Trinity Homes

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.

35.2% 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 159 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.5% 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 148 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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 141 beds and averages 137.6 residents a day — about 98% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 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 4.04 hrs/resident/day on weekends vs 4.32 on weekdays — 7% thinner on weekends. RN hours go from 1.06 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% 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.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · Gcited before2025-11-19 · 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 the facility reported incident (FRI) and investigation, review of competency/verification/training documents, and staff interview, the facility failed to provide supervision and assistance devices to prevent an accident for 1 of 1 sampled resident (Resident #1) injured during a facility van transport. Failure to secure the shoulder strap on the resident during transport resulted in Resident #1 sustaining a leg fracture. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:The surveyor determined a deficient practice existed 11/17/25. The facility implemented corrective action on 11/18/25. Review of the initial FRI report, dated 11/17/25 at 2:00 p.m. stated, Resident was being transported back to facility. Resident fell out of wheelchair when stopping at a stoplight. Resident was sent to ER [emergency room] due to pain in lower extremity.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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-09-05 · 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 the facility reported incident, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) with verbal, physical, and sexual behaviors towards other residents. Failure to assess, care plan, and operationalize a plan/process resulted in fear, anxiety, pain, and an unsafe environment for all residents residing in the memory care unit. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated, . Abuse: the willful infliction of injury, unreasonable confinement, intimidation . with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse . Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question and those residents that have had aggressive…

  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 · G2024-09-05 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 provide adequate dementia care and services for 1 of 1 sampled resident (Resident #1) with dementia and verbal, physical, and sexual abusive behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #1 and had a negative impact on other residents. Findings include: The facility failed to provide a policy on dementia care. Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated,. Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question . In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken . Social Services…

  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 before2024-08-08 · 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, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 5 sampled residents (Resident #68) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in an avoidable facility acquired pressure ulcer. Findings include: Review of the facility policy titled Skin Management -[NAME] Homes occurred on 08/08/24. This policy revised, December 2022, stated, . Nursing will follow the skin care procedures outlined below to . 2. Maintain the integrity of the resident's skin through monitoring and timely interventional skin care management . 8. Braden Scale will be repeated upon resident changes in condition . The resident's care plan will be updated by the nurse to include goals for prevention and management of pressure injuries with appropriate interventions. The care plan will be reviewed . at change of condition…

  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 before2024-08-08 · 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 2. Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 3 sampled residents (Resident #4) observed during a sit-to-stand lift transfer and (Resident #36) observed with bruises. Failure to use a mechanical lift properly and/or re-evaluate the suitability of a mechanical lift transfer, and monitor/ensure safe transfer methods placed Residents #4 and #36 at risk for injury. Findings include: Review of the EZ Way Smart Stand [type of sit-to-stand mechanical lift] 400, 500 & 800 lb [pound] Capacities Operator's Instructions, revised 09/29/23, pages 2-6, stated, . As patients do vary in size, shape, weight and temperament, these conditions must be taken in to [sic] consideration when deciding if the EZ Way Smart Stand is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow…

  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 before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility investigation, and review of facility policy, the facility failed to ensure adequate supervision and assistance for 1 of 2 sampled residents (Resident #68) who required staff assistance with transfers and experienced a fall with fracture injury. Findings include: Review of the facility policy titled Fall prevention policy occurred on 08/23/23. This policy, dated May 2022, stated, . residents will be assessed for risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . provide additional interventions as directed by the resident's assessment . rounding to be performed hourly . ambulation and toileting assistance . the plan of care will be revised and updated as needed . Review of Resident #68's medical record occurred on all days of survey. The care plan at the time of the fall showed Resident #68 transferred and ambulated with the assist of one. Nursing progress notes identified the following: *06/28/2023 at 11:39 p.m., . was on the other other side of the hall, when this…

