Luther Haven

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.

41.4% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 55.6% 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 36 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 55 beds and averages 50.2 residents a day — about 91% 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 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above 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 3.79 hrs/resident/day on weekends vs 4.39 on weekdays — 14% thinner on weekends. RN hours go from 0.87 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as 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 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.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-01-13 · 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 complete a timely comprehensive elopement risk assessment that addressed window type as a possible exit for mobile residents who were at risk for elopement for 1 of 3 residents (R1) who had a history of exit seeking. This resulted in immediate jeopardy (IJ) when R1 eloped from a window in her room and was found ½ mile from the facility approximately an hour later by the police and family member. The immediate jeopardy began on 12/28/24, when R1 eloped from the facility by exiting through the window in her room and was found an hour later 1/2 mile from the facility. The immediate jeopardy was identified on 1/9/25, and the assistant administrator was notified on 1/9/25, at 4:40 p.m. The immediate jeopardy was removed on 1/10/25, but noncompliance remained a lower scope and severity of a D with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding include: R1's Face Sheet dated 1/8/25, indicated 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
• Immediate jeopardy · Jcited before2024-09-12 · 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 appropriately assess and/or follow the care plan and ensure safe transfers were performed for 3 of 3 residents (R11, R16, and R37) while using sit-to-stand mechanical lifts (EZ stand) (requires a resident to be partial weight-bearing) to prevent or mitigate falls or risk thereof. This resulted in an immediate jeopardy (IJ) for both R11 and R16 who fell from and EZ-stand and required hospital evaluation and treatment). Both events had the potential for serious harm, injury, impairment, or death. The IJ began on 8/29/24, when nurse aide (NA)-A failed to follow R11's care plan and ensure 2 staff transferred R11 while using an EZ-Stand. R11 let go of the bars on the EZ -Stand and fell backwards out of the sling, resulting in a laceration to the back of her head. R11 was previously identified in June 2023 to be inconsistent with participation of the EZ-Stand: requires assist of two with the EZ-Stand: unable to recommend anything else and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-05 · 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 interview and document review, the facility did not assess or analyze trends of falls to determine causal factors or root cause and implement interventions to prevent or reduce the risk of falls with major injury for 1 of 3 residents (R1) reviewed who had falls. This resulted in actual harm when R1 suffered spinal compression fracture at T12 (thoracic spine last vertebrae), L1 and L2 (lumbar spine between the top two vertebrae) and a rib fracture as a result of two unsupervised falls. Findings include: R1's face sheet dated 6/5/25, identified diagnoses of Parkinson's disease (condition that affects movements), dementia (decline in mental ability), and depression (mood disorder characterized by persistent sadness). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment with diagnoses of Parkinson's Disease, dementia with behaviors, and depression. R1 had no behaviors, rejection of cares or wandering. R1 required maximal assist of one staff person for 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2025-08-20 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 15 sampled residents (R8 and R29).Findings include: R29 undated, current diagnoses sheet identified that R29 had a diagnosis of altered mental status, social phobia, depression, hallucinations, and psychotic disorder with delusions. R29's 2/02/23, Level I Preadmission Screening and Resident Review (PASRR) identified a referral for an OBRA Level II assessment for mental illness was required. R29's 2/08/23, Level II PASARR was completed and identified R29 had a mental illness. R29's 2/08/23, admission Minimum Data Set (MDS), section A identified R29 had no mental illness documented. R29's subsequent MDS assessments for section A from 2/8/23 through 7/25/25, identified they also had been marked no for mental illness. Interview and document review on 8/20/25 at 10:11 a.m., with the social worker (SW) identified R29's Level II PASARR diagnosis of mental…

