Aspen Meadows Health And Rehabilitation 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.

58.8% 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 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 27.2% 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 103 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 90 beds and averages 66.0 residents a day — about 73% 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.22 hrs/resident/day on weekends vs 3.79 on weekdays — 15% thinner on weekends. RN hours go from 0.36 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% is well above 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.

36 citations, most serious first. The 14 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · Gdisputed · IDR2026-03-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to identify, correct, and protect a resident who voiced neglect of care concerns, including when the neglect resulted in a lack of care by a staff member (NF7), and this failure contributed to psychosocial harm, for 1 (#47); and when grievances were brought forth, staff did not identify neglect included in the grievances, to neglect continued to occur. The system failure for the prevention of neglect of care contributed to the resident's ongoing anxiety, feelings of being unsafe, decline in mobility, lack of ADL care related to bowel and bladder, and ongoing skin concerns with the resident's ears, heels, and coccyx; out of 19 sampled residents. This failure also put other residents at risk of neglect due to the system failures and neglect not being addressed. Findings include:1. During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints about a specific previous staff member, NF7, who would leave his call light on for hours, would not help resident #47 with ADL cares which resulted in resident #47…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the system for pressure ulcer prevention was meeting the residents needs, and the processes used by staff for pressure ulcers did not effectively identify, assess, treat, monitor, or prevent pressure ulcers, which affected 4 (#s 47, 63, 78, and 82) of 28 sampled and supplemental residents. This failure placed the residents at risk for experiencing ongoing skin concerns or negative outcomes related to pressure ulcer development and treatment, stemming from staff not using protective measures to prevent pressure ulcers, not identifying pressure ulcers that developed (or are developing), not assessing or documenting pressure ulcers accurately, not implementing interventions to prevent pressure ulcers, and not updating resident care plans for pressure ulcer prevention. Findings include:1. Review of resident #78's nurse progress notes, dated 1/5/26, showed the resident was admitted with skin issues on the buttocks, both heels, and the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-26 · 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 in interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#4) of 3 sampled residents with insulin orders. The medication error of omission resulted in a deterioration of condition and an unplanned hospitalization for resident #4. Findings include:Review of resident #4's hospitalization, dated between 1/29/26 and 3/23/26 showed the following:- 1/29/26 - 2/20/26, hospitalized ,- 2/20/26 - 2/23/26, in facility, and- 2/23/26 - 2/26/26 hospitalized .Review of resident #4's insulin orders showed the following:- 1/23/26 - 1/29/26, Lantus insulin 10 units every evening, at bedtime,- 2/20/26 - 2/23/26, no order for Lantus insulin,- 2/26/26 - 3/10/26, Lantus insulin 10 units every morning.Review of resident #4's SNF admission orders from the hospital, dated 2/20/26, showed an order for Lantus insulin 10 units daily.Review of resident #4's admission orders in the EHR, dated 2/20/26, failed to show any Lantus insulin was ordered or given to the 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide wound care as ordered by the provider; and failed to implement and document physician ordered interventions intended to mitigate worsening of a pressure ulcer, for 1 (#14) of 3 sampled residents with pressure wounds. These deficient practices contributed to the worsening of a pressure ulcer from nearly healed to a Stage III ulcer on the resident's heel. Findings include: 1. Pressure ulcer dressing changes not done as ordered Review of resident #14's provider orders, dated 8/23/24, showed the dressing change was, LEFT HEEL: cleanse ulcer with vashe wash, . pack with silver alginate rope, cover with opti-foam dressing. one time a day every Mon, Wed, Fri. [sic] Review of resident #14's provider progress note, dated 9/18/24, showed the resident's left heel ulcer had worsened with increased sloughing of yellow green tissue. The note also showed, Continued to emphasize to [resident #14 First Name] regarding the importance of offloading this ulcer to support wound healing. Educated that these types of ulcers…

