Park Place Transitional Care 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.

48.9% 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 184 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 76.5% 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 102 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 189 beds and averages 147.1 residents a day — about 78% occupied, or roughly 42 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.85 hrs/resident/day on weekends vs 3.71 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.01 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

36 citations, most serious first. The 15 most serious are shown; the remaining 21 are one tap away and print in full.

• Actual harm · Gcited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents and hazards, failed to provide supervision necessary to prevent accidents related to falls, and failed to thoroughly investigate (including interviewing resident #129) and identify the direct root causes of falls for future fall prevention, for 4 (#s 5, 45, 156, and 160) of 29 sampled residents, and the falls resulted in resident #160 sustaining a hip fracture, resident #45 had a closed head injury, and #156 had a laceration above the eye; and the facility failed to ensure interventions and safety assessments were in place for a resident who was smoking on facility property, and who kept his smoking materials, and the facility reported they were a non-smoking facility, for 1 (#86) of 29 sampled residents. This deficient practice had the potential to place resident #86 or other residents at risk due to unsafe smoking practices and a lack of supervision. Findings include: 1. During an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-24 · 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 ensure a resident admitted without a pressure ulcer did not develop a pressure ulcer for 1 (#10) of 2 sampled residents with pressure ulcers. Resident #10 was admitted with intact skin on the sacrum and developed a Stage III pressure ulcer which progressed to a Stage IV with healing not achievable. The resident did have refusals of care, and the facility implemented interventions for wound prevention, but failed to identify the wound timely and prevent further deterioration or infection, of the wound, and implement and monitor sufficient intervetnions for healing, or resolve the resident's concerns with refusals and pain management which hindered wount healing. Findings include: During an observation on 4/21/25 at 2:32 p.m., resident #10 was seated in her wheelchair. Review of resident #10's Care Plan, initiated 3/31/25, showed the resident was to be in her wheelchair for only one hour, three times daily, at meals. Review of resident #10's turn and turn and reposition task documentation, dated 3/26/25 through…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 identify a discrepancy in weight recordings which would have identified a severe 16% weight loss in two weeks, for 1 (#40) of 1 dialysis resident sampled for weight loss. Findings include: Review of resident #40's Dialysis Communication Records, dated 3/18/24 - 4/3/24, showed an average of 2.06 lbs. of fluid removal at each dialysis treatment. The resident never had body or fluid weight gain between dialysis treatments, instead each pre-dialysis treatment record showed a consistently downward trending weight loss of one to four pounds. This loss of body weight represented a severe 16.27% weight loss in two weeks: - 3/18/24 pre-dialysis weight 205.48 lbs. Post dialysis weight was 200.6 lbs. The treatment resulted in 4.88 lbs. of fluid removal. - 3/20/24 pre-dialysis weight was 200.6 lbs. The resident had not gained any weight between treatments. Post dialysis weight was 199.54 lbs. The treatment resulted in 1.06 lbs. of fluid removal. -…

  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 · G2023-12-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff neglected to assess and monitor a new admission, and ensure antibiotic medications were provided properly and documented, for 1 (#2) of 4 sampled residents, whose condition deteriorated over a weekend. The facility terminated two staff involved, but did not report the event as resident neglect. The resident was later transferred to the hospital and passed away. Findings include: During an interview on 12/4/23 at 12:00 p.m., staff member D stated new admissions had a skilled daily charting note completed each day by the nurse. Staff member D also stated residents would have daily vital signs taken. During an interview on 12/4/23 at 2:45 p.m., staff member B stated it was the expectation that all new admissions for skilled nursing had a daily skilled note completed and vital signs taken. Staff member B stated the facility had terminated a nurse, and an on-call manager, in October, after it was noted that a resident went the weekend without his medical…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-25 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify signs and symptoms of infection which led to septic shock and admission to the hospital, with subsequent surgery and the placement of a Vacuum Assisted Wound Closure system for 1 (#1) of 3 sampled residents. Findings include: During an interview on 10/23/23 at 6:23 p.m., NF1 stated resident #1 had MRSA in his leg wound. NF1 stated the resident was in septic shock when he arrived at the hospital and he was very confused, had not known who the family member was or who he was. NF1 stated the facility staff told the family to wait until the next day because he would just have to sit in the ER. NF1 stated the family wanted the resident sent out right away. NF1 stated the resident was to return to the surgeon on 9/12/23 and the surgeon would remove the staples from the resident's right stump, but the facility had the nursing staff remove the staples off of the resident's incision on the stump. During an interview on 10/23/23 at 7:05 p.m., NF2 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-09 · 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, interview, and record review, the facility failed to ensure dietary staff in the kitchen preparing and serving food during meal service wore beard coverings, and failed to ensure kitchen refrigeration temperature logs were monitored and maintained. This deficient practice increased the risk for residents receiving food and meals which were prepared, served, and stored in the kitchen to experience negative food service safety outcomes. Findings include:During an observation on 4/6/26 at 1:02 p.m., staff member Y was preparing sandwiches in the kitchen, not wearing a beard net with visible facial hair.During an observation on 4/6/26 at 1:14 p.m., staff member X was in the kitchen serving food onto resident trays from behind a steam table. Staff member X did not have a beard net covering his facial hair.During an interview on 4/8/26 at 2:18 p.m., staff member W stated dietary staff working in the kitchen were expected to wear facial coverings if they had a grown beard or mustache. Staff member W stated she spoke with staff members X and Y about wearing a covering…

