Pine Grove Manor

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.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 77 beds and averages 51.9 residents a day — about 67% occupied, or roughly 25 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.79 hrs/resident/day on weekends vs 3.28 on weekdays — 15% thinner on weekends. RN hours go from 0.43 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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.

35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-22 · tag F0678 — failed to provide CPR when needed — isolated
  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 observation, interview, and record review, the facility failed to provide cardiopulmonary resuscitation (CPR, life saving measures) effectively to include rescue breaths, to a resident when the supplies needed to run a code were not available on the crash cart. This resulted in a delay of up to 9 minutes from the time CPR was initiated until rescue breaths and oxygen could be administered, for one resident (Resident #1). Staff were not knowledgeable on how to work the suction machine, resulting in an occluded airway. In addition, staff failed to ensure Emergency Medical Services (EMS) was in the room and ready to take over compressions before stopping CPR. Eighteen residents were identified to be a full code. The census was 48. The Interim Administrator was notified on [DATE] at 2:50 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Medical Emergencies - Code Blue, policy, dated [DATE],…

  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 before2024-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 record review, the facility failed to maintain an environment free of accident hazards by not maintaining safe water temperatures in resident rooms on the North and South halls between 105 degrees Fahrenheit (F) and 120 F for 16 (Residents #49, #14, #12, #15, #54, #34, #8, #3, #27, #5, #43, #258, #18, #11, #52, and #40) of 31 sampled residents. The hot water temperatures in these resident room bathrooms ranged from 141 to 153 degrees F. The census was 55. The administrator was notified on 3/28/24 at 7:00 P.M., of an immediate jeopardy (IJ), which began on 3/28/24. The IJ was removed on 3/29/24 as confirmed by surveyor verification. Review of the facility's Safety of Water Temperatures Policy, dated December 2009, showed: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; -Policy Interpretation and Implementation; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-07-01 · 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 ensure one resident (Resident #1), who was non-weight bearing on his/her left leg and required the use of a Hoyer (mechanical lift) for transfers, received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) B performed an assisted transfer without the use of a mechanical lift or gait belt. The resident reported pain during the transfer and sustained a fractured fibula (calf bone). The sample was 7. The census was 52 The Administrator was notified on 07/01/26 of the past non-compliance, which occurred on 05/05/26. Nursing staff were in-serviced on resident transfers. The deficiency was corrected on 05/14/26. Review of the facility's Total Mechanical Lift policy, revised 06/2020, showed:-Purpose: A mechanical lift is used appropriately to facilitate transfers of residents;-Policy:-Nursing staff will be trained to use the mechanical lift;-At least two people are present while resident is…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-10-13 · 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

  Based observation, interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #3). On 9/25/23 at 4:48 A.M., Certified Nurse Aide (CNA) A went into the resident's room and cursed at the resident to lay in his/her bed, calling the resident derogatory names and verbally threatening physical harm to the resident. The census was 65. The administrator was notified on 10/26/23, of the past non-compliance. The facility provided training and in-services for all staff regarding the facility's abuse prevention and resident rights policies. Review of the facility's Abuse Policy, revised 9/1/18, showed: -Purpose: The facility maintains a no tolerance policy on any form of abuse towards our residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · E2026-03-13 · 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 physician orders were followed by not accurately coding one resident (Resident # 8's) medication as not given on the medication administration record (MAR) and by failure to document if one resident (Resident #7's) medications, treatments, and skin assessments were completed on the MAR. In addition, the facility failed to ensure that skin assessments were completed as physician ordered for two residents (Residents #5 and #48). The resident sample is 18. The census was 53.Review of facility's physician order policy, last revised, June 2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Procedure: -A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the orders; -Orders will include a description complete enough to ensure clarity of the physician plan of care; -Whenever possible, the licensed nurse receiving the order will be responsible for…

  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 · E2026-03-13 · 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 ensure activities of daily living (ADL, bathing, dressing, eating, transferring and toileting) care was provided for four of 18 sampled residents. The facility failed to ensure one resident was toileted in a timely manner (Resident #28), failed to ensure two residents received at least two showers a week and were assisted by staff (Residents #4 and #38), and failed to ensure one resident was assisted with unwanted facial hair removal (Resident #5). The census was 53. Review of the facility's showering a resident policy, undated, showed:-Purpose: a shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors;-Policy: residents are offered a shower at a minimum of once weekly and given per resident request. Review of the facility's perineal (care to the surface area between the thighs, extending from the pubic bone to tail bone) care policy, dated 6/2020, showed:-Purpose: To maintain cleanliness 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-13 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  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 assess resident activity preferences and to provide an ongoing activity program that supports residents in their choices of activities (Residents #2, #4, #5, #10, #16, #25, and #48). In addition, the facility failed to provide one to one (1:1) activities to three residents who were identified as having the potential to benefit from them (Residents #6, #7, and #9). The sample was 18. The census was 53. Review of the facility's Activities Program policy, dated 6/2020, showed:-Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning;-Policy: The facility provides an activity program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests…

