Shelby Health and Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

54.4% 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 809 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.8% 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 362 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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 212 beds and averages 197.5 residents a day — about 93% occupied, or roughly 14 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 3.13 hrs/resident/day on weekends vs 3.69 on weekdays — 15% thinner on weekends. RN hours go from 0.46 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.

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.

37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Actual harm · Gcited before2025-04-02 · 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

  This citation pertains to intake MI00151590 Based on interview and record review, the facility failed to promptly identify, assess, and contact physician for an acute change in condition for one resident (R902) out of two reviewed for change in condition, resulting in pain and hospitalization. Findings include: A review of intake MI00151590 noted the following, This facility failed to provide [R902] with a timely evaluation of a head injury that likely was the cause of [R902's] mental status change and instead appeared to choose to attempt to sedate them. A review of the medical record revealed that R902 admitted into the facility on 3/10/2025 with the following medical diagnoses, Acute Posthemorrhagic Anemia and Gastrointestinal Hemorrhage. A review of the admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status(BIMS)assessment score of 15/15 indicating an intact cognition. It was also noted on the MDS that R902 did not have any behaviors on admission. R902 also required staff assistance with bed mobility and transfers. Further review of the progress…

  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 · Gcited before2024-11-13 · 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 This citation pertains to Intake MI00147833. Based on observation, interview, and record review, the facility failed to ensure a comprehensive nursing assessment was completed and timely acute care emergent hospital transfer for one Resident (R901) of three residents reviewed for care, when R901 sustained a fall with head trauma and bleeding while taking anticoagulant medication. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to assess a change of condition following the fall for R901. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] and discharged on 10/08/24 with diagnoses that include Quadriplegia and Atrial fibrillation (AFIB). A review of R901's quarterly Minimum Data Set (MDS) assessment dated [DATE], noted R901 with a moderate impaired cognition, functional limitation in range of motion upper as impairment on one side, and lower extremity (hip, knee, ankle, foot) impairment on both sides. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-27 · 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 This citation pertains to Intake MI00135407. Based on interview and record review, the facility failed to ensure the assessed number of staff were used during shower care for one resident (R901) of three whose falls were reviewed resulting in a resident fall from a shower bed and sustained bruising, lacerations and bleeding to the face and head. Findings include: A review of a complaint for R901 revealed: On 9/14/23, (R901) had one person assisting (them) in a shower and (R901) was dropped during the shower. (R901) sustained multiple fractures to the nose, jaw and skull. Additional injuries included five fractures to the right eye socket, 18-20 stitches on the forehead and a brain bleed. (R901) is currently at the hospital. The complaint further noted: the aides are overworked with 25 or more residents to care for at times, only one person was used for transfer to the shower bed with the lift, there are not enough lifts to provide timely care and the rails on the shower bed were held up by pins and did not…

  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 · G2023-09-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139057. Based on interview and record review, the facility failed to schedule a follow-up urology appointment as indicated upon admission, adequately document assessments immediately prior to and after the initial insertion of an indwelling catheter (tube inserted into the bladder to drain urine), notify the resident's representative when the catheter was inserted, and failed to recognize the need for outside care, for one resident (R1) of three reviewed, resulting in ineffective coordination of care, resident discomfort, catheter-related complications, and hospitalization. Findings include: A review of intake MI00139057 revealed allegations indicating that the resident's representative was not notified when a urinary catheter was initiated; that the facility did not schedule an outside urology appointment as per hospital instruction; that the resident began to experience increased pain and complications from the catheter; and that the facility failed to recognize that R1…

  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 before2026-04-30 · 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

