Sunplex Sub-Acute 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.

51.2% 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 62 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 73 beds and averages 58.3 residents a day — about 80% occupied, or roughly 15 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.54 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

41 citations, most serious first. The 25 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · L2025-10-28 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review, the facility failed to ensure the facility assessment contained required details regarding staffing needs by shift and by unit and failed to maintain an actionable contingency plan for staffing emergencies for (59) of (59) residents in the facility during the influenza outbreak from 10/8/25 through 10/12/25.The facility's failure of not specifying in the facility assessment the number of licensed nurses and Certified Nurse Aides (CNAs) needed per shift and per unit to meet resident needs and the contingency plan not containing clear procedures for securing coverage during emergencies or staff call-offs, resulted in the facility being unprepared for staff absences during the influenza outbreak, which placed all residents at risk for serious illness, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/12/25 when there was insufficient staffing during the influenza outbreak. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-10-28 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  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 staff interview, record review, and facility policy review, the facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control and staffing during an influenza (flu) outbreak for 59 of 59 residents residing in the facility from 10/8/25 through 10/12/25.The facility's failure to use its QAPI program to evaluate and address the lack of outbreak recognition including failure to initiate droplet precautions, failure to notify the local health department, failure to ensure antiviral medications were administered as prescribed, and failure to monitor staff illness and infection control compliance resulted in continued exposure and spread of influenza within the facility. Additionally, the facility failed to use its QAPI process to identify and correct deficiencies in staffing coverage and the absence of an actionable staffing contingency plan within the facility assessment. These failures demonstrated the facility's lack of an effective, ongoing, data-driven QAPI…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2025-10-28 · tag F0880 — failed to prevent and control infections — widespread
  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 review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices to prevent and contain the spread of influenza (flu) when three (3) residents (Residents #1, #53, and #63) tested positive between 10/8/25 and 10/12/25 for (59) of (59) residents in the facility. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care (a high contact care activity) for Resident #49.The facility's failure to identify the presence of an outbreak, initiate droplet precautions, post appropriate signage, notify the local health department, provide staff and family education regarding the outbreak, ensure the Infection Preventionist and clinical leadership verified isolation orders and monitored staff illness and infection-control compliance, and ensure antiviral medications were administered as prescribed resulted in the continued exposure of residents and the potential for transmission 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-10-28 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 observation, interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when licensed nursing staff failed to administer prescribed medications, failed to notify physicians of missed medications, and failed to ensure residents received appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak for five (5) of (5) residents reviewed for medication administration, Residents #12, #28, #36, #53, and #100. This had the potential to affect all 29 residents on the [NAME] Unit.The facility's failure to provide clear direction regarding nursing coverage responsibilities, ensure appropriate oversight, and timely physician notification for missed medications, placed all 29 residents on the [NAME] Unit at risk for serious illness, 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 10/12/25 when one (1) Registered Nurse (RN) was assigned…

  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 · Kcited before2025-10-28 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide sufficient licensed-nurse and nurse aide coverage to meet resident needs. Specifically, the facility failed to ensure adequate licensed nurse coverage during an influenza (flu) outbreak for one (1) of two (2) resident care units (the [NAME] Unit) and failed to ensure sufficient nurse aide staffing to provide scheduled showers for three (3) of (17) sampled residents (Residents #24, #54, and #58).The facility's failure to ensure sufficient licensed-nurse coverage resulted in missed medications and lack of resident monitoring on the [NAME] Unit, which placed all 29 residents on the [NAME] Unit at risk for serious illness, serious harm, serious impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/12/25 when one (1) Registered Nurse (RN) was assigned responsibility for all 58 residents in the facility, including 29 residents on the [NAME] Unit and 29 residents on the Transitional Care Unit (TCU), from approximately 12 AM until 7:00 AM.…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-09-24 · 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, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an elopement for one (1) of four (4) sampled residents, Resident #1. On 9/17/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of six (6), and was identified by the facility as an elopement risk, was assisted out of the front door by a Dietary Aide (DA) who thought she was a visitor. She remained outside the facility for approximately 35 minutes, during which the DA left the facility parking lot at approximately 8:50 PM. Resident #1 was found at 9:05 PM knocking on the front entrance door. The facility's failure to provide supervision placed Resident #1 and other vulnerable residents at risk for 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 9/17/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 9/23/25 at 2:00 PM and provided an IJ Template.…

