Pine Forest Health And Rehabilitation

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.

35.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 36.4% 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 55 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 97.8 residents a day — about 82% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 5.41 on weekdays — 34% thinner on weekends — a notable drop. RN hours go from 0.46 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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 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.

41 citations, most serious first. The 21 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-06-06 · 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, interviews, record review, and facility policy review, the facility failed to protect the resident's rights to be free from neglect when the resident eloped from the facility unsupervised and unmonitored and made her way to the middle of a busy intersection for (1) of 24 residents sampled. Resident #211 The facility's failure to ensure that Resident #211 was unable to exit the facility unsupervised resulted in her running into the middle of a busy intersection located at an intersection near the facility, placing the resident in a situation that was likely to cause serious injury serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/4/25, when Resident #211 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/5/25 at 11:40 AM. The State Agency (SA) validated the Removal Plan on 6/6/2025 and determined that the IJ was removed on 6/5/25, prior to exit.…

  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 before2025-06-06 · 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, interviews, record review, and facility policy review, the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention for one (1) of twenty-four (24) sampled residents. (Resident #211). This failure resulted in Resident #211 eloping from the building on 6/4/25, for an estimated 600 feet, and being found seated on the back of a trailer in a public intersection surrounded by traffic, thereby placing the resident in Immediate Jeopardy (IJ) for serious injury, harm, impairment, or death. This situation was determined to be IJ and Substandard Quality of Care (SQC), which began on 06/04/25 when Resident #211 eloped from the facility. The State Agency (SA) notified the Administrator of the Immediate Jeopardy on 06/05/25 at 11:40 AM and provided an IJ template. The facility provided an acceptable Removal Plan on 06/05/25, in which they alleged all corrective…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-12-05 · 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, interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect for five (5) of 22 residents reviewed as evidenced by facility staff: 1. Did not provide Pressure Ulcer (PU) assessments and care and treatment to prevent complications and worsening of PUs (Resident #53 and Resident #89) 2. Turn and reposition a resident (Resident #87) 3. Ensure incontinent residents were clean and dry (Resident #1 and Resident #31). The facility's neglect to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse…

  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 before2023-12-05 · 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 interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions as evidenced by: (1) the failure to develop comprehensive care plan interventions for residents with pressure ulcers (PUs) (Resident #53 and Resident #89), (2) the failure to ensure a resident was turned and repositioned (Resident # 87), (3) the failure to ensure residents were clean and dry (Resident #1 and #31), and (4) the failure to ensure nail care was provided to dependent residents (Resident #23 and Resident #41), for six (6) of 22 care plans reviewed. The facility's failure to develop comprehensive care plan interventions related to the prevention of skin breakdown and PU care resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The facility's failure to put Resident #53, Resident #89, and all other residents who are at risk for skin…

  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 · J2023-12-05 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, and facility policy review, the facility failed to revise resident-centered comprehensive care plan interventions for residents with Pressure Ulcers (PUs) to prevent worsening or complications from PUs for two (2) of 22 care plans reviewed. (Resident #53 and Resident #89). The facility's failure to revise comprehensive care plan interventions related to PU care put Resident #53, Resident #89, and all other residents with skin breakdown in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing a PU to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed and received care and treatment for Pressure Ulcers (PUs) to prevent complications and worsening of PUs for two (2) of four (4) residents reviewed for PUs. Resident #53 and Resident #89. The facility's failure to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 12/1/23 at 2:55 PM. 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 · J2023-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure the clinical staff were educated and trained on staging Pressure Ulcers (PUs), providing complete and accurate wound assessments, and implementing appropriate treatments for identified wounds for two (2) of four (4) residents reviewed for PU care. Resident # 53 and Resident #89. The facility's failure to ensure staff were competent with PU assessments, documentation, and treatments resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23…

  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 before2025-12-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and facility policy review, the facility failed to ensure the resident environment was free of accident hazards by failing to follow secure a wheelchair during van loading, which resulted in an avoidable accident that caused a scapular fracture and multiple rib fractures for one (1) of three (3) sampled residents (Resident #1).Findings Included:Review of the facility's policy Facility Vehicle Standard revised October 2025, revealed .Van Operation Standard The facility shall provide safe transportation for residents. Procedures.2. Loading and unloading residents.E. Follow manufacturer's instructions for operating the lift. 1. Load wheelchair onto lift.b. Lock brakes.C. In the event of a health emergency, the following steps will be followed: 1. The driver will call 911 and provide any necessary emergency first aid until trained medical personnel arrive and take over.Record review of the admission Record revealed the facility admitted Resident #1 on 5/16/25 with diagnoses including Hemiplegia, unspecified affecting right dominant side.Record review…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-26 · 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, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her. Findings Included: A review of the facility's policy, Freedom of Abuse, Neglect and Exploitation Standard, revised 11/2019, revealed, .The purpose of this written Freedom of Abuse .Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents .Standard Statement This facility shall not condone any acts of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-26 · 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

