Thorne Crest Retirement 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.

57.5% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 70.6% 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 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 52 beds and averages 43.3 residents a day — about 83% occupied, or roughly 9 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.43 hrs/resident/day on weekends vs 3.89 on weekdays — 12% thinner on weekends. RN hours go from 1.16 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% is well above 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 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.

36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to maintain resident supervision and safety to prevent accidents for 1 of 1 residents (R1) who was an elopement risk left the facility unsupervised through an unlocked door during the night and found outside. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 12/7/24 when R1 exited the building without staff awareness through an unlocked door to a courtyard between 11:15 p.m. and 3:30 a.m. (on 12/7/24) and found on the ground at approximately 4:10 a.m. with hypothermia and minor injuries. The administrator and chief operating officer (COO) were notified of the immediate jeopardy on 12/11/24 at 3:00 p.m. The facility had implemented immediate corrective action on 12/8/24 to prevent recurrence, so the IJ was issued at past non-compliance. Findings include: R1's admission Record identifies R1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) was not completed due to R1's admission date of 12/6/24.…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2024-10-15 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to immediately implement appropriate interventions to protect residents from sexual abuse from R1 who sexually abused R2 in the facility and posed an ongoing risk of serious harm resulting in immediate jeopardy. The IJ began on 10/6/24, when facility failed to implement protection measures after staff observed R1 inappropriately touching R2's breast/chest area on 10/6/24. The administrator, director (DON) and assistant director of nursing (ADON) were notified of the IJ on 10/11/24 at 4:43 p.m. The immediate jeopardy was removed on 10/13/24 at 9.11 a.m. but noncompliance remained at the lower scope and severity level 2 E - pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of facility reported incident dated 10/7/24 at 3:05 p.m., indicated on 10/6/24 around 11:50 a.m., nursing assistant (NA-A) walked out to the day room and saw 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure beds were a safe distance away from a wall heater to prevent entrapment and burns for 1 of 1 resident (R1) who had severe cognitive impairment, and a history of self-transfers and falls reviewed for accidents. This resulted in actual harm when R1 rolled out of bed onto the heater which caused second degree burns to his left hip and back. The facility immediately implemented corrective action and the deficient practice was corrected on 12/19/25, prior to the start of the survey and was therefore issued as a past non-compliance (PNC). Findings include: R1's face sheet dated 12/18/25, identified diagnoses of neurocognitive disorder with Lewy Bodies dementia with anxiety, and history of falling. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no issues with hearing or speech, had severe cognitive impairment, no behaviors; required some help with upper body dressing and was dependent on staff for lower body…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · D2026-05-20 · 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 comprehensively assess and evaluate care plan interventions for effectiveness, and develop individualized repositioning program to prevent pressure ulcer development and/or deterioration for 2 of 3 residents (R1, R2) reviewed for pressure ulcers.Findings include:Stage 2 pressure ulcer: partial-thickness loss of skin that presents as a shallow, open wound with a red or pink wound bed without exposure of fat or deeper tissues.Deep tissue injury: affects the deeper layers of tissue beneath the skin including muscles, subcutaneous fat, and sometimes bone which disrupt blood flow and oxygen delivery to the tissue.Braden Scale for Predicting Pressure Sore Risk is a standardized tool to assess the risk of developing pressure injuries. The scale evaluates six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category is scored from 1-4, except friction/shear which is scored 1-3. Scores are…

  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 · F2026-01-27 · tag F0725 — failed to have enough nursing staff — widespread
  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 Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance in a timely manner, when 15 of 47 residents (R3, R5, R7, R13, R15, R17, R22, R24, R25, R28, R34, R36, R39, R43, R47) reviewed for sufficient staffing, experienced excessively long call light wait times, and/or missed breakfast, or experienced a delay in getting to breakfast or delay in receiving care. This deficient practice had the potential to affect all 47 residents who resided in the facility. Findings include: Refer to F676- Based on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene care for 1 of 1 resident (R3) reviewed who needed assistance with fingernail care. Refer to F677 – Based on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R36) who was dependent upon staff for assistance with activities of daily living (ADL). Refer…

  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 · F2026-01-27 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 6 of 6 agency staff (nursing assistant (NA)-B, NA-C, NA-D, NA-G and registered nurse (RN)-G, RN-I) and 4 of 4 facility staff (NA-E, NA-J, RN-B, RN-J) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 47 residents who resided in the facility.Findings include: Refer to F760: Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant medication error for 1 of 5 residents (R44) reviewed for medication administration. Refer to F684: Based on observation, interview and document review, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer medications in accordance with provider-prescribed…

  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 before2026-01-27 · tag F0755 — failed to provide safe pharmacy services — widespread
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 document review, the facility failed to ensure complete narcotic and controlled substance reconciliation occurred for two of two medication carts, failed to provide secure storage of disposed medications, and failed to ensure consultant pharmacist involvement and awareness of medication reconciliation and disposal processes. This practice had the potential to affect all 47 residents residing in the facility. In addition, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 1 resident (R26) reviewed for medication administration. Findings include: Refer to F760: Based on observation, interview and document review, and staff interview, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant…