  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 · Past Non-Compliance
• Immediate jeopardy · J2023-09-28 · 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 interviews the facility failed to notify Resident #1's primary physician following immediately of a change in status following an incident that required the resident to be transferred to the hospital for evaluation for one (1) of four (4) sampled residents. Resident #1. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, and care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van after being abandoned on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. The facility failed to notify the primary physician for Resident #1 immediately when staff located the resident and determined that she had been left unattended in the facility van for over sixteen (16) hours following her return to the facility after her hemodialysis treatment. 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 Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-28 · 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 facility policy review, record review and interviews, the facility failed to ensure a resident was free from neglect for one (1) of four (4) sampled residents, Resident #1, as evidenced by on 9/15/23 at approximately 3:45 PM, after returning to the facility from a dialysis appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing medications, meals, hydration, and care and assessments, and expressing that she was anxious, hurting, and afraid and, I thought I was doomed. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when the facility abandoned 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-28 · 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

  Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions to ensure Resident #1 received care and services for monitoring after hemodialysis, significant medications, accu check and activities of daily living, for one (1) of four (4) resident care plans. Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility failed to implement the plan of care for Resident #1 when Resident #1 was left unattended, unsupervised without care or monitoring following transportation from hemodialysis treatment. Resident #1 was abandoned and restrained by seat belts in a wheelchair in the facility transport van. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23 for over sixteen (16) hours without care as listed on the care plan, placed this resident,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews the facility failed to provide resident centered care and services in accordance with the resident's individualized care plan and professional standards of practice that met Resident #1's physical, mental, and psychosocial needs for one (1) of four (4) sampled residents, Resident #1, as evidenced by the facility abandoned Resident #1 on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. Resident #1 was left alone and unattended on the transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van and transferred the resident to their room in the facility. Registered Nurse (RN) #1 completed an assessment revealing the resident's temperature 100.3 Fahrenheit, blood pressure 175/79, pulse 97, and Oxygen Saturation 100%. The facility did not obtain a blood glucose level 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-28 · 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 policy review, record review, and interviews, the facility failed to provide supervision for a resident who was left alone, abandoned, strapped in her wheelchair without monitoring on the facility transport van following a dialysis treatment for approximately 16 hours and 15 minutes for one (1) of four (4) Residents reviewed. Resident #1. The facility failed to remove the resident from the facility van following transportation from her hemodialysis treatment, abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's location from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility's failure to supervise Resident #1 placed this resident, and other resident, in a situation that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-28 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  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 Resident #1 received care and services following a hemodialysis treatment consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications after dialysis treatments for one (1) of four (4) residents reviewed, Resident #1 as evidenced by the facility failed to remove the resident from the facility van on 9/15/23 following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair restrained by the seatbelts in the facility van for sixteen (16) hours and fifteen (15) minutes without the staff's monitoring. The facility's failure to provide treatment, monitoring, care, food, or fluids after hemodialysis placed this resident and other residents in a situation that has caused and is likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-28 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to provide adequate staffing to ensure the safety and the necessary care and services for one (1) of four (4) residents reviewed, Resident #1. The facility failed to identify the location of a resident when the resident failed to return to the facility unit following transportation from her hemodialysis treatment. This resulted in the facility abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to staff the facility sufficiently resulted in Resident #1 been left unattended in the facility van for over sixteen (16) hours. This placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-28 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medication (anti-diabetic, anti-hypertension, bronchitis, and pain management medications) were administered to prevent discomfort or complications for one (1) of four (4) residents reviewed, Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. On 9/15/23 the facility failed to remove the resident from the facility van following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair in the facility van, unsupervised and without significant medications including insulin, respiratory and hypertensive medications for sixteen (16) hours and fifteen (15) minutes without the staff awareness. The facility's failure to transfer Resident #1 inside the facility and administer medications as ordered by the physician after hemodialysis placed Resident #1 in a situation that was likely to cause serious harm,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's safety during a bed bath, in which Resident #2 fell from the bed to the floor, sustaining fractures to her bilateral lower extremities for one (1) of four (4) residents reviewed for falls. Findings Include: A review of the facility's policy titled Accidents and Incidents, undated, revealed It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible . A record review of the facility's investigation of Resident #2's fall with fractures revealed that on 12/21/24 at approximately 10:45 AM, Certified Nurse Assistant (CNA)# 1 provided care and a bath to Resident #2 while turning her in the bed on her left side. CNA#1 attempted to reach to hold onto the resident, but due to her being slippery, she rolled out of bed. A record review of the Hospitalist Discharge Note, dated 12/22/24, indicated in the Hospital Course that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-02 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 protect Resident #1 from misappropriation of property when a Certified Nurse Aide (CNA) removed the resident's debit card without permission and used it at multiple locations for unauthorized purchases for one (1) of four (4) residents sampled. Resident #1Findings include: A review of the facility's ABUSE AND NEGLECT POLICY AND PROCEDURE revised, 10/21/25, revealed, .Policy: To provide a safe environment for all residents free of abuse.Procedure.II. Types of Abuse.7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. A review of the facility's incident documentation, with an Incident Date of 11/6/25, revealed that on 11/9/25, the Administrator received a report that Resident #1's bank card was missing and that multiple unauthorized charges occurred between 11/6/25 and 11/9/25. The local police department was notified on 11/9/25, and the State Agency…

