Western Horizons Care 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.

33.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.1% 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 27 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 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 638% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 31 beds and averages 28.6 residents a day — about 92% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.50 is at or above 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 4.02 hrs/resident/day on weekends vs 5.05 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.75 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 fewer than at the previous inspection — improving. 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.

35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Kcited before2023-08-29 · 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

  Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 3 of 4 sampled residents (Resident #19, #23, and #29) observed during a transfer. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 08/15/23 at 7:55 a.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (mechanical lift) in a manner to avoid a fall and/or potential injury. * 08/15/23 at 8:12 a.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). * 08/15/23 at 8:25 a.m., The SSA contacted the survey team after discussion with the CMS (Centers for Medicare & Medicaid Services) location and verified the presence of IJ. *08/15/23…

  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 before2026-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) injured during a transfer. Failure to utilize the appropriate equipment and staff assistance resulted in an injury to Resident #1 and placed all residents at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented.Findings Include:The surveyor determined a deficient practice existed on 11/23/25. The facility implemented and completed corrective actions by 03/24/26. Review of the facility policy titled Safe Resident Handling/Transfers With Use of Mechanical lifts occurred on 04/28/26. This policy, dated 05/23/25, stated, . All residents require safe handling when transferred to prevent or minimize risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and nobility, the use of…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-09-04 · 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 record review, facility policy review, and review of the facility reported incident (FRI) investigation, the facility failed to ensure residents remained free from abuse for 1 of 1 closed record (Resident #40) who experienced sexual abuse from another resident. Failure to protect residents from sexual abuse resulted in fear, anxiety, and mental anguish. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:The survey team determined a deficient practice existed on 04/27/25. The facility implemented corrective action immediately, completed corrective action on 04/28/25, and continued with staff education and monitoring. Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 09/03/25. This policy, revised May 2025, stated, Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including . other residents . Sexual Abuse is…

  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
• Actual harm · Gcited before2025-09-04 · 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 record review, review of facility procedure, review of manufacturer's use instructions, and staff interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #8) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury. Findings include:Review of the facility procedure Use of Hoyer (Full Body) Lift occurred on 09/04/25. This undated procedure stated, . Mechanical Lift from Bed to Chair . Positioned the lift under the bed and widened the base of the lift.Review of the Volaro Series 4 Lift Operator's Manual occurred on 09/04/24. This manual, dated March 2019, stated, . Safety Notes . Lift legs must be fully extended into the wide position when lifting a patient or resident. Lifting from Bed to Chair using the Divided Leg Sling: . If the base is in the narrow position, adjust it to the widest position once you are clear from the bed and always before…

  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 before2025-01-16 · 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, record review, review of the facility reported incident (FRI) report, review of facility investigation documents and camera footage, and staff interview, the facility failed to ensure resident safety for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to ensure door alarms are engaged and in working order allowed Resident #1 to elope from the facility and sustain injuries. Findings include: Review of the Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form occurred on 01/14/25. This form, dated 01/10/25, stated, . Date of the allegation: 01/10/25 . Time of the allegation: 0215 am [2:15 a.m.] . [Resident #1] . Amount of injury unknown at this time. Awaiting additional report from hospital. At this time, we only know resident has a cut on his head and abrasions to his body. Resident is frequently exit-seeking and attempts elopement. It is unknown at this time how resident was able to elope the building as all…

