Marion Health And Rehab, LLC

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.

28.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 75.6 residents a day — about 63% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.01 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 4.11 hrs/resident/day on weekends vs 5.50 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.02 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 89% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

28 citations, most serious first. The 17 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-11-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff and Resident Representative interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when staff provided inaccurate body audits and services for one (1) of four (4) sampled residents. Resident #1 The facility's failure to ensure that body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents 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) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ and SQC on 11/15/23 at 12:12 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 11/15/23, in which they alleged all corrective actions to remove the IJ were completed on 11/15/23, and the IJ removed on 11/16/23. The State Agency (SA) validated…

  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 before2023-11-16 · 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 interviews, record reviews, and facility policy reviews, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 The facility's failure to implement a care plan for weekly body audits and ensure the body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents 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) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ on 11/15/23 at 12:12 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 11/15/23, in which they alleged all corrective actions to remove the IJ were completed on 11/15/23, and the IJ removed on 11/16/23. The State Agency (SA) validated the Removal Plan on 11/16/23 and determined that the IJ was…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-03-12 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate pain management when nursing staff continued performing wound care to a resident's Stage 4 pressure ulcer after the resident verbalized pain and requested pain medication, resulting in the resident experiencing pain during the treatment for one (1) of three (3) residents reviewed for pain management. (Resident #7).Findings include:A review of the facility's policy, Pain Assessment/Management, revised 6/2005, revealed, .It is the policy of the facility to provide guidelines for the identification and treatment of residents at risk for acute and chronic pain.If possible the nurse will discuss with the resident the severity and quality of pain using the pain reference scale.On 3/11/26 at 8:42 AM, during an observation of wound care for Resident #7, Registered Nurse (RN) #3 and Certified Nursing Assistant (CNA) #2 washed their hands and applied personal protective equipment prior to beginning the wound care treatment. During the treatment, RN #3 removed the dressing from…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-25 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, facility investigation review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to resident transfers when a Certified Nurse Aide (CNA) transferred a resident without assistance, using the incorrect sling size, which resulted in the resident falling during the transfer, receiving a fracture and head laceration for one (1) of four (4) care plans reviewed. Resident #1 Findings include: A record review of the facility's policy Using the are Plan with revised date of 8/2/22 revealed, Policy Statement The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . Policy Interpretation and Implementation . 2. uses the care plan to direct care provided by the CNAs and nurses daily . A record review of Resident #1's Comprehensive Care Plan revealed a care plan Focus: The resident has…

  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 before2024-11-25 · 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, facility investigation review, and facility policy reviews the facility failed to ensure a resident was transferred safely while using a mechanical lift when a Certified Nurse Aide (CNA) performed the transfer without assistance and used the incorrect sling size, which caused the resident to fall, resulting in a fracture and head laceration for one (1) of four (4) sampled residents. (Resident #1) Findings include: A review of the facility's policy, Safe Transfer and Lifting of Residents, revised 08/02/2022, revealed, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . General Guidelines .6. Enough slings in sizes required by residents should be available at all times . VI. Procedure for transferring resident with full body lift .c. Ensures proper transfer is followed per care plan .e. Ensures resident is within weight requirements 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-05 · 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

  Based on interviews, record review, and facility policy review, the facility failed to identify and provide treatment to an open scalp wound for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Abuse Prevention Program, undated, revealed, .Our residents have the right to be free from .neglect . Review of the facility's policy, Skin Assessment revised 11/1/2022, revealed .It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ re-admission and weekly thereafter . In a phone interview on 10/5/23 at 10:15 AM, with the Resident Representative (RR) and his wife, they stated they visited Resident #1 at the facility on 9/18/23 and the resident was wearing a bonnet. The wife stated that when 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-05 · 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

  Based on interview, record review and facility policy review, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Comprehensive Care Plans, revised 8/24/22, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Record review of the Comprehensive Care Plan revealed a Focus of Resident has a dx (diagnosis) of carcinoma .of skin of scalp ., with a revision date of 7/11/2023. A review of the Interventions revealed, Assess for s/s (signs and symptoms) of infection. Report to NP (Nurse Practitioner). Record review of the admission Record revealed the facility admitted Resident #1…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-16 · 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, interviews, and facility policy review, the facility failed to apply a shoulder restraint during transportation in the facility van for one (1) of three (3) sampled residents (Resident #1).Findings include: A review of the facility's policy Procedure Accidents/Incident Reporting, undated, revealed, .Accident/Incident is defined as an unexpected happening, which may or may not have caused loss or injury to a visitor, resident and/or staff person. A review of the facility's policy Providing Resident Transport out of Facility, dated 7/2008, revealed, .It is the policy of this facility to arrange transportation for our residents to, out of the facility, consultation visits. A record review of the manufacture's guidelines Wheelchair Tie-Downs revealed, .Wheelchair restraints ensure the passenger remains in a safe, forward-facing position when the vehicle is in use.The wheelchair user should also use a shoulder and lap seat belt. A record review of the Resident Council Meeting Minutes dated 5/21/2026, revealed, Resident #1 was in attendance and discussed van safety…

  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 · F2026-03-12 · tag F0567 — failed to protect residents' money held by the home — widespread
  Honor the resident's right to manage his or her financial affairs.
  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 safeguard and ensure residents had access to their personal funds entrusted to the facility when the facility failed to deposit resident trust funds into an interest-bearing account and failed to ensure residents could access their funds following the change of ownership on 1/1/26 for three (3) of three (3) residents reviewed for resident funds (Resident #62, Resident #65, and Resident #74) and had the potential to affect all forty-three (43) residents with facility-managed trust funds.Findings include:A review of the facility's Resident Personal Funds policy, dated 6/2022, revealed, .Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Policy Explanation and Compliance Guidelines .2. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold,…