  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 · Fcited before2025-10-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 observation, staff interview, and facility policy review, the facility failed to ensure food items were stored and maintained in a safe and sanitary manner as evidenced by not discarding expired products and spoiled food and not refrigerating items according to manufacturer's instructions for one (1) of four (4) survey days.Findings include:A review of the facility's policy, Food Receiving and Storage, reviewed 7/24/23, revealed, .Foods shall be stored in a manner that complies with safe food handling practices .On 9/29/25, at 10:28 AM, during an observation and interview, there were (10) loaves of wheat bread that had an expiration date of 9/23/25. In the dry goods room, there were five (5) quarts of nectar-consistency Thick & Easy milk with a use-by date of 8/1/25, and five (5) quarts of moderately Thick & Easy with a use-by date of 5/31/25. Additionally, there was (1) gallon of opened Sweet Baby Ray's teriyaki sauce that was stored on a dry goods shelf despite manufacturer instructions requiring refrigeration after opening. In Refrigerator #1, there was peanut butter…

  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 · D2025-10-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 a resident's right to a safe, clean, and comfortable environment when a resident was left with soiled linens for multiple days for one (1) of 17 sampled residents, Resident #2. Findings include:A review of the facility's policy, Resident Rights, revised 11/28/2016, revealed, . (a) Resident Rights. The resident has a right to a dignified existence, self-determination . (i) Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment . The facility must provide . (3) Clean bed and bath linens that are in good condition.On 9/29/2025 at 12:07 PM, during an observation and interview, Resident #2 was lying in bed with blood noted on the bed sheet and incontinence pad. Resident #2 explained that her legs were weeping and bleeding and that was the reason for the blood. She stated her sheets are only changed on shower days.On 9/30/2025 at 2:00 PM, during an observation and interview, Resident #2 was sitting on the side of her bed. She reported that…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-28 · 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

  Based on interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with an indwelling catheter (Resident #49) and failed to implement care plan interventions related to baths/showers as scheduled (Resident #54 and #58) for three (3) of 17 sampled residents. Findings include: A record review of the facility's policy Care Plans, Comprehensive Person-Centered dated 10/2022 revealed . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required MDS (Minimum Data Set) assessment . and no more than 21 days after admission . 7. The comprehensive, person-centered care plan . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial…

