Middleton Oaks Health And Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

39.7% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 45.8% 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 59 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 0.16 therapist hours per resident per day in 2026Q1 — more than 15% 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 120 beds and averages 95.6 residents a day — about 80% occupied, or roughly 24 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 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 2.81 hrs/resident/day on weekends vs 3.32 on weekdays — 15% thinner on weekends. RN hours go from 0.58 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are 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.

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

• Actual harm · Gcited before2026-03-31 · 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 record review, interview, observation and facility policy review the facility failed to implement the comprehensive person-centered care plan related to contracture management and splinting to prevent decline in Range of Motion (ROM) for one (1) of three (3) resident reviewed. Resident #1. Findings Included:Record review of the facility policy titled Prevention of Decline in Range of Motion revealed .3. Appropriate Care Planning, a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .Record review of the Care Plan Report for Resident #1 revealed Focus: I have an ADL (activity of daily living) self-care performance deficit related to Stroke, Hemiplegia, and immobility putting me at risk for functional decline.Interventions: Apply splint to right ankle after breakfast. Provide passive stretch to right ankle after applying splint. Remove splint to right ankle at lunchtime. Apply splint to right ankle after supper. Provide passive stretch to right ankle after applying splint. Remove…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-03-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve Range of Motion (ROM) and prevent further decline for one (1) of three (3) resident reviewed for ROM limitations Resident #1. Findings Included:Record review of the facility policy Prevention of Decline in Range of Motion, date reviewed/revised 11/10/2025 revealed Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Observation on 3/31/26 at 10:15 AM, revealed a foot splint lying in the chair in Resident #1's room. Resident #1's right hand was contracted into a fist with no hand roll in place.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure of the last time staff had applied the splint to her foot and stated she had never had a hand roll.Interview with Licensed Practical Nurse…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-27 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene (Resident #5, #12, #51), wound treatment (Resident #11), staff assistance with meals (Resident #42) and treatment for nausea and vomiting (Resident #75), for six (6) of 22 resident care plans reviewed. Findings include: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident #5 Record review of Resident #5's…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-03-27 · 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 observation, staff interview, record review and facility policy review, the facility failed to ensure necessary care and services were provided for one (1) of 38 residents (Resident #75) reviewed for PEG (percutaneous endoscopic gastrostomy) tube management and PRN (as needed) medication administration. Specifically, nursing staff failed to administer Zofran 4 mg (milligrams) PRN for vomiting/gagging on multiple documented occasions, despite physician orders and clinical indications. This failure resulted in Resident #75 experiencing vomiting and feeding intolerance, requiring cessation of tube feeding, and caused unnecessary discomfort. Findings include: Record review of the facility policy titled, Enteral Feedings - Enteral Nutrition Pump, with revision date of 11/12/18, revealed, Nurses administer enteral feedings when volume control is indicated and as ordered by physician. Record review of facility policy titled, Administering Medication, dated 4/19, revealed, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered…

  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 · D2025-09-18 · 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, facility investigation review and facility policy review the facility failed to ensure residents were free from misappropriation of property when narcotics belonging to two residents were unaccounted for two (2) of three (3) residents reviewed for misappropriation. Resident #1 and Resident #2. Findings Include Findings Include Findings Include Review of the facility policy titled “Abuse, Neglect, Exploitation and Misappropriation” revised 11/16/22 revealed, “Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property…” Record review of the facility investigation revealed that on 8/16/25 at approximately 5:15 PM, Licensed Practical Nurse (LPN) #1 identified a discrepancy on the Controlled Drug Count Sheet. The narcotic count was altered, with numbers scratched out and rewritten, resulting in a two-card difference. Review of the narcotic count sheets documented 34…

  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 · Dcited before2025-09-18 · 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, record review and facility policy review, the facility failed to maintain complete and accurate medical records for one (1) of three (3) residents reviewed for post-operative care. This deficient practice resulted in the omission of a physician-ordered post-operative appointment from the resident's medical record and contributed to the resident missing the appointment. (Resident #3).Findings Include Review of the facility policy titled Physician's Orders revealed Policy The center will ensure that all physician orders are accurately documented, promptly implemented, and authenticated in the resident's medical record in accordance with Center for Medicare and Medicaid (CMS) regulations and state requirements . Record review of Resident #3's “After Visit Summary” (AVS) upon admission revealed an order for a post-operative visit on 5/6/25 at 1:00 PM with the Orthopedic Physician. Record review of Resident #3's Order Summary Report revealed an entry for an appointment on 5/20/25 at 10:15 AM with the Orthopedic Physician, with an onset date of 5/6/25. No order…

  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 · F2025-03-27 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure that staff received adequate education and training regarding the use and implementation of Enhanced Barrier Precautions (EBP). As a result, staff did not utilize the required personal protective equipment (PPE) during four (4) high-contact resident care activities observed, potentially putting all residents residing in the facility at risk for the spread of multidrug-resistant organisms (MDROs). Findings include: cross-reference F 880 Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed the following: Policy: Enhanced barrier precautions (EBP) are used to reduce the spread of multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities. Procedure: 4.) Educate the staff on EBP, including but not limited to: a.) use of PPE (personal protective equipment) . b.) High-contact care areas . During observations of four (4) high-contact resident care activities, staff…

