures taken: pancakes 98 degrees F; and oatmeal 128 degrees F. On 3/24/2025 at 7:55 a.m., Activities Aide (AA) EE was observed assisting with meal tray delivery in the [NAME] Unit dining…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-26 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to 1. Perform hand hygiene at appropriate opportunities for hand hygiene related to meal service and medication administration, 2. Appropriately don and doff disposable single use gloves, 3. Ensure contaminated ice was discarded. 4. Rinse and dry respiratory treatment equipment between medication treatments, 5. Maintain a sanitary medication cart, and 6. Ensure Infection Control Polices are update at least annually. Findings include: On 3/23/25 at 12:31 PM, Certified Nurse Aide (CNA) FF was observed in the 100-unit (Oak Lane) lounge preparing to deliver meal trays. After removing a meal tray from the meal cart and placing a can of soda pop on the tray, CNA FF walked toward a table in the lounge and inadvertently bumped into an open ice chest filled with ice. The can of soda pop fell from the meal tray into the open ice chest. CNA FF reached into the open ice chest with an ungloved, unwashed hand and removed the can of soda pop to place back on the meal tray. CNA FF placed the meal tray on a table in the lounge…

  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

“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

$39,000 in federal fines across 1 penalty.

• $39,000 — penalty dated 2025-03-26

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 CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 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 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

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