  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 · Edisputed · IDR2026-03-26 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to fully investigate allegations of abuse and neglect for 3 (#s 26, 47, and 77) of 28 sampled and supplemental residents. The deficient practice failed to ensure the facility identified all residents who may have been abused or neglected, in an attempt to prevent ongoing or future abuse or neglect. Finding include: 1. During an interview on 3/24/26 at 10:08 a.m., resident #26 stated NF8 had been nasty and pushy with her while helping her brush her teeth one night. Resident #26 stated she only had partial dentures and NF8 had told her she should not take so long brushing her teeth because she only had eight teeth. Resident #26 stated NF8 made me hurry up and did not give her the time she needed. Resident #26 stated, We all need help, and I don't even need a ton of help. During an interview on 3/24/26 at 4:40 p.m., staff member A stated they were looking for the staff interviews for resident #26's incident with NF8. Staff member A stated when NF8 was questioned about the incident with resident #26, he instead resigned from his…

  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
• Potential for harm · Ecited before2026-03-26 · tag F0655 — pattern
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a baseline care plan that provided instructions needed to provide resident centered care for 3 (#s 11, 78 and 82) of 28 sampled and supplemental residents. The failure to have a baseline care plan placed the residents at risk of not being provided care to meet their basic needs. Findings include: 1. Baseline Care Plan Concernsa. Review of resident #11's electronic health records showed an admission date of 2/19/26. Resident #11 was admitted with diagnoses which included acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, right femur fracture, morbid obesity and muscle weakness. Review of the nurse progress note dated 2/19/26 at 8:14 p.m., showed resident #11 had wound to coccyx reported stage I open. [sic]Review of resident #11's baseline care plan showed no care plan had been started to direct staff in caring for resident #11's wounds, pain management or caring for chronic medical conditions. A care…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-26 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to provide education and information to the residents or responsible party on the risks and benefits of psychotropic medication, so they were able to make an informed decision, and the facility did not have documentation to show the resident/responsible party consented to the use of the medications, for 2 (#s 2 and 83) of 19 sampled residents. Findings include:1. Review of resident #83's Hospitalist History and Physical, dated 3/1/26, showed resident #83 had diagnoses which included mixed anxiety and depressive disorder. Review of resident #83's Medication Administration Record, dated March of 2026, showed Ativan, an antianxiety medication, was ordered on 3/11/26. The Ativan could have been given every eight hours as needed for anxiety. Review of resident #83's electronic health record, accessed on 3/26/26, failed to show a consent was provided to resident #83 educating him on the risks verses benefits of using a psychotropic medication. During an interview on 3/26/26 at 7:48 a.m., staff member B said resident #83 had not…

  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 · Ddisputed · IDR2026-03-26 · tag F0563 — failed to protect the right to visitors — isolated
  Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure the resident's right to have visitors of their choice for 1 (#53) of 28 sampled and supplemental residents. Specifically, the facility failed to allow resident #53's friend to visit her in the facility. Findings include:During an interview on 3/24/26 at 3:55 p.m., NF1 stated she had been a friend of resident #53 for many years prior to the resident being admitted to the facility. NF1 stated the first time she tried to visit, staff member B escorted her out of the building and was told if she tried to return, law enforcement would be called. NF1 stated she had been an employee of the facility approximately four years ago and was terminated due to an allegation of abuse towards a resident.During an interview on 3/26/26 at 8:48 a.m., NF2 stated he knew the facility was not allowing NF1 to visit resident #53. NF2 stated he was aware of the abuse allegation and was not worried about NF1 abusing resident #53. NF2 stated he wanted NF1 to be allowed to visit resident #53. NF2 stated the facility did not offer supervised…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-26 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to provide written notice of charges not covered when the resident was no longer receiving Medicare skilled services for 1 (#89) of 3 residents sampled for coverage notifications. Findings include: Review of the SNF ABN for resident #84, failed to show this notification was provided to the resident as required. During an interview on 3/24/26 at 2:45 p.m., staff member D stated she was responsible for completing the required notifications when a resident was no longer receiving Medicare A skilled services. Staff member D stated she should have completed the SNF ABN for resident #89. Staff member D stated she did not know why the form was not completed on 1/9/26 when the resident was discharged from skilled care. Staff member D stated the resident stayed for several more days while waiting for approval of his admission to a facility which contracted with the Veterans Administration. Staff member D stated the resident was charged the daily per diem rate until his discharge from the facility on 1/13/26. During an interview 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-26 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a grievance was completed for an abuse and neglect allegation for 1 (#47); and failed to thoroughly investigate and document the findings for 1 (#53) of 28 sampled and supplemental residents. This deficient practice resulted in resident #47 reported feeling afraid and more anxious when NF7 would care for resident #47. Resident #47 also felt neglected in his care at the facility and feared retaliation for speaking up about NF7's care at the facility. The deficient practice affecting resident #53 increased the risk of discomfort from not repositioning the resident for comfort. Findings include:1. During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints about a specific previous staff member, NF7, who would leave his call light on for hours and would not help with ADL cares which resulted in resident #47 experiencing bowel and bladder incontinence while waiting for his call light to be answered. Then once NF7 would respond to the needs of resident #47, resident #47 stated NF7 would force…

