Cleveland Community Care Center

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: 40.7% 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 27 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 120 beds and averages 109.6 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 2.94 hrs/resident/day on weekends vs 4.05 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.51 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are 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.

22 citations, most serious first. The 17 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · J2023-09-11 · 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 record review, policy/procedure review, and interviews, the facility neglected to identify a crisis of suicidal ideation of Resident #1 and neglected to provide the psychiatric services that were necessary to prevent death for one (1) of seven (7) residents sampled as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote-control cord from his bed and using an exposed pipe on the ceiling in his room. On [DATE], during the admission process Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 elected to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. An order was written on [DATE] with no time noted to place Resident #1 on one-on-one monitoring…

  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
• Immediate jeopardy · J2023-09-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 record review, policy/procedure review and interviews, the facility failed to report an injury of unknown origin resulting in a serious bodily injury to law enforcement agencies after the death of one (1) of seven (7) residents sampled, Resident #1 as evidenced by Resident #1's suicide on [DATE]. Resident #1 told the admitting nurse during the admission process on [DATE] that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident…

  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
• Immediate jeopardy · J2023-09-11 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening and Resident Review (PASARR) program under Medicaid by not referring a resident that expressed suicidal ideations on admission for a significant change in status assessment for review by the State Designated Authority for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by…

  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
• Immediate jeopardy · J2023-09-11 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 Based on policy and procedure review, record review, and staff interviews, the facility failed to provide behavioral health services to address a resident's needs as evidenced by failure to act upon Resident #1's verbalized suicidal ideations which resulted in Resident #1's suicide in the facility for one (1) of seven (7) residents sampled. During the admission process on [DATE], Resident #1 expressed suicidal thoughts when he told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On [DATE], the facility obtained an physician order for a psychiatric evaluation. On the same day [DATE], the facility obtained a physician order for hospice services and obtained a second physician order to discontinue the psychiatric evaluation. The facility did not notify hospice services of the order for a psychiatric evaluation or the order to D/C (discontinue) the psychiatric evaluation. Record review revealed a physician order dated [DATE], with no time noted, to place Resident…

  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 · J2023-09-11 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 record review, policy/procedure review and interviews, the facility failed to be administered effectively and efficiently to provide the mental health care for one (1) of seven (7) residents, Resident #1, as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote control cord from his bed and using an exposed pipe on the ceiling in his room. During the admission process on [DATE], Resident #1 told the admitting nurse that he wanted to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/ On [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-11 · tag F0841 — isolated
  Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
  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 record review, policy/procedure review and interviews, the Medical Director failed to coordinate, implement and evaluate the facility's care of one (1) of seven (7) residents, Resident #1, as evidence by Resident #1 committed suicide by hanging himself with the remote control cord of his bed on an exposed pipe in the ceiling of his room [ROOM NUMBER] days after the Medical Director discontinued the Physician Order for a Psychiatric (psych) Evaluation (eval) for suicidal ideations. During the admission process on 8/9/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to 8/17/23 when he went to every hour…

  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 · J2023-09-11 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 Based on record review, policy/procedure review and interviews, the facility failed to ensure an effective communication process, including how the communication would be documented between the Long-Term Care (LTC) facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours a day for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-08 · 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 record review, staff interview, and facility policy review the facility failed to ensure a resident who was admitted with multiple pressure ulcers and other wounds received necessary treatment and services to promote healing and prevent worsening by failing to obtain wound treatment orders and initiate wound care upon admission for one (1) of three (3) residents reviewed for pressure ulcers. Resident #1.Findings included:Record review of the facility policy Wound Care revealed Policy.Wound Care Orders and Care Plans. Each individual wound site requires a separate wound care order.A record review of progress notes for Resident #1, dated 4/17/26, revealed the resident refused assessment of her wounds. The physician was notified; however, there was no documentation that wound treatment orders were obtained.Further record review of a nursing progress note for Resident #1, dated 4/19/26, documented the resident had multiple wounds including a right heel pressure ulcer with slough, a right hip pressure ulcer with eschar, Stage four (4) pressure ulcers to the right buttock,…

  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 · D2026-01-08 · 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 observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to dignity, choice, and self-determination by failing to assist one (1) of the twenty-seven sampled residents to attend the facility's beauty shop as requested. Resident #37Findings Include: Review of the facility policy titled, Resident Rights with revision date of December 2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . On 1/5/26 at 11:45 AM, an observation and interview revealed Resident #37 seated in her wheelchair with visibly overgrown hair, measuring approximately four inches of gray overgrowth with red coloring remaining on the bottom half of her hair. Resident #37 revealed she was admitted to the facility in June 2025 and had been requesting assistance to go to the beauty shop since admission. She stated, It's like it falls on deaf ears. No one ever takes…

  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 · D2026-01-08 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interview, record review and facility policy review the facility failed to ensure residents' grievances regarding missing personal clothing were investigated, resolved, and communicated to the resident for two (2) of 27 sampled residents. Resident #29, and Resident #37. Findings Include:Record review of the facility policy titled Resident Care Grievance Policy with an effective date of 6/26/2023 revealed, Grievance decisions should include the following: .date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the decision was issued .Resident #29During an interview on 1/05/2026 at 11:45 AM, Resident #29 reported that Unsampled Resident A repeatedly entered her room and removed her clothing from the hangers in her closet.…