  Based on observation, interview, and record review, the facility failed to maintain a homelike dining environment for seven anonymous resident council residents of eight reviewed for homelike environment. Findings include: On 4/28/26 at 12:15 PM, it was observed the main dining room was empty with no residents occupying the room during the lunch meal. Subsequent observations made on 4/29/26 at 12:20 PM and 4/30/26 at 12:23 PM, also revealed the main dining room with no residents eating the lunch meal. A review of the resident council meeting minutes for the months of January 2026-April 2026 revealed a discussion by the residents in the group of wanting dining rooms open so they could eat together instead of eating alone in their rooms. On 4/29/26 at 10:40 AM, a group meeting was conducted with eight group members and asked about dining in the facility, the group indicated they would like the main dining room to be reopened as soon as possible so they could eat together again. Further questioning of the group about the dining room revealed that it had been closed for meals since 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 · Dcited before2026-04-30 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  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 2982336.Based on interview and record review, the facility failed to ensure a copy of the care plan and updates were provided to the resident or the resident representative for one resident (R120) of two reviewed for participation in care planning. Findings include: On 04/28/2026 at 1:53 PM, two resident representatives (Representatives one and two) were seated bedside with R120. The two representatives were listed on the resident's face sheet as contacts for R120. The representatives reported R120 had been at the facility since 03/27/26 and expressed concerns and frustrations about the timing of care and lack of information provided. It was reported the representatives had been told R120 was no longer receiving physical (PT) or occupational therapy (OT) and themselves, or the Power of Attorney (POA) had been informed or received an explanation. The representatives also reported two messages were left with the with Director of Nursing (DON) on Friday (4/24/26) and they had not…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents (R1 and R12) out of two reviewed for care plans. Findings include: R1 On 04/28/2026 at 6:25 AM, R1's catheter bag was observed to be hooked onto their bed in a low position and was partially touching the floor with the rest of the bag leaning onto their fall mat. A review of the Electronic Medical Record (EMR) for R1 revealed they were admitted into the facility on [DATE] with diagnoses of neuromuscular dysfunction of bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent Minimum Data Set (MDS) dated [DATE] section H revealed R1 had an indwelling catheter. Section C of R1's MDS revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of R1's active orders revealed: Maintain (name of indwelling catheter) Catheter and provide care every shift. Catheter Size/French: 18Balloon Cubic Centimeters (CC): 10 Diagnosis:…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · 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 observation, interview, and record review the facility failed to ensure repositioning and dressing changes were completed timely for one resident (R120) of five reviewed for pressure ulcer care and skin management. Findings include: On 04/28/2026 at 1:53 PM, family of R120 reported concerns with the bed sores and wound care for the bilateral heel wounds and the coccyx/sacral/buttocks of R120. They expressed observations of R120 not being turned for four hours and the heel boots not being placed back on during the times they had visited R120. They had concern that the wounds had worsened or increased since admission. They further noted the Low Air Loss (LAL) mattress went out or turned off intermittently and had to be unplugged then plugged back to get it working. A sign handwritten on a folded piece of lined notebook paper indicated to do this. They further noted the dressings to the feet/heel had been completed on Thursday (04/23/26) and did not get changed until Sunday. Family reported they 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure indwelling catheter and hand hygiene infection control practices were followed for one resident (R1) out of one reviewed for catheter care and hand hygiene during care. Findings include:A review of the Electronic Medical Record (EMR) for R1 revealed they were admitted into the facility on [DATE] with diagnoses of neuromuscular dysfunction of bladder, obstructive and reflex uropathy, and unspecified dementia. The most recent Minimum Data Set (MDS) dated [DATE] section H revealed that R1 had an indwelling catheter. Section C of R1's MDS revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of R1's active orders revealed: Maintain (name of indwelling catheter) Catheter and provide care every shift. Catheter Size/French: 18Balloon Cubic Centimeters (CC): 10 Diagnosis: Neurogenic Bladder every shift for (name of indwelling catheter) care, dated 3/5/2026 On 04/28/2026 at 6:25 AM, 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-04 · 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

  This citation pertains to intake 2568581.Based on observation, interview and record review, the facility failed to ensure resident care needs were met timely for six residents (R707, R700, R708, R709, R706, and R704) of twelve reviewed for resident care. Findings include: R707On 09/04/25 at 9:23 AM, R707 was interviewed and reported their number one concern was that staff do not answer the call bell all the time. R707 reported the call system had been down on their unit for at least a month and a half and they had been given a small hand bell to ring when help was needed. R707 further reported they did not feel safe with the call system down, especially when put in the bathroom. R707 noted the hand bell was not brought into the bathroom. R707 noted they required staff assistance to get up (using a stand lift) and could not ring the bell more than two or three times before they dropped it due to numbness in the hands. R707 was observed to have bilateral wrist and hand splints. R707 reported they just wanted a little respect as yesterday it was an hour and a half before they were…