  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 · F2026-01-27 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review the facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven quality assurance and performance improvement (QAPI) program. These findings had potential to affect all 47 residents who resided in the facility.Findings include:See F684: Based on observation, interview, and document review, the facility failed to ensure necessary care and services were provided for 1 of 1 resident (R2) reviewed for non-pressure skin concerns, when staff failed to appropriately assess, treat, and manage bilateral lower-extremity wounds. This included failure to timely notify the provider and obtain and implement wound care orders following a change in skin condition, and failure to ensure wound care was provided as needed. These failures resulted in R2 going multiple days without wound care and placed the resident at risk for worsening skin breakdown, infection, and complications related to delayed treatment. Further, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-01-27 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough data collection, analysis and evaluation of identified concerns during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 47 residents who resided in the facility.Findings include:During an interview on 1/27/26 at 2:31 p.m., with the administrator, the director of nursing (DON) and registered nurse (RN)-B known as regional director of clinical services, the DON stated the facility PIP (performance improvement project) for 2025, had been short stay pressure ulcers, which had been selected by the previous regional nurse consultant. The DON stated there had been no concerns and nothing to improve. Despite this conclusion, the DON could not provide documentation that a performance improvement process had been utilized to arrive at this conclusion. No rationale for selection of this PIP, no data gathered, no feedback from staff, no analysis, no conclusion.…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-01-27 · 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 Based on observation and staff interview, the facility failed to ensure laundry was handled, transported, and processed in a manner that prevented the spread of infection. Specifically, soiled linens were transported unbagged from resident rooms and through hallways, and the facility failed to implement oversight, staff education, and monitoring of laundry infection control practice, further the facility failed to follow infection prevention and control practices related to enhanced barrier precautions (EBP), wound care, and appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R2) reviewed for non-pressure skin concerns,, failed to identify residents who met criteria for EBP, post required signage, educate staff on EBP versus contact precautions, and ensure staff used appropriate PPE and infection control practices during wound care. Findings include: Laundry On 1/21/26 at 8:16 a.m., observation and interview with staff who requested anonymity, was observed in a utility room, removing…

  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 · F2026-01-27 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review the facility failed to implement and maintain an effective Infection Prevention and Control Program specific to antibiotic stewardship. The facility did not have a system to track antibiotic use, culture results, organisms identified, or antibiotic resistance to ensure residents received appropriate treatment, this had the ability to affect all 47 residents. Findings Include:Review of the Infection Prevention and Control (IPC) case log dated 1/22/26, showed documentation included resident name, room number, onset date, current prescription, prescriber, infection type, infection site, diagnosis, and category. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, and whether organisms were resistant to prescribed antibiotics.On 1/22/26 at 12:10 p.m., the assistant director of nursing (ADON), identified as the infection prevention nurse, stated antibiotic use was not tracked. The ADON stated the facility completed a log to monitor resident symptoms, possible infections, and provider…

  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 · E2026-01-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 maintain a clean and sanitary environment free from persistent odors for one of three hallways, which resulted in strong and ongoing odors of urine and bowel movements. In addition, the facility failed to ensure clean air/heating vents in common areas including two resident hallways and one day room. This had the potential to affect residents, staff or visitor who resided and/or used hallways and common areas. Findings include: Odors R24's annual Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact, no behaviors, no rejection of care, utilized a walker and wheelchair, required partial/moderate assistance with toileting hygiene, personal hygiene, dressing, toilet transfer, chair to bed transfer, independent with sit to lying and, rolling, no trial of toileting program, occasionally incontinent of urine, always continent of bowel, diagnoses included benign prostatic hyperplasia (BPH) (enlarged prostate), obstructive uropathy (blockage…

  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 · Dcited before2026-01-27 · 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 document review, the facility failed to ensure the provider was timely notified and appropriate orders were obtained and implemented following a change in condition related to worsening skin integrity for 1 of one 1 resident (R2) reviewed for skin changes. This failure resulted in delayed treatment, lack of wound care orders, and inconsistent care, placing the resident at risk for infection and further skin breakdown. In addition, the facility failed to notify the resident representative when there had been a change in condition for 1 of 1 resident (R26), reviewed for notification of change. Findings include: Physician Notification R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, no rejection of care, utilized a wheelchair, dependent on staff for toileting, dressing, and transfers, and partial/moderate assistance with personal hygiene, and transfers, and skin concerns identified moisture associated skin damage (MASD)…

  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

“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

$43,082 in federal fines across 1 penalty.

• $43,082 — penalty dated 2024-10-15

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 AMERICAN BAPTIST HOMES OF THE MIDWEST — 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 18 rows in the source record cover these 17 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.

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 $431K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2024. 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, FY2024). 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 MN