  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 · D2026-01-08 · tag F0603 — failed to not confine residents against their will — isolated
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, resident and staff interviews, record review, and a review of facility policy, the facility failed to honor residents' rights by secluding two (2) of twenty (20) residents in a locked Memory Care unit without proper assessment. This practice violated the residents' right to be free from involuntary seclusion. Resident #23 and Resident #83Findings Include: Review of the facility policy titled, Abuse Component Plan, with an effective date of 10/24/22, revealed under policy, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. Resident #23 An observation and interview on 01/05/2026 at 11:50 AM with Resident #23 revealed him sitting up in chair watching television in his room. His room was located on the back side of the north hall and was behind locked double doors. Resident #23 revealed that he moved to that room recently because he was acting a fool on the other hall. He revealed that they threw him back here…

  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
• Potential for harm · D2026-01-08 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure a resident's Minimum Data Set (MDS) was accurately coded for one (1) of twenty-seven (27) MDS assessments reviewed (Resident #105). Findings include:Review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revealed, All personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of the portion of the assessment .An observation on 1/05/26 at 11:30 AM revealed the resident's bilateral hands appeared contracted in appearance.Review of Section GG0115, Functional Limitation in Range of Motion (ROM), of the Quarterly MDS dated [DATE] revealed the resident was coded as having no impairment to the upper extremities.An interview with the Director of Nursing (DON) on 1/06/26 at 3:00 PM revealed she stated she had observed the resident's contracted hands and that the resident was supposed to have splints applied to his hands. She further stated that…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to develop a communication care plan for (Resident #46), failed to implement a Behavioral care plan for (Resident #22), failed to implement an activities of daily living (ADL) care plan for (Resident #29, #64, and #105), and failed to implement a range of motion (ROM) care plan for (Resident # 105) for six (6) of 27 care plans reviewed.Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, last revised March 2022, revealed the policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #22 Review of the Behavior Management care plan, last revised 12/06/25, revealed the intervention: 1 on 1 (one-on-one) precautions. During an observation and interview with Resident #22 on 1/05/2026…

  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 · D2026-01-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  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 observations, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for three (3) of 113 residents residing in the facility. Resident # 29, #64, and # 105 Findings Include: Review of the facility policy titled, ADLs Supporting undated, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy titled, Fingernail Care, Foot Care, and Podiatry Referral, effective date 4/18/2017, revealed the stated purpose was to provide guidelines for the delivery of safe, evidence-based nail and foot care which promote good personal hygiene, prevent hand, foot, and nail infections, soft tissue injury, and foot ulcers . Resident #29 An observation and interview on 1/05/2026 at 11:30 AM revealed that Resident #29 was lying in bed, with her hair disheveled, and was wearing 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 · D2026-01-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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, resident and staff interview, record review, and facility policy review, the facility failed to provide Range of Motion (ROM) services for (2) two of 60 residents who have limited ROM. (Resident #24 and #105) Findings include: Review of the facility policy titled, Resident Mobility and Range of Motion, with no revision date, revealed the policy statement: Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion . Resident #24 An observation and interview on 01/05/2026 at 11:17 AM with Resident #24, revealed him sitting up in his wheelchair in his room. He had contractures to the second, third, fourth, and fifth digits on his left hand. His fingers were stiff and bent inward, and his fingernails were touching the palm of his hand. Resident #24 stated he had a brace that he wore sometimes, and it was located in the top drawer of his dresser. Resident #24 revealed that the last time he had therapy, the Certified…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of twenty-seven (27) residents on the sample (Resident #22). Findings include:Review of a facility policy titled, Safety and Supervision of Residents, with no revision date, revealed the policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .An observation and interview with Resident #22 on 1/05/2026 at 11:40 AM revealed the resident stated he wanted to go back to where he came from, and the conversation with the resident continued for approximately five minutes. When asked if the gentleman asleep in a chair in the room was his family member, Resident #22 stated, No, he is supposed to be watching me but just look at him sleeping. The gentleman asleep in the chair did not awaken during the observation and interview.During 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 · E2024-02-15 · tag F0725 — failed to have enough nursing staff — pattern
  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

  Based on observation, staff interview, Payroll Based Journal data, record review and facility policy review the facility failed to provide adequate staffing to provide nursing and related services to meet the residents' needs safely and in a timely manner for one (1) of 28 sampled residents during survey and five (5) of 5 weekends in July 2023. Findings Include. The Administrator (ADM) provided on facility letterhead that the facility does not have a policy on staffing, the facility follows the State Department of Health Licensure regulations. A record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2023 (July1-September 30), revealed Excessively Low Weekend Staffing - Triggered. Triggered = Submitted Weekend Staffing data is excessively low. During an observation and interview on 02/12/24 at 01:34 PM revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she is not certified, she stated she has completed her course…

  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

“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

$229,213 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $229,213 — penalty dated 2023-09-11
• Medicare payment denial — starting 2023-10-07 for 4 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 79% 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 $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in MS