  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 · E2026-03-13 · 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 establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 53. Review of the facility's Storage of Controlled Substances policy, last revised August 2020, showed:-Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations;-Procedures: -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerator times, is conducted by two licensed personnel and is documented; -Controlled substance inventor is regularly reconciled to the medication administration record (MAR) and documented on a control count sheet or similar form or in accordance with facility policy; -Current…

  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 · E2026-03-13 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  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 monthly medication reviews were completed and that the physician provided responses to recommendations for five of 18 residents sampled. (Residents' #1, #3, #6, #5, and #8). The census was 53.Review of the facility's Drug Regimen Review policy, revised January 2025, showed:-Purpose: -The intent is that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON);-Policy: -The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications; -It may be necessary for the pharmacist 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to maintain kitchen equipment in a clean condition and failed to ensure that the floors were swept and mopped during five of five days of observation. The facility also failed to ensure that a pipe was repaired from the underneath the sink and that the floor was repaired. The census was 53.1. Observations of the kitchen on 3/9/26 at 8:57 A.M., 3/10/26 at 3:33 P.M, 3/11/26 at 7:20 A.M., 3/12/26 at 10:48 A.M., and 3/13/26 at 1:10 P.M. showed:-Stove: -Caked-on stains along the front and on the top of the stove; -Heavy caked-on stains and spots on the burners on the stove; -Oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, top, and sides of oven;-Reach in cooler: -Noticeably dirty and streaked spots going down the front of the doors;-Reach in freezers: -Noticeably dirty and streaked spots going down the front of the doors;-Floor: -Noticeably dirty with food…

  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 · Dcited before2026-03-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure bathrooms on the second floor were cleaned routinely, affecting one of 18 sampled residents (Resident #10). The sample was 18. The census was 53 Review of the facility's Housekeeping policy, dated 8/2020, showed:-Purpose: To ensure that the facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors;-Policy: All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents;-Procedure: The housekeeping department is responsible for completing the daily, weekly, and monthly cleaning procedures. 1. Observations of the second floor bathrooms, on 3/9/26 at 9:57 A.M., showed:-The toilet in the bathroom by the emergency exit door had brown and yellow matter on the seat. A strong bowel movement (BM) odor permeated from the bathroom;-The shower room floors had various dark stains. Small hairs were on the ground of…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining dressing change orders on admission and transcribing the wound physician orders for one resident (Resident #57). The sample was 18. The census was 53.Review of facility's physician order policy, last revised, June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Procedure:--A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the orders;--Orders will include a description complete enough to ensure clarity of the physician plan of care;--Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order;--Medication and treatment orders will be transcribed onto the appropriate resident administration record;--Documentation pertain to physician orders will be maintained in the resident's medical record, current month's administration will be maintained in the medication…

  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 · D2026-03-13 · 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

  Based on observation, interview, and record review, the facility failed to ensure one resident had weekly skin assessments completed, and was repositioned and cleaned after being incontinent of urine for an extended period. The facility failed to ensure treatments orders were accurate and completed on a newly identified pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) (Resident #28). The sample size was 18. The census was 53.Review of the facility's Pressure Injury Prevention policy, last revised, June 2020, showed:-Purpose: To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure injury and minimize complications;-Policy: The facility will identify residents at risk for pressure injuries and provide care and services to promote the prevention of pressure injury development;-Procedure:--Risk identification and assessment:---The licensed nurse will compete a Braden Scale assessment (an assessment tool used to identify pressure injury risk) upon admission 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
• Potential for harm · D2026-03-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 #9 and Resident #6) received appropriate gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) care to avoid potential complications from the tube feeding. Facility staff failed to label the water flush bag and failed to ensure the resident's head of bed was elevated to prevent aspiration (choking). The facility also failed to include Resident #6's tube feeding care on the care plan. The sample was 18. The census was 53.Review of the facility's Tube Feeding/Total Parenteral Nutrition (TPN)/Partial Parenteral Nutrition (PPN) operational manual revised, 9/24/24, showed:-Purpose: -To ensure that the facility meets the nutritional guidelines and residents' nutritional requirements per physician orders;-Policy: -A physician order is required to administer enteral tube feedings/total parenteral nutrition/partial parenteral nutrition. Commercial…

  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

“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

$31,665 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $9,510 — penalty dated 2025-12-22
• $22,155 — penalty dated 2024-04-03
• Medicare payment denial — starting 2024-05-15 for 13 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 OPCO SKILLED MANAGEMENT — 66 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 34 rows in the source record cover these 27 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.

16 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 98% 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 $600K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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