The Oaks Rehabilitation And Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

38.7% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.0% 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 50 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 0.34 therapist hours per resident per day in 2026Q1 — more than 56% 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 some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 82 beds and averages 72.5 residents a day — about 88% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.99 hrs/resident/day on weekends vs 3.61 on weekdays — 17% thinner on weekends. RN hours go from 0.62 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% 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.

34 citations, most serious first. The 15 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-04-04 · 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, the facility's investigation, and facility policy review, the facility failed to ensure residents' right to be free from physical and verbal abuse when Certified Nurse Aide (CNA) 1 was reported by two staff members (CNA #2 and CNA #3) to have physically abused Resident #1 on 3/7/25 at 6:45 AM and verbally abused Resident #2 date/time unknown, both vulnerable residents, and the facility did not take immediate protective action for two (2) of four (4) sampled residents. Additionally, the Administrator was not informed of the allegation until 3/17/25, at which time CNA #1 was suspended. This left residents vulnerable for ten (10) days after the abuse was initially witnessed by staff. The facility's failure to provide immediate protective action placed these residents and other vulnerable residents at risk for serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The facility…

  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 before2025-04-04 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for two (2) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) #1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not intervene to prevent the violation of the residents' rights to be free from abuse. The facility's failure to intervene and immediately report to the Administrator placed Resident #1, Resident #2 and other residents at risk for similar abuse including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM and the facility provided an acceptable Removal Plan on 4/3/25 and the IJ…

  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 before2025-04-04 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, the facility's investigation and facility policy review, the facility failed to report abuse within the required two (2) hour timeframe (Resident #1 and #2) and failed to submit a completed investigation for an allegation of abuse (Resident #3) to the State Agency (SA) within five (5) working days for (3) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) 1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not immediately report the abuse, until 3/17/25, which was ten (10) days after the first instance of abuse was witnessed. The facility's failure to immediately report the abuse placed Resident #1 and Resident #2 and other residents at risk for continued abuse by the abuser including the risk for serious harm, injury, impairment, or death. The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-03-28 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 honor a resident's right to refuse treatment when Resident #1, who was a hospice patient and had a signed Do Not Resuscitate (DNR) Physician's Order, received cardiopulmonary resuscitation (CPR) by facility staff for one (1) of four (4) residents reviewed. Resident #1 Resident #1's medical record had conflicting information regarding the code status of the resident and caused Resident #1 to receive CPR by facility staff for 25 minutes, which was against his wishes and the Physician's Order. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility received a signed DNR Physician's Order. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-03-28 · 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 develop comprehensive care plan interventions regarding Advanced Directives for one (1) of four (4) residents reviewed. Resident #1 The facility's failure to develop comprehensive care plan interventions caused Resident #1 to receive cardiopulmonary resuscitation (CPR) by facility staff which was against his wishes and the Physician's Order. Resident #1 received CPR for 25 minutes. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on [DATE],…

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

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-05-07 · 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 staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan to reflect actual falls with interventions for one (1) of four (4) sampled residents. Resident #1.Findings include:A review of the facility's policy, Comprehensive Care Plans, dated 11/14/25, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.to meet a resident's medical, nursing.needs.A record review of the Care Plan Report revealed Resident #1 had a Focus including at risk for falls r/t (related to) confusion. The care plan was not revised to include the two (2) actual falls, along with interventions, that occurred on 3/27/26. The care plan also had an intervention dated 4/1/24 for Bed in low position.A record review of the Nursing Progress Note, dated 3/27/26 at 7:22 AM, for Resident #1 revealed, .Nurse called to room at 0710 (7:10 AM). Found resident on floor.Called (proper name of ambulance service).Will notify AM (morning) nurse.A record review of the ED (Emergency…

  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 · D2026-05-07 · 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 observation, interview, record review, and facility policy review, the facility failed to ensure the environment remained as free of accident hazards as possible as evidenced by failure to investigate an initial fall, implement interventions to prevent recurrence, and ensure the resident's bed was maintained in a low position for one (1) of four (4) residents reviewed for accidents. Resident #1 Findings include:A review of the facility's policy, Fall Prevention Program, dated 11/7/25, revealed .Each resident will.receive care services in accordance with their individual level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines.9. When any resident experiences a fall, the facility will.d. Complete an incident report.A record review of the Nursing Progress Note, dated 3/27/26 at 7:22 AM, for Resident #1 revealed, .Nurse called to room at 0710 (7:10 AM). Found resident on floor.Called (proper name of ambulance service).Will notify AM (morning) nurse.A record review of the ED (Emergency Department) information for Resident #1 from a local…

  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 · D2026-05-07 · tag F0700 — isolated
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure bed rails were assessed for clinical indication, safety, and resident need and failed to obtain informed consent for bed rail use for one (1) of four (4) sampled residents. Resident #1Findings Include:A review of the facility's policy Proper Use of Bed Rails, dated 11/7/25, revealed, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails.Resident Assessment.2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails.On 5/6/26 at 11:49 AM, in an observation, Resident #1 was sitting in a wheelchair in her room. She had quarter-length bedrails on both sides of the bed that were raised.Record review of Resident #1's clinical record revealed there were no bed rail assessments and no…

