Aspen Point Health And Rehabilitation

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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.

Met the expected recovery: 14.3% 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 21 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% 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 180 beds and averages 54.4 residents a day — about 30% occupied, or roughly 126 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 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 3.04 hrs/resident/day on weekends vs 3.56 on weekdays — 15% thinner on weekends. RN hours go from 0.85 to 0.77 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 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.

74 citations, most serious first. The 30 most serious are shown; the remaining 44 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-08-29 · 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 record review, the facility failed to safely transfer one cognitively intact resident (Resident #157), who had a diagnosis of quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), in a review of 17 sampled residents. Per the resident's interview, two unidentified staff (only identified by gender) failed to maintain control of the resident during a mechanical lift transfer, causing the resident's legs to hit the lift. When the resident was over the bed, staff hit the emergency release instead of the lowering button, and the resident dropped to the bed with his/her legs bent underneath him/her. During assessment, staff identified the resident had skin tears to both of his/her legs. The resident had pain and swelling in his/her legs and was sent to the hospital for evaluation. The resident was diagnosed with bilateral leg fractures consistent with the described incident. Staff failed to safely transfer two residents (Residents #12 and #36) in 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
• Immediate jeopardy · Jcited before2024-08-29 · tag F0725 — failed to have enough nursing staff — isolated
  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 record review, the facility failed to provide sufficient staff to meet the residents' needs in the event of an emergency for two residents (Residents #25 and #157), in a review of 17 sampled residents. The residents' care plans directed for four staff to lower the resident to the ground with a sling and drag the residents out of the building to safety on a lift pad in the event on an emergency evacuation. The facility staffing showed three or less staff worked on the night shift on seven days between 7/12/24 and 8/26/24. Insufficient staff to evacuate the resident had the potential to cause serious injury, harm or death in the event of an emergency requiring an emergency evacuation. The facility assessment identified five staff were needed on the night shift to meet the residents' needs. The facility failed to ensure at least five staff worked on the night shift on 19 days between 7/12/24 and 8/26/24. The facility failed to provide sufficient staff to ensure two residents…

  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
• Immediate jeopardy · Kcited before2023-11-09 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to ZNHX12 Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff failed to provide incontinence care per the facility's perineal care policy/procedure and to wash their hands when they removed contaminated gloves while performing post-incontinence care for Resident #2 and #4. The facility census was 70. The administrator was notified on 11/08/23 at 4:45…

  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
• Immediate jeopardy · K2023-10-12 · tag F0678 — failed to provide CPR when needed — pattern
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure systems were in place to clearly document residents' choice for code status. The facility also failed to clearly communicate the choice of code status to direct care staff so staff knew immediately what actions to take in the event of an emergency for four residents (Residents #2, #3, #4, and #5) in a review 79 residents. This had the potential to result in a resident who wished to be full code status not receiving cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) in the event of an emergency, or residents receiving CPR who wished to be a do-not-resuscitate (DNR) (when a person elects to not have CPR attempted on them if their heart or breathing stops). The facility census was 79. The administrator was notified on [DATE] at 11:10 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility…

  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 before2023-10-12 · 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 interview and record review, the facility failed to ensure a resident with pressure ulcers and skin conditions received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and worsening of pressure ulcers and skin conditions for one resident (Resident #6). On 8/15/23, staff documented the resident had open areas to the left great toe, right rear thigh and left rear thigh. No measurements or staging of the wounds was documented. On 8/16/23 staff obtained treatment orders for the wound on the left toe. On 8/25/23, staff documented the resident had open areas, identified as pressure, to the right gluteal fold and right hip. On 8/26/23 staff obtained treatment orders for the wounds to the buttocks and right hip. On 8/31/23, the resident was seen by a wound care consultant nurse in the facility who documented an acute unstageable pressure ulcer to the right hip, chronic unstageable pressure ulcer to the right buttock, an acute stage 3…

  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 before2023-10-12 · 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

  Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one resident (Resident #1) who resided on the locked dementia unit. The resident had a diagnosis of dysphagia (difficulty swallowing, taking more time and effort to move food from the mouth to the stomach) and was identified by the facility as a choking risk. The resident had an order to receive a mechanical soft diet and, per his/her physician orders, staff were to supervise and cue the resident due to unsafe eating habits (eating too fast and not completely chewing food). On 8/16/23, the resident obtained oatmeal pies as well as half a peanut butter sandwich without staff knowledge from an unsupervised snack cart. Certified Nurse Assistant (CNA) A was the only staff member on the unit for 15 residents. CNA A initially noticed the resident coughing in the hallway while CNA A passed dinner trays to residents in the dining room. When the resident was no longer able to cough, CNA A performed a finger sweep without result. CNA A then left the resident alone (no…

  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 · Kcited before2023-08-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff failed to provide incontinence care per the facility's perineal care policy/procedure and to wash their hands when they removed contaminated gloves while performing post-incontinence care for Resident #2 and #4. The facility census was 70. The administrator was notified on 11/08/23 at 4:45 P.M. of 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
• Actual harm · G2025-02-27 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure staff provided personal privacy and treated one resident (Resident #4), in a review of 17 sampled residents, with dignity and respect when providing personal care. Staff provided a bed bath to the resident with the resident's privacy curtain and door open while talking to other residents in the hallway. The facility census was 56. Review of the facility policy, Promoting/Maintaining Resident Dignity, last revised 10/01/23, showed the following: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality; -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; -The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 consistently implement, evaluate, and modify interventions to prevent unintended weight loss for one resident (Resident #26), in a review of 17 sample residents, who had a 8.61% weight loss in one month. The facility census was 56. Review of the facility policy, Weight Monitoring, last revised 9/1/22, showed the following: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; -The facility will utilize a systemic approach to…

  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 before2024-12-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four residents (Resident #2, #3, #4, and #5) in a review of five sampled residents were treated with respect and dignity, when residents reported staff cursed at them when responding to the residents and their needs. The residents reported the comments made them feel bad, worthless, upset, and less than human. The facility census was 53. Review of the facility policy for Resident Rights with a revision date of 9/3/22 showed the following: -The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; -The resident has the right to a dignified existence. 1. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 11/8/24 showed the following: -Able to make self understood and able to understand others; -Alert and oriented able to make decisions; -Diagnosis of schizophrenia (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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  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 interview and record review, the facility failed to ensure one resident (Resident #1) in a review of five sampled residents was free from verbal abuse. The resident reported staff cursed at him/her when responding to the resident and his/her needs. The resident said the verbal abuse made him/her feel angry and upset. The facility census was 53. Review of the facility policy for Abuse, Neglect and Exploitation with a revision date of 8/23/22 showed the following: -It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-02 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, received necessary care and services in accordance with professional standards of pactice when staff failed to obtain laboratory tests and administer lactolose (a liquid medication used to treat liver failure by removing ammonia from the blood, a waste product normally processed in the liver and removed through the urine. Ammonia build up in the blood can be very dangerous and can be toxic to the brain) as ordered by the resident'sphysician. The resident, with known liver disease, became lethargic and dehydrated (loss of more fluid than taken in, the body does not have enough water and other fluids to carry out its normal functions) with an elevated blood level of ammonia, critially elevated levels of sodium and chloride (minerals required for normal body function) and elevated kidney function laboratory tests indicating severe dehydration and kidney failure. The resident was…

  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 before2024-01-18 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to ZNHX13 Based on interview and record review, the facility failed to obtain and administer pain medication in a timely manner after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, and failed to ensure the medication was available for administration for two residents (Resident #1 and #2), in a sample of eleven residents. Resident #1 had an order for morphine sulfate (a narcotic medication used to treat severe pain), and oxycodone (a narcotic medication used to relieve moderate to severe pain) for pain, and Lyrica (a medication used to treat nerve and muscle pain). The facility failed to obtain Resident #1's morphine sulfate and oxycodone, resulting in the resident having increased pain, becoming angry and upset and ultimately self-discharging from the facility. Additionally, facility staff documented administering Resident #1's Lyrica on 1/3/24 at 9:00 P.M. when it had not been administered. Resident #2 had an order for hydrocodone acetaminophen…