  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 · Dcited before2025-07-10 · 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

  This citation pertains to intake MI00153799. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment in one of one kitchenettes located off the main dining room. Findings include: Review of a complaint intake received 6/19/25, noted that on 6/18/25, the cupboard located underneath the sink in the main dining room kitchenette, was observed to be wet and stained with mold. On 7/9/25 at 10:20 AM, the kitchenette located off the main dining room was observed with the Administrator. The cabinet located under the sink was observed with water damaged doors. The particle board was swollen and warped from past water damage. The bottom shelf of the cabinet was wet, and there was a black, mold-like substance on the surface. The Administrator stated he was unaware of the problem with the cabinet, and would have it cleaned right away. On 7/9/25 at 10:30 AM, the Administrator stated they had spoken over the phone with the Maintenance Supervisor and said that Maintenance wasn't aware it looked as bad as it did. The Maintenance Supervisor stated…

  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 · D2025-04-02 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 MI00151476. Based on interview and record review, the facility failed to provide supervision during medication administration for one resident (R900) out of one reviewed for self administration of medications. Findings include: On [DATE] at 9:43 AM, a phone interview was conducted with R900's Family Member (FM) E. FM E reported they were told the day that the resident died they complained about being short of breath (SOB). FM E reported that they were informed the nurse put the nebulizer mask on R900 and left the room. FM E reported they were informed when the nurse came back R900 was found to be unresponsive. A review of the medical record revealed that R900 admitted into the facility on [DATE] with the following medical diagnoses, Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure with Hypoxia. A review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating an impaired cognition. R900 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-03-05 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R106 On 03/20/2025 at 07:35 AM, Licensed Practical Nurse (LPN) B retrieved the glucometer tray from medication carts bottom drawer and entered R106's room that had a PPE [NAME] on the door with a sign specifying what PPE to don (gown, gloves, and mask) for the room. LPN B was observed to place glucometer tray and blood pressure cuff on R106's bed without a barrier, hand hygiene was not performed, PPE was not used. LPN B was not satisfied with the reading obtained for R106's blood pressure and left the room to obtain a wrist blood pressure machine. No hand hygiene performed. Upon completion of these tasks LPN B took the equipment and left R106's room. Hand hygiene was not performed. Blood pressure equipment was returned to nursing station, the glucometer tray replaced in medication cart without cleaning. No hand hygiene was performed upon leaving R106's room. On 3/4/2025 at 2:00 PM, LPN B was asked what the cleaning protocol was for the glucometer and blood pressure cuffs. LPN B stated the glucometer tray, 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for two residents (R51 and R78) of ten residents reviewed, three of thirteen medication carts. Findings include: R78 On 3/3/25 at 1:30 PM, an observation was made of a medicine cup filled with a red liquid on R78's dresser. R78 was interviewed and asked about the medicine cup on their dresser and stated, I think it's cough medicine. R78 was asked if they self-administered their medication and said nursing administered their medications to them. On 3/3/25 at 1:35 PM, Unit Nurse Manager, Licensed Practical Nurse (LPN) I was requested to come to R78's room and was shown the medicine cup on R78's dresser and asked about it. LPN I indicated the medicine cup contained a protein supplement and removed the medicine cup from R78's dresser and discarded it. A review of R78's electronic medical record (EMR) indicated the following physician's order, Start date: 1/22/25; End date: 3/5/25. Order:…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$41,847 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $41,847 — penalty dated 2025-03-05
• Medicare payment denial — starting 2025-04-25 for 6 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 OPTALIS HEALTH & REHABILITATION — 36 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 31 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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 $8.2M paid to related parties — landlords or management companies under common ownership — equal to about 30% 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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