Vineyard Court Nursing Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 55 beds and averages 51.2 residents a day — about 93% occupied, or roughly 4 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 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.47 hrs/resident/day on weekends vs 4.16 on weekdays — 17% thinner on weekends. RN hours go from 1.08 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 20 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · J2023-10-20 · 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 observation, staff and resident interviews, record review, and facility policy the facility neglected to provide prescribed pain medication to a resident who experienced severe/uncontrolled physical pain and caused mental anguish or emotional distress as evidenced by the resident's verbalization of Just need to die for one (1) of five (5) residents reviewed for pain management. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. The facility neglected to ensure nursing staff had sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room resulting in Resident #25 going without essential pain medication for days. It was also determined…

  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 · Jcited before2023-10-20 · 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 Surveyor: [NAME], [NAME] Based on staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for administering pain medications as ordered (Resident #25), applying an anti-contracture device as ordered (Resident #32), and serving a correct therapeutic diet as ordered (Resident #26) for three (3) of 19 residents reviewed. The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving…

  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 · J2023-10-20 · 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 Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident received adequate pain management as evidenced by a resident experiencing excruciating unrelieved pain for one (1) of five (5) residents assessed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility failed to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize 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 · J2023-10-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff were competent in medication administration, pain assessment and treatment, notification of providers and pharmacy when medications were needed, and in the procedure for using the automated medication dispensing system for obtaining needed medications for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications.…

  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 · Jcited before2023-10-20 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, record review, and facility policy review, the facility failed to acquire and administer the resident's pain medication in a timely manner causing Resident #25 to experience severe/uncontrolled pain multiple times for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern…

  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
• Immediate jeopardy · J2023-10-20 · 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

  Based on staff and resident interviews, record review, and job description review the facility Administrator failed to ensure care was coordinated between the facility, Nurse Practitioner (NP) and the Medical Director (MD) for pain management for a resident who experienced severe/uncontrolled pain that resulted in the resident being transferred to the emergency room (ER) for pain control for one (1) of 19 sampled residents. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative…

  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 · J2023-10-20 · 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

  Based on observation, resident and staff interviews, record review, and Medical Director Agreement review, the facility's Medical Director (MD) failed to coordinate medical care and ensure that he or his Nurse Practitioner (NP) responded to the facility for pain control when a resident experienced severe/uncontrolled pain for one (1) of five (5) resident reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-27 · 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 interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented when a resident did not receive two (2) doses of a scheduled antiarrhythmic medication for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Findings Include: Record review of the facility policy titled Care Plans updated on 02/20/20 revealed that, Each resident will have a person centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .Procedure: 6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the interventions. Record review of Resident #4's Care Plan with start date of 02/16/2024 revealed an intervention to receive Multaq 400 mg tablet - one tablet by mouth…

  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 · Past Non-Compliance
• Actual harm · Gcited before2024-02-27 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure that an antiarrhythmic medication was available for a resident which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross reference F760 Findings Include: Record review of the facility policy, Medication Shortages/Unavailable Medications with revision date of 01/01/13 revealed under Procedure: 3. If a medication shortage is discovered after normal Pharmacy hours: If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: Emergency delivery; or, Use of an emergency (back-up)…

  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 · Past Non-Compliance
• Actual harm · G2024-02-27 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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, record review, and facility policy review the facility failed to ensure that a resident was free from a significant medication error as evidenced by not receiving two (2) doses of an antiarrhythmic medication which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross Reference F755 Findings Include: Record review of the facility policy Medication Errors updated on 02/03/2023 revealed, Medication/Treatment errors shall be documented on the Medication Error Report. An error shall be defined as any variation in administration of medication from the physician's orders and/or facility policy. The facility policy also revealed under Procedure: 1. Report all medication errors/drug reactions to the shift charge nurse/supervisor. 2. Notify 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · D2025-09-23 · 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 observation, resident and resident representative interviews, staff interviews, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect by the use of inappropriate language and by not providing privacy during care for two (2) of five (5) residents sampled. Resident #1 and Resident #4Findings include:Record review of facility policy titled, Resident Rights with date of 2022, revealed, The resident has the right to a dignified existence . 4. The resident has a right to be treated with respect and dignity. Resident #1An observation of facility's video footage with the Administrator and an interview with the Administrator on 9/22/25 at 1:05 PM revealed Resident #1 in her wheelchair in the hallway and Certified Nursing Assistant (CNA) #1 leaned the resident forward in her wheelchair and looked in the back of the resident's brief in a common area where other residents were present. The Administrator stated this treated the resident like she…