  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 before2023-12-14 · 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 Based on interview and record review, the facility failed to follow professional standards of practice for two residents(Resident #1 and Resident #2) out of seven sampled. Staff failed to notify the physician when Resident #2, who is dependent upon oxygen, had oxygen levels fall below the recommended range as ordered by the physician, causing the resident to become incoherent and having difficulty breathing and required hospitalization. Staff also failed to document the change in condition for Resident #1 and failed to monitor and document the resident's oxygen saturation (SPO2 levels). Staff failed to follow professional standards for Resident #1, when the resident experienced a change in the ability to swallow and staff used to a syringe to give the resident food and fluids without the order from the physician or consulting speech therapy. The facility census was 65. Review of the facility undated policy for Oxygen Administration showed: -Oxygen is administered to residents who need it, consistent with…

  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 before2023-11-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Refer to ZNHX12. Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and to communicate with outside agencies (e.g. sate surveyors) regarding any matter. Review of the facility's policy, Resident and Family…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-09 · 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 Refer to ZNHX12. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room. Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. The facility failed to provide adequate supervision and monitoring for Resident #15, who resided on a locked dementia unit and was on a pureed diet, when staff placed a peanut butter 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 before2023-08-15 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and to communicate with outside agencies (e.g. sate surveyors) regarding any matter. Review of the facility's policy, Resident and Family Grievances, dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-15 · 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 deficiency is uncorrected. For previous examples, refer to Statement of Deficiencies dated 10/12/23. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room. Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. The facility failed to provide adequate supervision and monitoring for Resident #15, who resided…

  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 before2023-08-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 two residents (Resident #1 and #2), of 14 sampled residents, received care and services to prevent weight loss. Staff failed to obtain weights per facility protocol or document intake per facility policy. The facility to failed carry through with recommendations from the Registered Dietitian, notify the physician and dietitian with further weight loss, and failed to update the resident's care plan timely when new weight loss was identified. Resident #1 had a 15% weight loss in six months and a 33% weight loss since his/her admission in October of 2022. Resident #2 had a 15% weight loss in six months. The facility census was 92. Review of the facility's policy for Weight Monitoring dated 6/2/22 showed: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance,…

  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 before2023-08-15 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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 routinely assess pain, obtain and administer pain medication timely after pain was identified, failed to notify the physician the resident did not have pain medication available for administration and failed to plan care with interventions to address the resident's pain for one resident (Resident #4) a 14 sampled residents. Resident #4 had a bacterial infection of the knee and osteoarthritis and was to receive physical therapy. The failure to have pain medication for the resident caused pain with therapy and a delayed the resident's progress with therapy. The census was 70. Review of the facility policy for Pain Management dated 9/1/21 showed: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain; -In order to help 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
• Potential for harm · E2026-02-11 · tag F0755 — failed to provide safe pharmacy services — pattern
  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

  Based on interview and record review, the facility failed to ensure an accurate reconciliation and documentation of destruction of Schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence), Schedule IV and schedule V narcotic controlled substance medications (substances in these schedules have a lower potential for abuse), for one sampled resident (Resident #51) and three additional residents (Resident #46, #27 and #50). Review showed staff documented the number of narcotic medications destroyed as two different amounts on two different forms for Resident #46 and Resident #27. Further review showed staff documented the removal of narcotic medication from the controlled drug record, after the medication had been destroyed, for Resident #46, #27, #51 and #50, but there was no documentation on the medication administration record to show staff had administered the medication. The facility census was 53. Review of the facility policy, Controlled Substance Administration…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-11 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 opportunities observed, six errors occurred, resulting in a 24.0% error rate, affecting one resident (Resident #45), in a medication administration review of four sampled residents. The facility census was 53. Review of the facility, Medication Administration Policy, dated 02/07/24, showed the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician;-Review the Medication Administration Record (MAR) to identify medication to be administered;-Compare the medication source (bubble pack, etc.) with the MAR to verify resident name, medication name, form, dose, route and time;-Administer medication as ordered in accordance with manufacturer specifications;-Do not crush medications with do not crush instructions;-Do not crush medications include slow release and enteric coated medications. 1. Review of drugs.com for pantoprazole sodium delayed release…

  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 · Dcited before2026-02-11 · 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