  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 · E2025-09-04 · 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, review of facility policy, and staff interview, the facility failed to store meds and biologicals appropriately in 2 of 4 medication storage and supply areas (West Wing medication cart and [NAME] Wing medication room). Failure to secure medications in the medication cart and to dispose of expired needles has the potential for unauthorized access of medications and has the potential for inaccurate laboratory results. Findings include:Review of the facility policy titled Expiration of Medications and Supplies occurred on [DATE]. This policy, dated [DATE], stated, . 2. Weekly on every Wednesday, the CMA [certified medication aide]/nurse working on the East and [NAME] Nurses' station will check . the medication room . for . supply expiration dates . Any expired . supplies will be disposed of after removal from . medication rooms .The facility failed to provide a policy regarding locking the medication cart.-Observation on [DATE] of the [NAME] wing medication cart showed the cart unlocked 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-04 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (EMAR) on 1 of 2 units (West Wing) observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. Findings include:A review of facility policy titled Violation Sanctions HIPPA Policies occurred on 09/04/25. This policy, dated June 2020, stated, . Confidentiality: It is the right of an individual to have personal, identifiable information kept private . Violations are defined into categories . failure to properly sign off from or lock computer when leaving a workstation.Observation on 09/02/25 of the [NAME] wing medication cart showed the EMAR open and visible to visitors and residents at 11:51 a.m. and 12:30 to 12:34 p.m. without a nurse present.During an interview on 09/03/25 at 4:20 p.m., two administrative staff members (#1 and #2) stated they expected staff to close and lock the EMAR when unattended.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-04 · 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 record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 1 supplemental resident (Resident #10) reviewed for hospitalizations. Failure to provide a notice of transfer and a bed-hold notice does not allow the resident and/or their representative to make informed decisions regarding their rights, or inform the Ombudsman of the transfer. Findings include:Review of the facility policy titled Bed Hold Policy occurred on 09/04/25. This policy, dated 05/15/25, stated, . will provide written information to the resident or resident's representative regarding the bed hold policy prior to a transfer . the resident or resident's representative will be provided written information regarding the bed hold policy. will be notified in writing the reasons for the move in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long term 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-04 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, and staff interviews, the facility failed to obtain a physician's order for 1 of 1 supplemental resident (Resident #17) observed receiving crushed medications. Failure to notify the provider regarding the resident's ability to swallow whole medications and obtain an order for crushed medications may result in an inconsistency in care and choking. Review of a nurse's report sheet occurred on 09/04/25. This form, dated 08/15/25, showed Resident #17 takes her medications Whole.Observation of medication administration occurred on 09/02/25 at 12:42 p.m. and showed a nurse (#11) crush Resident #17's medication, placed them in pudding, and administered them to the resident. The medication administration record (MAR) lacked documentation indicating staff were to crush the resident's medications. During an interview on 09/02/25 at 12:43 p.m. a staff nurse (#11) stated, We have been crushing her meds for a couple of weeks now since she (Resident #17) came back from the hospital after her stroke.During an interview on the morning of 09/04/25, two administrative 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-04 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, review of a dietary document, and staff interview, the facility failed to provide food in a form to meet individual needs for 2 of 2 sampled residents (Resident #15 and #20) with a physician's order for a minced and moist diet. Failure to provide minced and moist food as ordered may result in reduced meal intake, choking, and aspiration pneumonia. Findings include: Review of a document titled Hormel Health Labs Checklists for IDDSI [International Dysphagia Diet Standardization Initiative - standardized system for classifying food and drink textures for individuals with swallowing difficulties] Levels 7, 6, 5, and 4 provided by the dietary manager (#14) occurred on 09/04/25. This undated document described Level 5 Minced and Moist requirements as Soft and moist particle size - very small pieces ([less than] 1/8 inch - adults); Pieces fit between fork tines; Mimics a soft chewed bolus [a soft round mass] . -Review of Resident #20's medical record occurred on all days of survey. Diagnoses included cerebral infarction (stroke) and dysphagia…

  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 · Dcited before2025-09-04 · 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 and policy review, the facility failed to follow standards of infection control and prevention for 1 of 6 sampled residents (Resident #19) and 1 of 1 supplemental resident (Resident #17) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 09/04/25. This policy, revised December 2024, stated, Hand hygiene is the act of cleaning one's hands to remove potentially harmful substances and organisms. Hand hygiene . highly effective method for preventing the spread of pathogens, such as bacteria and viruses, which can lead to infections. PROCEDURE Indications for Performing Hand Hygiene: Before moving from work with a soiled body site . to a clean body site . After contact with . body fluids . -Observation on 09/02/25 at 10:18 a.m. showed two certified nurse aides (CNAs) (#8 and #9) applied gloves and provided perineal cares for Resident #17. The CNAs removed their soiled gloves 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 · Dcited before2024-11-14 · 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 record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from resident to resident abuse for 1 of 1 sampled residents (Resident #3) who experienced unwanted sexual contact with another resident. Failure to identify sexual abuse placed residents at risk for mental and emotional distress. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 11/14/24. This policy, revised 03/02/22, stated, . Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'Sexual Abuse' is non-consensual sexual contact of any type with a resident . The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: .…

  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 · D2024-11-14 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview the facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 sampled residents (Resident #3) who experienced abuse. Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 11/14/24. This policy, revised 03/02/22, stated, . Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.'Sexual Abuse' is non-consensual sexual contact of any type with a resident . Anyone in the facility can report suspected abuse . When abuse, neglect or…

  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 · E2024-07-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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, review of facility policy, and staff interview, the facility failed to prepare and/or store food in a sanitary manner in 1 of 1 kitchen and 2 of 2 kitchenettes. Failure to ensure proper concentration of the sanitizer solution and failure to apply an identifying label and/or open date to food items has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: SANITIZING FOOD PREP AREAS During an interview on 07/22/24 at 10:25 a.m., when asked to test the solution in the sanitizing bucket, a dietary staff member (#4) stated, EcoLab was here a couple of weeks ago to replace some parts [of the automatic dispenser]. The sanitizer is not working. The sanitizer bucket isn't right. I just have hot water in there. LABELING/DATING FOODS Review of the facility policy titled Food Receiving and Storage occurred on 07/24/24. This policy, revised 05/18/09, stated, . Food shall be . stored in a manner that complies with safe food handling practices. All foods stored in 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-24 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 2 of 2 multi-compartment sinks observed in the main kitchen. Failure to provide the required air gap for a multi- compartment sink has the potential to allow contamination of the sink in the event of a sewer back-up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment…

  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.

  Environmental 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

$62,703 in federal fines across 3 penalties.

• $17,252 — penalty dated 2025-09-04
• $26,598 — penalty dated 2025-01-16
• $18,853 — penalty dated 2023-08-29

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.

Who owns this facility

CMS files one row per role, so the 17 rows in the source record cover these 10 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.

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 $258K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ND