  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 · D2025-10-28 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 medications were administered in accordance with professional standards of practice, as evidenced by nursing staff did not notify the physician or attempt to obtain medications from an alternate pharmacy source when ordered medications were unavailable for one (1) of five (5) residents observed for medication administration, Resident #9.Findings Include:A review of the facility's policy, Medication Administration - General Guidelines, dated 8/25/14, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices.On 10/1/25 at 8:37 AM, during a medication administration observation, Licensed Practical Nurse (LPN) #1 failed to administer Resident #9's Icar-C Oral Tablet 100-250 milligrams (mg), one (1) tablet by mouth daily, and Cyanocobalamin Oral Tablet, one (1) tablet by mouth daily. LPN #1 stated the medications were not in the medication cart and were on order. LPN #1 documented a 9 on the MAR, indicating the medications were 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
• Potential for harm · D2025-10-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that residents who were dependent upon staff for activities of daily living (ADL) care received assistance with bathing and personal hygiene as scheduled and in accordance with their needs and preferences for three (3) of (17) sampled residents (Residents #24, #54, and #58).Findings include: A review of the facility's policy, Bath, Shower/Tub, dated 8/25/2014, revealed, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident.Documentation.The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed.5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting.1. Notify the supervisor if the resident refuses the shower/tub bath. Resident #24A record review of the admission Record revealed the facility admitted Resident #24 on 8/11/25 with diagnoses including Encounter for Other Orthopedic…

  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 · D2025-10-28 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration for one (1) of (17) sampled residents (Resident #2).Findings include:A review of the facility's policy, Self-Administration of Medication, revised February 2021, revealed, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Policy Interpretation and Implementation.9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.On 9/29/2025 at 12:07 PM, during an observation and interview, Resident #2 was observed with an inhaler on the bedside table in plain view. Resident #2 explained she used the inhaler as needed.On 9/30/2025 at 2:00 PM, during an observation, Resident #2 was sitting up on the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review, the facility failed to accurately document a resident's weight in the medical record for one (1) of 17 sampled residents. Resident #10 Findings include:A record review of the Weights and Vitals Summary for Resident #10 revealed that on 9/5/25 a weight of 76.7 pounds was recorded in the clinical record. However, two (2) days earlier, on 9/3/25, his weight was recorded as 167.2 pounds. Also, on 6/6/25, Resident #10's weight was recorded as 159.5 pounds and five (5) days later, on 6/11/25, the resident's weight was documented as 189 lbs.On 10/1/25 at 3:30 PM, during an interview, the Director of Nursing (DON) identified that weights dated 9/5/25 and 6/11/25 for Resident #10 were entered incorrectly in the electronic medical record.On 10/1/25 at 4:44 PM, during an interview with Registered Nurse (RN) #1 (Nurse Supervisor), she confirmed that the weights documented on 9/5/25 and 6/11/25 were inaccurate and caused the resident's record to incorrectly trigger weight alerts. RN #1 explained that Licensed Practical Nurse (LPN) #2 entered 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-28 · tag F0867 — failed to act on quality-improvement findings — isolated
  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 record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure food items were stored and maintained in a safe and sanitary manner by not discarding expired products and spoiled food, and not refrigerating items according to manufacturer's instructions and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of (13) deficiencies cited. F812.Findings Include:Record review of the facility's policy, Quality Assessment and Performance Improvement QAPI Program, dated 10/2022, revealed, .This facility shall.maintain an ongoing, facility-wide, data-drive QAPI program.Policy Interpretation and Implementation The objectives of the QAPI program are to.4. Establish system through which to monitor and evaluate 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-27 · 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 staff interview, record review, and facility policy review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively addressed and prevented the recurrence of resident accidents. This failure resulted in a resident sustaining bilateral fractures, despite a prior citation for F689 on 10/3/24, which indicates the facility did not sustain systemic corrective actions to prevent the recurrence for one (1) of four (4) sampled residents. Resident #2. Findings Include: A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program dated 10/22, revealed, .The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . A record review of the Centers for Medicare and Medicaid Services (CMS) Form 2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), dated 10/3/24, revealed the facility 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.

  Administration 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

$144,927 in federal fines across 3 penalties.

• $118,303 — penalty dated 2025-10-28
• $12,428 — penalty dated 2025-09-24
• $14,196 — penalty dated 2025-01-27

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 COMMUNITY ELDERCARE SERVICES — 17 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 5 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.

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 82% 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 18% 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 2024. 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, FY2024). 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