  Based on observation, interview and record review, the facility failed to ensure staff maintained infection control practices for one additional resident (Resident #45), in a medication administration review of four residents. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) (a Centers for Disease Control and Prevention recommended infection control intervention for nursing homes designed to reduce multidrug-resistant organism transmission) for one resident (Resident #3), in a review of 18 sampled residents. Resident #3 had a gastrostomy tube (a device inserted through the nose, mouth, or directly into the stomach/intestine to deliver essential nutrients, fluids, and medication directly to the gastrointestinal tract) and documented methicillin resistant staphylococcus aureus (MRSA - a bacteria that spreads through skin to skin contact or contaminated surfaces) in a wound. Staff failed to use appropriate infection control practices during incontinence care. The facility census was 53. Review of the facility, Medication Administration Policy,…

  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 before2025-08-14 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe, clean, and homelike environment for three residents (Resident #64, Resident #10, Resident #30) in a sample of 24 residents and one additional sampled resident (Resident #55). The facility census was 55. Review of the facility policy, Resident Environmental Quality, revised 09/01/2021, showed the following: -It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public;-Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents;-Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment;-All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. 1. Observation on 08/11/25 at…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-14 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to change gloves in between dirty and clean tasks, complete appropriate hand hygiene and properly handle dirty linens and trash for four residents (Resident #9, #18, #27 and #51) in a review of 24 sampled residents. The facility census was 55. Review of the facility policy, Infection Prevention and Control Program, revised 04/23/25, showed the following: -Thes facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines;-All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services;-Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures;-All staff shall…

  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 before2025-02-27 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for three residents (Residents #5, #14, and #30), in a review of 17 sampled residents. Staff failed to follow physician's orders for oxygen therapy and immunizations/vaccinations for Resident #5, failed to pack a wound as ordered for Resident #14, and failed to apply a soft hand splint for Resident #30. The facility census was 56. Review of the facility policy, Medical Provider Orders, revised 4/7/22, showed the following: -The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements staff should contact…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-27 · 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 observation, interview, and record review, the facility failed to provide three residents (Residents #102, #14, and #12), who relied on staff to assist with their activities of daily living (ADLs), in a review of 17 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 56. Review of the facility's policy, Oral Care, last reviewed/revised 09/01/21, showed it was the practice of the facility to provide oral care to residents in order to prevent and control plaque associated oral diseases. (The policy did not address how often staff were to provide assistance with oral care.) Review of the facility's policy, Providing Nail Care, reviewed/revised 9/1/21, showed the following: -Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care; -Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis; -Routine nail care, to include…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-27 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  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 provide evidence the facility offered the pneumococcal vaccination to three residents (Residents #5, #29, and #36), in a review of 17 sampled residents, and failed to provide education to each resident or resident representative regarding the benefits and potential side effects of the pneumococcal vaccination. The facility census was 56. Review of the facility policy, Pneumococcal Vaccine, dated 9/1/21, showed the following: -It is the facility policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with Centers for Disease Control and Prevention (CDC) guidelines and recommendations; -Each resident will be assessed for pneumococcal immunization upon admission, self-report of immunization shall be accepted, any additional efforts to obtain information shall documented, including efforts to determine date of immunization or type of vaccine received; -Each resident will be offered 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #26 and #4), in a review of 17 sampled residents, had call lights within reach. The facility census was 56. Review of the facility policy, Call Lights: Accessibility and Timely Response, last revised September 2021, showed the following: -The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance; -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -All residents will be educated on how to call for help by using the resident call system; -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; -Special accommodations will be identified on the resident's…

  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 · D2025-02-27 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for two residents (Residents #405 and #102), in a review of 17 sampled residents. The facility census was 56. Review of the facility's policy, Baseline Care Plans, last reviewed 09/01/21, showed the following: -The facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; -A baseline care plan would be developed within 48 hours of a resident's admission; -The admitting nurse, or supervising nurse on duty, should gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with…

  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

“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

$340,683 in federal fines across 7 penalties. 1 Medicare payment denial on record.

• $44,298 — penalty dated 2025-02-27
• $12,012 — penalty dated 2024-12-09
• $150,799 — penalty dated 2024-08-29
• $110,638 — penalty dated 2024-02-23
• $4,587 — penalty dated 2023-10-02
• $4,587 — penalty dated 2023-09-25
• $13,762 — penalty dated 2023-09-05
• Medicare payment denial — starting 2024-05-18 for 73 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 VERTICAL HEALTH SERVICES — 15 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 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 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.

About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $286K 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 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 MO