  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 before2025-08-27 · 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, resident and staff interviews, record review, and facility policy review, the facility failed to adequately supervise residents during smoking breaks which allowed residents to smoke marijuana for two (2) of three (3) residents reviewed for smoking. Resident #1 and #2Findings include:Record review of facility policy titled, Resident Smoking dated 10/24/22, revealed, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 8. Any resident who is deemed safe to smoke will be allowed to smoke under supervision in designated smoking areas .During an interview on 8/26/25 at 3:35 PM, Resident #1 revealed he was a smoker and would smoke during scheduled smoke breaks. He stated he was outside smoking with other residents and Resident #2 was smoking marijuana and gave the joint to him to smoke. He stated he had a drug problem in the past and did not refuse the joint even though he knew he should not…

  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 before2025-08-27 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to provide an ordered pain medication for a resident who had pain for one (1) of four (4) residents reviewed. Resident #1Findings include:Record review of facility policy titled, Pharmacy Services dated 3/14/24, revealed, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Record review of facility policy titled, Medication Shortages/Unavailable Medications with revision date of 1/1/13, revealed, Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from Pharmacy.2.2 If the next available delivery causes delay or a missed dose in the resident's 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-20 · tag F0656 — failed to write and follow a full care plan — pattern
  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

  Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for the use of an anti-contracture device for (1) one of 16 resident care plans reviewed. (Resident #6) Findings include: Review of the facility policy titled, Care Plans, with an update of 2/20/20 revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care . Record review of a care plan for Resident #6 revealed, Focus: (Resident proper name) requires assistance with anti-contracture device to left hand, revised 12/11/24, with Goal .will have application of anti-contracture .Interventions .assist with applying for scheduled wearing time . An observation of Resident #6 on 2/18/25 at 10:00 AM revealed the resident's left hand was contracted with no contracture device in place. In an interview with the Director of Nursing (DON) on 2/19/25 at 10:50 AM, she confirmed after review of the contracture care plan for Resident #6 that staff did not…

  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 before2025-02-20 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
  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

  Based on observation, staff interview, record review, and facility policy review, the facility failed to provide the services to ensure a resident maintained/improved his/her highest level of range of motion (ROM) as evidenced by failure to apply an anti-contracture device for (1) one of (5) five residents reviewed for positioning and mobility. (Resident #6) Findings include: Review of the facility policy titled, Prosthesis and Splint Policy, with no revision date revealed, Procedure: Applied and removed as ordered. On 2/18/25 at 10:00 AM, an observation of Resident #6 revealed a contracture to the left hand, no device in place. Record review of the Order Summary Report for Resident #6 revealed an order dated 9/25/24, remove the anti-contracture device from the left hand at least five minutes every shift and observe the skin for any impaired integrity . An observation and interview on 2/19/25 at 8:45 AM, with Licensed Practical Nurse (LPN) #1 he confirmed that Resident # 6 did not have an anti-contracture device on her left hand. He also confirmed the resident was supposed to have 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 · Dcited before2025-02-20 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review, the facility failed to implement infection control practices to prevent the possibility of the spread of infection for 2 (two) of sixteen sampled residents. Resident #6 and Resident #7. Findings Include: Review of the facility policy titled, Infection Prevention and Control Program, revised March 23, 2023, revealed, .Equipment Protocol: .b.) Single-use items must be discarded after use . Review of the facility policy titled, Enteral Tube Medication Administration Procedures, revised July 14, 2015, revealed, .Procedure: .10.) Clean feeding syringe . Review of the facility policy, Nebulizer Policy dated 02/06/15 revealed that .12. When not in use the nebulizer and the tubing should be stored in a zip lock bag . Resident #6 An observation and interview during medication administration for Resident # 6 on 2/19/25 at 8:35 AM, revealed Licensed Practical Nurse (LPN) #1 administer medications via percutaneous endoscopic…