  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
• Potential for harm · Fcited before2025-03-27 · 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 observations, staff interviews, record reviews, and policy review, the facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for five (5) of thirty-eight (38) sampled residents (Residents #11, #25, #32, #65, and #75). Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact resident care activities (wound care and percutaneous endoscopic gastrostomy (PEG) tube handling), failed to prevent the reuse of a single-use medical device (PEG tube declogger), and failed to store a biliary drainage collection bag in a sanitary manner. These failures created an increased risk for the transmission of infectious organisms among residents requiring complex care. Findings include: Cross- reference F726 Review of the facility policy titled Infection Prevention and Control Program with a revision date of 10/2018 revealed under, Policy Statement: An infection prevention and control program (IPCP) Is established and…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-27 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect as evidenced by improper feeding practices and failure to cover biliary and urinary catheter drainage devices with privacy covers for three (3) of 93 residents residing in the facility. Resident #57, #65, and #439 The scope and severity of this deficiency was increased to E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Record review of the facility policy titled, Policies and Procedure with a revision date of 9/19/2017 revealed Subject; Catheterization, Male and Female Urinary .Foley bag to be covered by a privacy bag to preserve dignity of resident . Review of the typed statement on facility letterhead, signed by the Administrator and dated 3/27/25 revealed, (Proper name of the facility) does not have a specific policy for privacy bags for biliary drainage tubes. Resident #57 An interview with the Regional Director of Clinical Services (RDCS) on 3/27/25 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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, resident and staff interview, record review and facility policy review, the facility failed to provide a safe homelike environment as evidenced by missing air conditioner unit cover, damaged furniture, no fitted sheets and a foul odor from a stopped-up toilet for four (4) of 93 residents residing in the facility. Residents #3, #22, #28 and #47 The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Review of the facility policy titled Policies and Procedures unrevised revealed under, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Review of the facility policy titled, Resident/Patient Room Cleaning with a revision date of 2/1/25 revealed, (Proper Name) is committed to providing a safe, clean, and hygienic environment for residents . Resident #3 On 03/25/25, at 11:00 AM, and again on 3/26/25, at 10:21 AM, an…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for three (3) of 38 sampled residents. Resident #5, #12 and #51. The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 02/01/2022, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, care and assistance as necessary. ADL's includes bathing, dressing, grooming hygiene, toileting and eating. Resident #5 An observation and interview on 3/25/25 at 11:16 AM and again on 3/26/25 at 10:25 AM with Resident #5 revealed the resident had numerous visible gray facial hairs that measured approximately one-fourth (1/4) in length and his fingernails on both hands were…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-27 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident/staff interview and record review, the facility failed to ensure a resident's medications were not left unattended in the resident's room for one (1) of 38 sampled residents. Resident #28. The scope/severity for this deficiency was increased to E due to previous citation on the last annual recertification survey. Findings include: Record review of a statement on the facility's letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for unattended medication. During an observation and interview on 3/25/25 at 10:45 AM, a small bag of intravenous (IV) fluids with a vial of medication attached to the bag was observed from the open doorway, lying on Resident #28's bedside table. The resident confirmed it was her antibiotic medication, and the nurse needed to restart her peripheral IV before administering it. During an observation on 3/25/25 at 1:37 PM with Registered Nurse (RN) #1, confirmed the presence of the IV…

  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 · E2025-03-27 · tag F0810 — pattern
  Provide special eating equipment and utensils for residents who need them and appropriate assistance.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment and staff assistance for three (3) of three (3) dining observations. Resident #42 Findings include: Review of the facility policy titled Assistive Devices with a revision date of 10/2022 revealed under, Policy Statement .Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently. An observation on 3/25/25 at 11:50 AM revealed Resident #42 unassisted, eating her lunch; her meal was on a regular plate, and the resident was struggling with holding her spoon. No adaptive utensil equipment was noted. During an observation and interview on 3/25/25 at 12:00 PM, the Assistant Director of Nurses (ADON) confirmed that Resident #42 did not have her divided plate and stated that it was on her meal ticket to have one, and the resident is supposed to have a Certified Nurse Aide (CNA) assisting her with her meals also. On 3/26/25 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-27 · 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, staff interview, and facility policy review, the facility failed to provide accommodation of needs for a residents call light not being within reach for two (2) of three (3) survey days. Resident #71 Findings Include The facility provided a statement on letterhead signed by the Administrator and dated 3/27/25, (Proper name of the facility) does not have a specific policy for Call Lights. Resident #71 An observation of Resident # 71 on 3/25/25 at 11:25 AM revealed he was lying in bed. Further observation revealed his call light was hanging over a small picture on the wall, and the end of the call button was on the floor behind a bedside dresser. The resident did not have access to his call light. An observation on 3/26/25 at 10:43 AM of Resident #71 revealed he was sitting in a chair in his room. His call light was unreachable and hanging over a small picture on the wall with the end of the call button on the floor behind a beside dresser. An observation and interview with Licensed Practical Nurse (LPN) #3 on 3/26/25 at 10:47 AM revealed Resident #71 knew how to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$10,868 in federal fines across 2 penalties.

• $5,434 — penalty dated 2025-03-27
• $5,434 — penalty dated 2025-03-27

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 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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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 83% 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 $468K 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