  Based on interview, record review, and facility policy review, the facility failed to ensure comprehensive care plan interventions were implemented regarding a resident's behavior during care for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right Hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her during care. Findings included: A review of the facility's policy, Comprehensive Care Plan, dated 03/2019, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance…

  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
• Actual harm · Gcited before2025-01-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, and facility policy review, the facility failed to secure a resident in a mechanical lift and maintain necessary supervision during a transfer resulting in a laceration requiring staples and Emergency Department (ED) visit for one (1) of seven (7) sampled residents. Resident #1 Findings included: Review of the facility's policy, Transferring Clients with a Mechanical Lift, undated, revealed Read the manufacturer's instructions on: How to properly operate the lift .Promotes safety and To operate the lift for transfer from the bed to a chair/wheelchair: Follow the manufacturer's instructions to operate the lift .Promotes safety. Record review of the Incident Report dated 12/21/24 5:10 AM prepared by Licensed Practical Nurse (LPN) #1, revealed Incident Description: UPON NURSE ENTERING ROOM, RESIDENT BODY SLANTED SLIGHTLY UNDER BED BUT MOSTLY ON FLOOR BUT HER LEGS REMAINED OVER BOTTOM OF LIFT AND BACK OF HEAD ALSO ON LIFT WITH MODERATE AMOUNT OF BLOOD NOTED ON LIFT AND FLOOR . RESIDENT'S RP(Responsible Party) IS (RP name). CONTACTED HER AND NOTIFIED…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-28 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection during Activities of Daily Living (ADL) care for one (1) of four (4) care observations. Resident #7.Findings Include:Record review of facility policy Hand Hygiene with a revision date of 5/2023 revealed, .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.On 5/27/26 at 3:00 PM, an observation of Activities of Daily Living (ADL) care was conducted for Resident #7 with Certified Nursing Assistant (CNA) #1. CNA #1 entered the resident's room carrying supplies and was not wearing a gown. She did not perform hand hygiene upon entering the room. CNA #1 donned (put on) gloves, informed the resident she would be providing care, adjusted the bed using the bed remote, and pulled back the bed sheet while wearing the same gloves. CNA #1 then removed her gloves and…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-08 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, record review and interview the facility failed to notify the Resident Representative (RR) of a change in condition for one (1) of four (4) sampled residents with falls. Resident #1. Findings Included:Record review of the facility provided Nursing Home Residents' Rights, undated, revealed Residents of nursing homes have rights that are guaranteed to them under Federal and State laws.Choice about designating a representative to exercise his or her rights.Right to be Fully Informed of.Changes to the plan of care, or in medical or health status.Record review of the facility policy titled, Resident Rights & Dignity Management with a revision date of September 2025 revealed .3. The resident has the right to be informed of, and participate in, his or her treatment, including c. The right to be fully informed.of his or her total health status, including but not limited to, his or her medical condition.The right to participate in the planning process.The right to be informed in advance, of the care to be furnished.Record review of the facility policy titled…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · 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

  Based on facility policy review, record review, and interviews the facility failed to evaluate, assess and identify potential injury for one (1) of four (4) residents who experienced a fall. Resident #1. Findings Included:Record review of the facility policy titled Falls Standard with Revision Date February 2018 revealed the policy stated, When a resident is found on the floor the facility is responsible for investing the reason for this.PROCEDURE POST-FALL.Obtain blood pressure and pulse while resident is on the ground.Do neuro-checks (assessment of resident's pupil equality and level of consciousness) for witnessed head injury or unwitnessed fall with or without injury. Move resident in bed or chair only if no obvious injury. Nursing to complete: Fall Risk Assessment form, Incident report.Accident/incident report, Post Fall Investigation report.MEDICAL RECORD DOCUMENTATION GUIDELINES The INITIAL NOTE/ASSESSMENT SHOULD CONTAIN THE FOLLOWING AND INCLUDE A DESCRIPTION OF WHAT WAS DONE: A. Vital signs.Document who was notified and time of notification for all attempts to do so (e.g.,…

  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 before2025-09-04 · 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, interview, record review and facility policy review, the facility failed to implement the care plan for two (2) of (2) sampled residents related to participation in structured activities. (Resident #1 and Resident #2).Findings Include:A record review of the facility policy, Resident Rights & Dignity Management, revised 5/22, revealed on page 30: 1. The resident has a right to a dignified existence, self-determination and .3. Planning and Implementing Care .iv. The right to receive the services and/or items included in the care plan.On 9/3/25, between 9:33 AM and 11:30 AM, the State Agency (SA) observed Resident #1 in a Geri-chair and Resident #2 in a wheelchair sitting in the dayroom with no care planned or structured activity present. Neither one of the residents participated in an activity observed in the activity room at 10:35 AM.On 9/3/25 at 12:20 PM, both residents returned from lunch and again sat in the dayroom with no activities present. Later, at 1:25 PM, the SA observed a music…