  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 · Dcited before2024-06-04 · 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 staff and resident interviews, record review, and facility policy review the facility failed to immediately notify administrative staff and the local police department to ensure the immediate safety of a cognitively intact resident who left the facility parking lot on foot when he returned after being out on pass with a friend for one (1) of three (3) residents reviewed. Resident #1. Findings included: Record review of the facility policy, Incidents and Accidents Investigating and Reporting with revised date of 05/25/24 revealed Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .Compliance Guidelines: 1 .It is the responsibility of the department supervisor to notify the Administrator or Director of Nursing Immediately . Record review of the facility policy, Missing Resident/Elopements updated 2/3/2023 revealed .Procedure: 1. It is 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 · D2024-02-27 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review the facility failed to ensure that a bottle of medication was locked securely inside a medication cart to prevent resident access by one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the undated facility policy titled, Medication Storage revealed, .All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . On 02/14/24 at 9:05 AM, an interview with the Administrator (ADM), revealed that she had reported the incident where Resident #1 took the bottle of Vitamin D3 off the med cart. They watched the surveillance camera videos and saw that on 12/09/23 at 10:13 AM, the bottle of Vitamin D3 was given to Licensed Practical Nurse (LPN) #1 by Registered Nurse (RN) Supervisor, and she placed it on top of the medication cart. The ADM revealed that camera footage showed that Resident #1 walked down the hall, stopped at 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2023-10-20 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding anticoagulant medication usage during the 7-day observation look-back period for 1 (one) of three (3) residents sampled for anticoagulant use. Resident # 38 Findings include: Review of the facility policy titled, MDS Assessment undated, revealed, The facility shall conduct an interdisciplinary assessment using the MDS assessment as defined by Federal/State regulations. This assessment provided information on the resident's condition to facility development of a plan of care and is a means by which the facility can track changes in a resident's status . Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/23 revealed under Section N, Resident #38 received seven (7) days of Anticoagulant medication for the observation look back period of 7/5/23 through…

  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 before2023-10-20 · 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 observations, staff interviews, record review, and facility policy review the facility failed to apply an anti-contracture device as Physician prescribed for one (1) of 16 residents with limited range of motion. Resident #32 Findings include: Facility policy review titled, Prostheses and Splint Policy, no date, revealed, Prostheses and splints will be utilized safely as follows: .Procedure . Applied and removed as ordered . Record review of Resident #32's Physician Orders List revealed an order with a start date of 6/17/2022, Remove anticontracture device from left hand at least for 5 (five) minutes Q (every) shift and observe the skin for any impaired integrity. Notify TX (Treatment) nurse of abnormal findings. An observation on 10/10/23 at 10:20 AM, 10:45 AM, 2:20 PM, and 4:10 PM revealed Resident #32 with his left hand contracted closed with his fingertips touching the palm of his hand. No anticontracture device was observed in his left hand. An observation and interview on 10/11/23 at 10:45 AM,…

  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

$78,952 in federal fines across 3 penalties.

• $6,264 — penalty dated 2024-02-27
• $6,265 — penalty dated 2024-02-27
• $66,423 — penalty dated 2023-10-20

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 BRIAR HILL MANAGEMENT — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 32 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 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 73% 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 $866K paid to related parties — landlords or management companies under common ownership — equal to about 15% 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