  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 · F2026-03-12 · tag F0568 — widespread
  Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
  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 provide residents with account statements upon request for two (2) of three (3) residents reviewed for resident funds (Resident #65 and Resident #74), with the potential to affect all (43) residents with facility-managed trust funds.Findings include:A review of the facility's Resident Personal Funds policy, dated 6/2022, revealed, .Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds . Accounting and Records .3. The individual financial record must be available to the resident .upon request .A record review of the facility's list Residents with Trust Funds revealed (43) residents had facility-managed trust funds.Resident #65A record review of the admission Record revealed the facility admitted Resident #65 on 03/13/24 with diagnoses including Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26…

  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 · F2026-03-12 · tag F0583 — failed to protect personal privacy — widespread
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights to personal privacy and confidentiality of their medical records when resident charts containing identifying information were stored in hallways near the nurses' stations for two (2) of (2) nurses stations observed. Findings include:A review of the facility's policy, Resident Rights updated 04/04/25, revealed, .Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.d. Privacy and confidentiality.A record review of the facility's Confidentiality and Non-Disclosure Agreement, dated revised 05/16/22, revealed staff are not to leave workstations unattended without securing hard copy information so that it may not be disclosed to unauthorized persons and that staff must abide by Health Insurance Portability and Accountability Act (HIPAA) policy and procedures and current regulations governing privacy issues.On 03/09/26 at 3:00 PM, 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of individual needs when the facility failed to ensure soap was available in the resident's bathroom to allow the resident to maintain personal hygiene after the installation of a wall-mounted soap dispenser for one (1) of (20) residents reviewed for resident rights. Resident #50.Findings include:A review of the facility's policy, Resident Rights, dated 4/4/25, revealed, .Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation.2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.A record review of the admission Record revealed the facility admitted Resident #50 on 7/18/23 with diagnoses including Bipolar Disorder.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/26 revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, and facility policy review the facility failed to ensure residents were allowed to make choices regarding food preferences when dietary staff continued to serve pureed bread to Resident #68 after the resident had requested not to receive it and when the facility failed to accommodate Resident #49's preference for fried eggs after the facility stopped ordering eggs, affecting two (2) of (20) residents reviewed for resident choices.Findings include:A review of the facility's policy, Resident Rights, dated 4/4/25, revealed, .Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation.2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.Resident #68On 3/9/26 at 2:02 PM, during an observation and interview, Resident #68 reported she had complained to staff that she did not want pureed bread served on her meal trays. Resident #68 stated the pureed bread was too thick and she believed she could choke on it. Resident #68 reported she had…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-12 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 the accuracy of the Minimum Data Set (MDS) assessment when the facility coded an antipsychotic medication on the MDS despite no physician orders or Medication Administration Record (MAR) documentation for an antipsychotic medication for one (1) of (20) residents reviewed for MDS accuracy. (Resident #12).Findings include:A review of the facility's policy, MDS Assessment, dated 5/2006, revealed, .The facility will follow direction per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI (Resident Assessment Instrument) manual.A record review of the admission Record revealed the facility admitted Resident #12 on 2/18/2022 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/26 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired. A review of Section N revealed…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · 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 interview, record review, and facility policy review, the facility failed to provide an ongoing activities program designed to meet the interests and preferences of residents when scheduled weekend activities were not conducted and residents reported limited opportunities for activities on weekends, for one (1) of (20) residents reviewed for activities (Resident #74), which affected all residents who participate in activities.Findings include:A record review of the facility's policy, Activity Program, dated 01/21/2022, revealed, .An ongoing program of activities is designed to meet the needs of each resident. Policy Interpretation and Implementation.2. Activities are scheduled daily and residents are given the opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the program. 3. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes.b. Indoor and outdoor…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to follow the posted menu as written and failed to ensure alternate menu items were available as listed on the menu for two (2) of (20) residents reviewed for food services. Residents #65 and #74.Findings include:A review of the facility's policy, Alternative Foods For Food Preferences or Menu Changes, dated 10/23, revealed, .Procedure: 1. The food and nutrition services departments prepares an alternate food choice that is available for residents who refuse food or beverages at meals. 2. Alternate foods and beverages are prepared or are available at each meal.7.Menu changes will be posted.On 03/09/26 at 11:15 AM, during an observation and record review of the posted menu, the menu for Monday Lunch revealed Red Beans and Rice, Mustards, Cornbread or Country Fried Steak, French Fries, and Seasoned Cabbages. The dessert was Banana Pudding with Whip Cream.On 03/09/26 at 11:20 AM, during an observation of the lunch meal…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-11 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, and facility policy review the facility failed to ensure resident council members' complaints regarding food that was served cold were recorded and resolved in a timely manner for nine (9) of 11 Resident council members. (Resident #4, #18, #20, #27, #42, #49, #52, #62, and #68) Findings include: Review of the facility's policy, Resident and Family Grievances revised 6/1/23 revealed, . It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Policy Explanation and Compliance Guidelines .8. Grievances may be voiced in the following forums .d. Verbal complaint during resident or family council meetings .10. Procedure .d. The Grievance Official will take steps to resolve the grievance .e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances .12. The facility will make prompt efforts to resolve grievances . Review of the Resident Council Minutes dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“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

$244,855 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $6,370 — penalty dated 2024-11-25
• $6,371 — penalty dated 2024-11-25
• $232,114 — penalty dated 2023-10-05
• Medicare payment denial — starting 2023-10-28 for 40 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 BEDFORD CARE CENTERS — 7 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 18 rows in the source record cover these 14 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 81% 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 $1.3M 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in MS