  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 · D2025-09-04 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, the facility failed to ensure residents were provided with activities designed to meet their physical and mental needs and interest for two (2) of (2) residents reviewed for activities. (Resident #1 and Resident #2).Findings include:A review of the facility policy titled Resident Rights & Dignity Management, revised 5/22, stated on page 32: 6. Self-Determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to (a). The resident has the right to choose activities . consistent with his or her interest, assessments, and plan of care .During an observation on 9/3/25, between 9:33 AM and 11:30 AM, the State Agency (SA) observed Resident #1 in a Geri-chair and Resident #2 in a wheelchair sitting in the dayroom with no care planned or structured activity present. Neither resident participated in an activity observed in the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-06 · 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, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan for two (2) of 24 residents reviewed. Resident # 41 and Resident #98. Findings include: A record review of the Comprehensive Care Plan Policy, revised 4/2025, revealed .Standard It is the standard of this facility to develop and implement to a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #98 Record review of the Care Plan Report revealed Focus: The resident has bladder incontinence .Interventions/Task .Incontinent care q (every) 2 hours and prn (as needed); Keep skin clean and dry . Record review of the Care Plan Report revealed Focus: The resident has an ADL (activities of daily living) Self-Care Performance Deficit .Interventions/Task .Incontinent care q 2 hours and prn with total assist . During an…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-06 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection during Percutaneous Endoscopic Gastrostomy (PEG) care for Resident #14 and during suprapubic catheter care for Resident #62 for two (2) of five (5) care observations. Findings include: A record review of the facility's policy Incontinence Management Suprapubic Catheter Care with a revision date of 1/2020 revealed Objective To promote hygiene, comfort, and reduce migration of infectious organisms to the bladder .Procedure: 8. Clean around the area where the catheter enters the abdomen in a circular motion, moving in a bullseye pattern out to 2-3 inches beyond where catheter enters abdomen . A record review of the facility policy Infection Control Enhanced Barrier Precautions dated 2024 revealed .The Centers for Disease control and Prevention (CDC) recommends using Enhanced Barrier Precautions (EBP) with residents, regardless of Multidrug-resistant Organisms (MDRO) status, who have . an indwelling medical device such as a feeding tube…

  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 before2025-06-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, the facility failed to provide wound care in a manner to promote healing and prevent infection for one (1) of three (3) residents reviewed for wound care. Resident #98. Findings Include: A record review of the facility's policy titled Skin Management Standards, revised April 2021, revealed Bacteria are present on all skin surfaces. When the primary defense provided by intact skin is lost, bacteria will reside on the wound surface. Follow infection control policies to prevent self-contamination and cross-contamination in individuals with pressure ulcers. Record review of the facility policy Skin Management Standards dated 04/2021 revealed .Protocol .3. Change dressing as ordered per physician . An observation and interview on 06/05/25 at 9:45 AM, revealed Licensed Practical Nurse (LPN) #1, assisted by LPN #6, providing wound care for Resident #98. LPN #6 removed the resident's bed linens and brief, which were heavily soiled with yellow and brown urine. LPN #1 removed the wound vacuum and dressing, which was saturated…

  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 before2025-06-06 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in December 2023. This was for two (2) recited deficiencies originally cited in December 2023 on an annual recertification survey. The deficiencies were in the area of the care plan not being followed and infection control. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of seven (7) deficient practice citations. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, September 2019, revealed, .It is the standard of this facility to .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . F656: Based on interviews, record reviews, and a review of facility policy, the facility failed to ensure a Certified Nursing Assistant followed the comprehensive care plan when repositioning one (1) of 24…

  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 · D2025-06-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide incontinent care in an appropriate manner to related to bowel and bladder care for one (1) of 24 residents reviewed. Resident #98. Findings include: A record review of the facility's policy Perineal Care with a revision date of 12/20 revealed the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . On 06/04/25 at 11:20 AM, during an observation of perineal care provided by Certified Nursing Assistant (CNA) 2 and assisted by CNA #3 revealed the CNAs performed perineal care and applied a clean brief. The State Agency (SA) asked CNA #2 to remove the clean brief and recheck the resident for cleanliness. CNA #2 removed the clean brief and wiped the anus area a total of seven additional times. Each time, the peri wipe was smeared with a brown substance. On 6/4/25 at 11:33 AM, an interview with CNA #3 confirmed that CNA #2 did not provide proper care. She stated that CNA #2 should wipe until the peri cloth is…

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

  Quality of Life and Care Deficiencies · 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

$136,799 in federal fines across 6 penalties. 2 Medicare payment denials on record.

• $12,935 — penalty dated 2025-12-09
• $7,255 — penalty dated 2025-06-06
• $7,256 — penalty dated 2025-06-06
• $12,438 — penalty dated 2025-01-17
• $37,518 — penalty dated 2025-01-17
• $59,397 — penalty dated 2023-12-05
• Medicare payment denial — starting 2026-01-06 for 24 days
• Medicare payment denial — starting 2025-02-15 for 20 days

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

Part of a chain

This home belongs to VANGUARD HEALTHCARE — 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 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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 74% 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 12% 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