  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 · E2026-04-09 · tag F0658 — failed to meet professional standards of care — pattern
  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, and record review, the facility failed to ensure professional standards were followed by protecting patient health information from visitors for 3 (#s 79, 121, and 134) of 29 sampled residents and failed to ensure medication carts were locked when unattended. Findings include: 1. During an observation on 4/6/26 at 4:27 p.m., the medication cart on the 100 hall was not locked. No staff member was present at this time.During an observation and interview on 4/8/26 at 8:32 a.m., staff member Z left the medication cart open after medications were prepared for a resident and staff member Z entered the resident's room to administer the medications. After returning to the hallway, staff member Z stated the medication cart should always be locked to ensure a visitor or resident could not take medications in the cart. Staff member Z also stated the medication keys should be in her pockets at all times to prevent a visitor or resident from getting into a medication cart or rooms. Staff member Z stated the medication cart should always be locked if she was 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) in accordance with the Resident Assessment Instrument (RAI) Manual for 1 (#126) of 29 sampled residents. This deficient practice had the potential to affect quality measures, and care planning related to diabetes management. Findings include:Review of resident #126's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/23/26, showed under Section N (Medications), item N300 (number of injections received in the last 7 days) was coded as 7, and item N350 (number of days insulin injections were received) was coded as 7.Review of resident #126's physician's orders, dated 1/23/26, showed, Victoza Subcutaneous Solution Pen-injector 18 MG/ML (Liraglutide) Inject 0.6 mg subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS. [sic] Victoza is a GLP-1(Glucagon Like Peptide-1), which is a hormone that is used for weight loss and diabetes and is not considered insulin.During an interview on 4/9/26 at 11:12 a.m., staff member F stated she was…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · 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 — the official record, unedited, may be distressing

  Based on observation, interview, and record review, the facility failed to include interventions related to catheter care on the care plan for 1 (#6) of 29 sampled residents. Findings include:During an observation and interview on 4/7/26 at 11:37 a.m., resident #6 was sitting in her wheelchair in her room and an indwelling catheter tube was coming out of the bottom of her pajama pants. NF3 stated the facility was continuing catheter use for resident #6 due to incontinence and the resident wanted the catheter due to convenience.During an interview on 4/9/26 at 9:25 a.m., staff member D stated catheter interventions should be on a resident's care plan.Review of resident #6's care plan, dated 3/11/26, reflected a lack of catheter care interventions.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility staff failed to review and revise the comprehensive care plan to reflect changes in resident conditions for 1 (#91) of 29 sampled residents. This deficient practice increased the risk of staff not monitoring or providing cares related to resident #91's treatment for pneumonia with an antibiotic. Findings include:During an interview on 4/9/26 at 11:09 a.m., staff member N stated she had a list of residents taking antibiotics used to treat infections. Staff member N stated she would update a resident's care plan with problems and interventions when a resident was identified to have an infection. Staff member N stated resident #91 had enhanced barrier precautions as an intervention in her care plan. Staff member N stated enhanced barrier precautions would cover part of the droplet precautions to use for a resident diagnosed with pneumonia. Review of resident #91's provider progress notes, dated 3/24/26, showed: . Patient experienced 2 episodes of emesis on March 24, 2026, with 4 hours of nasal congestion since this morning. Patient…