  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 before2025-08-20 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  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, interview, and document the facility failed to have a process for monitoring personal refrigerators located in 1 of 15 sampled resident's (R23) room to ensure temps were monitored, food was not expired, and the refrigerator maintained to prevent potential food born illness. Findings include: Observation on 8/18/25 at 11:30 a.m., in R23's room identified a small dorm style refrigerator. Inside the refrigerator was a small freezer. The refrigerator contained sausage, sliced cheese, several bottles of boost supplement, and soft chocolate candy. The freezer contained an item wrapped in white paper labeled Souse (meat made from various parts of the pig such as head, feet, and ears) with a freeze by date of July 2024. The freezer nor refrigerator contained a thermometer. Outside of the refrigerator identified no log to show that staff were monitoring or maintaining the refrigerator. Interview on 8/20/25 at 9:00 a.m., with the administrator identified the facility was not monitoring 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 · Dcited before2025-03-19 · 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 document review, the facility failed to ensure appropriate transmission based precautions used for 1 of 1 resident (R4) with diagnosis of Respiratory Syncytial Virus (RSV). Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe impaired cognition with diagnosis of dementia. R4's progress note dated 3/14/25 at 9:39 a.m., indicated R4 continued to have a runny nose and wet cough and complained of not feeling well. 4-plex (nasal swab allowing staff to quickly identify whether a person is infected with Influenza A, Influenza B, Respiratory syncytial virus (RSV), or COVID-19) and placed on precautions. R4's progress notes dated 3/14/25 at 11:12 a.m., indicated call from physician that R4 had RSV, and R4 was placed on droplet precautions. During an observation on 3/18/25 at 12:36 p.m., R4's room door was open, and there was a droplet precaution sign outside door with a 3-drawer isolation bin with gloves, goggles, and face shields. During 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 · F2024-09-12 · tag F0585 — failed to handle grievances — widespread
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review the facility failed to ensure 1 of 1 grievance policy and procedures were followed. The facility failed to post the grievance policy prominently and throughout the facility and provide forms to submit a grievance anonymously if desired. In addition, the facility also failed to document all grievances, the action taken to resolve grievances and the summary of the resolution to each grievance. This had the ability to affect all 54 residents. Findings include: Interview on 9/9/24 at 12:09 p.m., with R39 who reported that he must wait for someone to come help him. He likes to get up around 7:30 a.m., and no one came to help him until 9:00 a.m. and he was so mad he could have burnt the place up. Interview on 9/9/24 at 1:27 p.m. with R9 who reported the staff are good when they have time. The staff try however, this morning she had put her call light on to get up and had to wait 2 hours before someone came to help her and that is not unusual. Interview on 9/11/24 at 2:43 p.m., with R48's family member identified she had complained about long call…

  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 · F2024-09-12 · 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 record review, facility failed to ensure 8 of 8 nursing assistants ((NA)-A, NA-B, NA-F, NA-G, NA-H, NA-I, NA-J, and NA-K) 4 of 4 registered nurses (RN)-D, RN-E, RN-F and the infection preventionist (IP)), and 1 of 1 licensed practical nurse (LPN)-F were deemed competent on the operatioon of mechanical lifts and following care plans and care sheets, upon hire, yearly thereafter, or as needed when identified concerns with competence were noted. This had the potential to affect all 54 residents who had/may use mechanical lifts, and had care plans and care sheets. Findings include: Review of the NA employee files identified: 1. NA-A had a hire date of 8/27/24. 2. NA-B had a hire date of 2/4/22. 3. NA-F had a hire date of 3/27/24. 4. NA-G had a hire date of 6/11/24. 5. NA-H had a hire date of 5/15/23. 6. NA-I had a hire date of 1/22/4. 7. NA-J had a hire date of 7/17/24. 8. NA-K had a hire date of 4/25/24. None of the above mentioned NA staff had competencies performed for the use of mechanical…

  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 before2024-09-12 · 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, interview, and document review, the facility failed to ensure staff were not co-mingling personal food and effects with resident food. This had the potential to affect all 54 residents who ate food prepared from the kitchen. Findings include: Observation on 9/9/24 at 10:45 a.m., during the initial tour of the facility kitchen with the dietary manager present, a reach-in refrigerator in the baking area of the kitchen had two separate compartments. The top compartment contained 5 tumbler style drink cups with straws sticking out of staff's, and 2 Tupperware containers containing staff personal food. The refrigerator also contained food used for residents including butter, frosting, liquid eggs, ice cream topping, and glucerna supplements. The bottom compartment was not cooling and contained staff effects including shoes, pretzels, clothing, and bags containing unknown items of staff's. Interview on 9/10/24 at 1:17 p.m., with the dietary manager identified she agreed with the above findings and did not know why staff had been storing things in the resident kitchen…