  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 beforedisputed · IDR2026-03-26 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to timely report an abuse and neglect allegation to the State Survey Agency for 1 (#47) of 19 sampled residents. Findings include:During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints of about a specific previous staff member, NF7, who would leave his call light on for hours, would not help with ADL cares which resulted in resident #47 soiling his brief (bowel and bladder) from waiting so long, and NF7 would encourage resident #47 to sign refusal of care form. Resident #47 stated NF7 would then want resident #47 to ambulate to the restroom, but resident #47 stated he had already gone in his brief. During an interview on 3/26/26 at 9:19 a.m., staff member B stated no care concerns from family or the resident were brought to their attention. Staff member B stated they did not report the alleged abuse or neglect of care. Refer to F600 - Abuse and Neglect on the lack of identification of neglect for the resident. A request was made for documentation for resident #47's interdisciplinary team notes, any…

  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
• Potential for harm · D2026-03-26 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews the facility failed to provide written documentation to the resident and/or the resident's representative upon transfer. The resident or representative was not provided with documentation showing the reason for transfer and the opportunity to enact a bed hold for 1 (#78); and the facility failed to send a copy of the notice of hospital transfer to the local facility Ombudsman for 2 (#s 47 and 78) of 28 sampled and supplemental residents. This deficient practice affected the resident's ability to ensure the transfer was appropriate and did not allow the resident or representative to request the facility to hold their bed. The deficient practice prevented the Ombudsman from tracking transfers. Findings include:1. During an interview on 3/25/26 at 2:21 p.m., NF9 stated she was not notified for resident #47's hospitalization on 2/11/26. During a follow-up interview on 3/25/26 at 3:58 p.m., NF9 stated she did not have any hospitalization notifications for January, February, or March 2026 (until the current date of 3/25/26). Review of resident #47'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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-26 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident assessment was completed accurately for 2 (#s 2 and 24) of 19 sampled residents. Findings include:1. During an observation and interview on 3/24/26 at 11:34 a.m., resident #24 was oriented to her surroundings, able to converse, and answer questions appropriately. Review of resident #24's Comprehensive MDS, with an ARD of 2/7/26, showed the resident interview should have been completed. The MDS failed to show a BIMS had been completed during the look-back period. All of the questions in the section were answered as not assessed or no information. Review of resident #24's Quarterly MDS, with an ARD of 12/18/25, showed a BIMS of 15, which correlated with intact cognition. During an interview on 3/26/26 at 8:24 a.m., staff member F stated she was responsible for completing all MDS assessments. When asked why resident #24 did not have a BIMS completed on her Comprehensive MDS assessment, staff member F stated, I just missed it. 2. During an interview on 3/24/26 at 3:59 p.m., staff member C stated…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-26 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (#63) of 19 sampled residents. Findings include: During an observation on 3/25/26 at 10:15 a.m., resident #63's dressing to the pressure ulcer on the resident's coccyx was changed by NF10. The wound was almost healed with no drainage or odor. NF10 placed a small hydrocolloid dressing to the wound. Review of resident #63's PPS Part A Discharge MDS assessment, with an ARD of 1/12/26, showed the resident had a Stage IV pressure ulcer which had been present on admission [DATE]). Review of resident #63's care plan, dated 3/5/26, showed a problem statement of, The resident has risk for impaired skin integrity r/t (related to) fragile skin d/t (due to) limited mobility . She has a coccyx wound stage III since admission. with an initiation date of 3/5/26 and a revision date of 3/23/26. There was nothing related to a pressure ulcer on the care plan until 3/5/25, approximately three months after…

  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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$115,183 in federal fines across 2 penalties.

• $67,525 — penalty dated 2026-03-26
• $47,658 — penalty dated 2024-10-21

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 EVERGREEN HEALTHCARE GROUP — 44 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 38 rows in the source record cover these 17 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.

9 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.

This home reported $150K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in MT