  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 before2026-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 complete a reweight with a resident having a 22% weight loss (severe weight loss) after one week for 1 (#72), and failed to complete monthly follow ups with a resident who voiced concern about her consistent low weight for 1 (#110) of 29 sampled residents. Findings include:1. Review of resident #72's EHR showed an initial weight of 207.8 pounds (on 2/10/26). Resident #72's next weight (on 2/22/26) was 170 pounds. This is a 22.2% weight loss in a week.Review of resident #72's Care Plan, revised 2/21/26, showed: . Notify registered dietician and medical provider of weight loss greater than 5 pounds.During an interview on 4/9/26 at 7:50 a.m., staff member BB stated a fifty-pound weight loss in a week was most likely due to an incorrectly obtained weight, such as from equipment.During an observation and interview on 4/9/26 at 7:52 a.m., staff member AA stated resident #72 had come into the facility with a wheelchair from the hospital. Staff member AA stated that those wheelchairs almost always weighed about 50…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-09 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interview, the facility failed to ensure appropriate and safe PEG tube practices were followed for 1 (#5) of 29 sampled residents. Findings include:During an observation on 4/7/26 at 9:24 a.m., resident #5's PEG tube was unclamped and unhooked from any tubing.During an observation and interview on 4/8/26 at 8:47 a.m., resident #5's PEG tube was unclamped, and still hooked up to the kangaroo pump with the enteral nutrition not running. Staff member T stated the kangaroo pump had been turned off at 6:30 a.m. and the tubing should have been flushed, clamped, and unhooked from the resident. Staff member T looked at resident #5 and stated, She got me there. Staff member T had been referring to the PEG tube being incorrectly still being hooked up and unclamped. Staff member T stated they did not worry about a clogging PEG tube as often with this resident due to the larger circumference of the PEG tubing.According to the University Hospital PEG tube feeding guidelines, a PEG tube should be clamped after being flushed with water (University Hospitals, 2025).…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility staff failed to adhere to nationally recognized standards of hand hygiene when passing meal trays for 2 (#s 85 and 92) of 2 supplemental residents sampled for infection control during meals. This deficient practice had an increased risk of transmitting infections to all residents who received meals in the dining room. Findings include:During an observation on 4/8/26 at 12:05 p.m., staff member K obtained a meal tray from the kitchen and placed it on a dining room table without performing hand hygiene. Staff member K removed the plate cover and left the area. Staff member K walked back to the kitchen and obtained another meal tray and delivered it to resident #85 without performing hand hygiene.Staff member K walked over to resident #92 and grasped the wheelchair handles and pushed her to the dining room table where the uncovered meal tray had been placed and proceeded to handle resident #92's silverware without performing hand hygiene between contact with the wheelchair and the meal tray items.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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident with a history of elopements had a Wander guard in place and doors were secured for 1 (#1) of three sampled residents with elopements; and failed to ensure staff were aware of and employing appropriate fall interventions for 1 (#3) of 5 sampled residents with fall risks. Findings include:1. Review of a facility reported incident investigation indicated resident #1 eloped from the facility on 6/23/25 at approximately 8:00 p.m. and was found 7 blocks away and returned to the facility. A BIMS was completed and indicated resident #1 had a BIMS of 4/15, severely impaired. Review of resident #1's EHR reflected that resident #1 was admitted on [DATE] at 10:38 a.m. and had an elopement risk score of 1.0.Review of resident #1's nursing progress note, dated 6/23/25 at 3:15 p.m., reflected that a wander guard was placed on resident #1's left ankle. Review of resident #1's Baseline Care Plan, dated 6/23/25, reflected that 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-06 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment in resident rooms for 2 (#11 and 15); ensure the proper-storage and emptying of full urinals for 2 (#s 16 and 17); and ensure proper disposal of trash/recycling for 2 (#s 4 and 5) of 22 sampled residents. Findings include: 1. Recycling:a. During an observation on 8/6/25 at 11:10 a.m., resident #4 had nine soda pop cans on the floor, next to the bed, which were empty. Resident #4 was unable to answer questions as to why the empty cans were on the floor. b. During an observation and interview on 8/6/25 at 11:41 a.m., resident #5 had nine empty bottles of soda and 11 empty cans of soda pop on the floor, next to his bed, which were empty. Resident #5 stated he did not know where the recycling was located, so he left the items on the floor. A trash/recycling policy was requested on 8/6/25 at 12:55 p.m. Staff member A stated the facility did not have a policy specific to trash/recycling and cleaning of resident rooms. 2. During an observation and interview on 8/6/25…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$130,272 in federal fines across 6 penalties.

• $13,065 — penalty dated 2026-04-09
• $13,065 — penalty dated 2026-04-09
• $42,770 — penalty dated 2025-04-24
• $21,133 — penalty dated 2024-03-28
• $17,014 — penalty dated 2023-12-04
• $23,225 — penalty dated 2023-10-25

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 SWEETWATER CARE — 8 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 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

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