  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 · F2024-09-12 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  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 implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. Findings include: Refer to F726 Interview on 9/12/24 at 9:04 a.m., with administrator stated the facility competency requirements listed on the facility assessment did not reflect the practice of staff training on the floor. The facility had recently made changes to the facility assessment, under the direction of regulation mandated for nursing homes in July of 2024. All staff were not informed and were not updated of the facility assessment changes recently. The Quality Assessment and Assurance (QAA) committee was to approve the assessment revision and would relay to all staff the facility's operational goals related to person-centered cares, staffing services, and resources. Review of 9/2024 [NAME] Haven Nursing Home 2024 Facility Assessment Tool identified staff education and competencies 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-09-12 · 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 ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 54 residents. Findings include: Review of the quarterly QAPI meetings covering March of 2024 through July of 2024, identified the facility departments were submitting data to be reviewed by the committee as follows: QAPI minutes dated 3/28/24 identified: 1) The facility departments had brought forth concerns regarding urinary tract infections (UTI's) with contributing factors of standing order concerns with providers, antibiotic stewardship, and staff training. The QAPI committee did not identify a analysis of the data, a measurable goal, or an action plan to help reduce the prevalence of UTI's in the facility. 2) The infection preventionist identified the facility had 5 UTI's, 2 residents with pneumonia, 2 with respiratory symptoms, 2 with confirmed norovirus, and 34 residents on…

  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 · E2024-09-12 · 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 Based on interview and document review the facility failed to ensure call lights were answered timely for 4 of 4 residents (R9, R29, R39, and R48) reviewed for activities of daily living (ADL's). Findings include: R39 Interview on 9/9/24 at 12:09 p.m., with R39 who reported that he must wait for someone to come help him. He likes to get up around 7:30 a.m., and no one (satff) came to help him until 9:00 a.m., and he was so mad he could have burnt the place up. He reported the pool staff are really crabby they do not give a [expletive] as they are only here a short time. One time a pool staff came and fell asleep in the parking lot in her car. R39's 8/30/24, quarterly Minimum Data Set (MDS) identified Brief Interview for Mental Status (BIMS) score as 15 cognition was intact. He had verbal behaviors directed towards others andrequried sustantial to partial assistance by staff for cares. He took scheduled pain medication, an antidepressant, anticoagulant, and a diuretic. R39 had diagnoses of anemia, coronary artery…

  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 before2024-09-12 · 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 and interview the facility failed to follow their policy and ensure discontinued medications for 5 of 5 residents (R12, R16, R52, R55, R108) were removed timely and not co-mingled with other current medication supply located in the East and [NAME] double locked narcotic medication drawer within the medication cart. Findings include: Observation and interview on [DATE] at 2:26 p.m., of the west medication cart narcotic count between registered nurse (RN)-A and licensed practical nurse (LPN)-A. During the controlled substance count it was identified that R12 had 4 bottles of morphine 100 milligrams (mg)/5 milliliter (ml) with 3 of the bottles being partially used and one bottle being unopened who staff reported had passed away on [DATE]. R108 had 2 bottles of morphine 100 mg/5 ml that were unopened who staff reported had discharged on [DATE]. R55 also had 2 bottles of morphine 100 mg/5 ml that were unopened in the cart, staff reported she had passed away on [DATE]. R12's [DATE], Physician…

  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

$101,268 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $77,705 — penalty dated 2025-01-13
• $23,563 — penalty dated 2024-09-12
• Medicare payment denial — starting 2024-10-10 for 18 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.

Who owns this facility

CMS files one row per role, so the 24 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.

4 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.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in MN