  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 before2025-11-19 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy when Licensed Practical Nurse (LPN) #2 did not immediately notify the Administrator or designee of an abuse allegation for one (1) of 3 sampled residents, Resident #1.Findings Include: A review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 10/14/2025, revealed, .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment.are reported immediately to the Administrator of the facility.Compliance Guidelines.8Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated 1. The Licensed Nurse will.c. Notify the Administrator or designee. A record review of the facility's Verification of Investigation revealed the DateTime of Occurance was 08/06/2025 at 12:20 PM and was completed by 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · E2025-06-26 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff and resident interviews, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) plan as evidenced by one (1) re-cited deficiency originally cited in January 2024 on an annual recertification survey. This is for (1) of seven (7) cited deficiencies on the current annual recertification survey. Findings include: A review of the facility's policy, Policies and Procedures .Quality Assurance Performance Improvement, with a revision date of 11/30/2014, revealed, .Performance Indicators: 10. The center will establish performance indicators for data collected .Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance . A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies on the recertification survey from January 2024 revealed the facility was cited F677 for failing to ensure a resident's nails were clipped for one (1) of eighteen (18) sampled residents. On 6/23/2025, at…

  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 · D2025-06-26 · 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 provide reasonable accommodation of needs by not individualizing a blind resident's call system for one (1) of nineteen (19) sampled residents (Resident #17). Findings included: A record review of the facility's policy, Policies and Procedures .Resident Rights, with a revision date of 11/30/2014, revealed, Policy: The facility will ensure that the resident is not deprived of his/her rights . On 06/23/2025 at 11:30 AM, during an interview with Resident #17, who is in a private room, she explained that she is blind and unable to see or reach the current call light system. She reported that even when the call light is within reach, she has no way of knowing whether it is functioning correctly. The resident expressed uncertainty and vulnerability when needing assistance and stated she often yells out for help. On 06/23/2025 at 11:41 AM, during an interview Certified Nursing Assistant (CNA) #3, explained that she occasionally provides care for Resident #17 and confirmed that the call light…

  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 · D2025-06-26 · 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 observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure ongoing assessment and documentation of skin integrity for one (1) of two (2) residents reviewed for wound care. Specifically, Resident #35, who was at high risk for skin breakdown, did not receive Weekly Skin Integrity Reviews as required by facility policy and clinical standards of practice. Findings Include: A record review of the facility's policy Skin Evaluation with a revision date of 4/1/2017 revealed a license nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. Record review of the Weekly Skin Integrity Review documentation for Resident #35 revealed that it was completed only on 6/4/25, with no further documentation of weekly assessments as required, including after the initiation of a Quality Assurance and Performance Improvement (QAPI) intervention on 6/5/25. Interview with the Director of Nursing (DON) on 6/25/25 at 9:30 AM, confirmed that the facility became aware of the missed reviews 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-26 · 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 observation, interviews, record reviews, and facility policy review the facility failed to provide perineal (peri) care in accordance with professional standards of care for one (1) of two (2) peri care observations (Resident #35). Findings include: A review of the facility's policy, Perineal Care, with a revision date of 9/5/2017, revealed, .Perform hand hygiene . On female residents, wash from front to back to avoid urethral or vaginal contamination . On 06/25/2025 at 10:23 AM, during an observation of wound care for Resident #35 provided by Registered Nurse (RN) 1, who is the Wound Care Nurse, and assisted by Certified Nursing Assistant (CNA) #5 revealed RN #1 stated to CNA #5 that the resident had a bowel movement. CNA #5 removed gloves and gown, sanitized hands, and exited the room. CNA #5 returned with a brief in hand and gown on. CNA #5 did not sanitize hands upon re-entry and applied clean gloves. He pulled out three peri wipes and wiped the anus three times front to back. CNA #5 asked RN #1 to assist in turning the resident over and applied a clean brief. CNA #5…

  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 before2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and facility policy review, the facility failed to properly dispose of food and to seal open foods in bags to prevent the possibility of a foodborne illness for one (1) of two (2) kitchen tours. Findings include: A review of the facility's policy, Food Preparation, with a revision date of 2/2023, revealed, .Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. On 06/23/2025 at 10:45 AM, during an initial kitchen tour with the Dietary Manager (DM), there was a ten (10) pound box of Sunkist oranges under the prep table, dated 6/10/2025. The box was three-fourths full, and three oranges had black and white mold. Gnats were observed flying out of the box when opened. Additionally, there was an unsealed bag of food thickener with a hole in it, exposed to the air. On 06/23/2025 at 11:14 AM, during an interview, the DM stated it was the cook's responsibility to dispose of the oranges. She confirmed the oranges were received on 6/10/2025 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to provide perineal (peri) and wound care in a manner to prevent the possibility of spreading infection for two (2) of five (5) observations of care (Resident #35). Findings included: A review of the facility's policy, Hand Hygiene, with a revision date of 02/05/2021, revealed, Hand hygiene should be performed before initiating procedure, before and after care. A review of the facility's policy, Dressing Change, with a revision date of 12/06/2017, revealed, .Cleanse wound as ordered .dispose of gauze, remove gloves .perform hand hygiene . Apply treatment as ordered and clean dressing . On 06/25/2025 at 10:23 AM, during an observation of wound care for Resident #35 provided by Registered Nurse (RN)# 1, who is the Wound Care Nurse, and assisted by Certified Nursing Assistant (CNA)# 5 revealed RN #1 did not perform hand hygiene after initiating wound care. She stated to CNA #5 that the resident had a bowel movement. CNA #5 removed his gloves and gown, sanitized his hands, and exited 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.

  Infection Control 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

$32,432 in federal fines across 3 penalties.

• $18,675 — penalty dated 2025-02-26
• $8,827 — penalty dated 2024-03-28
• $4,930 — penalty dated 2023-11-28

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 AVARDIS HEALTH — 38 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 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

10 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 $388K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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