  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 before2025-08-14 · 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 1. Based on observation, record review, and resident and staff interviews, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 5 residents (Resident #29) observed for transfers. Failure to utilize a gait belt during transfers placed the resident at risk of injury. Findings include: Review of Resident #29's medical record occurred on all days of survey. The current care plan stated, . Transfers: Pivot transfer to and from bed with gaitbelt and assist of 1 [staff]. Non-weight bearing to right leg. -Observation on 08/11/25 at 2:57 p.m. showed Resident #29 seated on a motorized scooter. When asked how staff assisted with transfers between the scooter and other surfaces, Resident #29 stated, They grab the back of my pants and swing me over. Observation on 08/12/25 at 11:35 a.m. showed Resident #29 rested in bed. Two certified nurse aides (CNAs) (#8 and #9) entered the resident's room and assisted the resident to sit on the edge of the bed. The CNA (#8) grabbed 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
• Potential for harm · Ecited before2025-08-14 · 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 observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 11 sampled residents (Resident #12, #29 and #59) and 1 supplemental resident (Resident #126) observed for cares and/or medication administration. Failure to practice infection control standards related to enhanced barrier precautions (EBP), glove use, hand hygiene, and disinfecting of shared equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Copy of Enhanced Barrier precautions occurred on 08/14/25. This policy, dated September 2024, stated, . Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multi-Drug Resistant Organism] as well as those that have . open wound that requires a dressing. high-contact activities . dressing . transferring . Review of the facility policy titled Blood glucose/Hypoglycemia occurred on 08/14/25. This…

  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 · D2025-08-14 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  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 resident, resident representative, and staff interviews, the facility failed to ensure the right to participate in the development and implementation of a person-centered plan of care for 2 of 31 sampled residents (Resident #6 and #118). Failure to ensure residents or their representative received notice of care planning conferences and/or interviewed the resident or their representative regarding care concerns/needs if they chose not to attend the conferences, limited their right to make decisions/provide input related to the resident's care, treatment, and services.Findings include: Review of the facility policy titled Care Planning occurred on 08/14/25. This policy, dated April 2025, stated, . It is the policy of [NAME] Nursing Care Facility that a written plan of care be developed and maintained for each resident in coordination with all services and individuals involved in the care of the resident. Family members, support persons with the permission 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 31 sampled residents (Resident #84) reviewed for advance directives. Failure to ensure the resident's medical record reflected the most current resident wishes may result in unwanted treatment. Findings include:Review of the facility policy titled Code Status occurred on 08/14/25. This policy, revised October 2021, stated, . Nursing services will verify order between providers orders and/or resident's decision and that the code order in the electronic health record matches whatever the resident/residents representative has signed .Review of Resident #84's medical record occurred on all days of survey and identified a physician's order, dated 02/18/25, indicating a full code status. The resident identification ribbon in the electronic health record (EHR) also showed a full code status. On 08/12/25 at 5:25 p.m., a management staff member (#17) presented the surveyor a code status form dated 08/12/25…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · 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 ensure all alleged violations involving possible abuse/neglect were reported immediately to officials including the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to immediately report alleged violations to the SSA placed Resident #1 and other residents at risk for possible neglect and/or injury.Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . The Director of Nursing and/or Director of Social Services will report the alleged . neglect . to the Administration and/or their designee and the State Health Department. An initial Allegation of Abuse Reporting form will be…

  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 · D2025-08-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 thoroughly investigate alleged violations of neglect for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to thoroughly investigate Resident #1's elopement, implement corrective actions, and evaluate the effectiveness of those actions, placed Resident #1 and other residents at risk for possible neglect and/or injury.Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . The supervisor will then contact the Director of Nursing and/or Director of Social Services to initiate the investigation process. All staff with knowledge of the alleged incident will be required to make a written, signed, and dated statement.…

  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 · Dcited before2025-08-14 · 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 record review, review of professional reference, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #30) with orders for a physical therapy/occupational therapy (PT/OT) evaluation. Failure to transcribe and obtain a PT/OT evaluation placed Resident #30 at risk for delayed treatment. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out.Review of the facility policy titled Provider Orders occurred on 08/14/25. This policy, dated September 2022, stated, . PHYSICIANS ORDERS . all orders must be on the chart of the resident . Observed, sign, date and time, in red, beneath the providers written orders on Provider order sheets. enter order into the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 23 sampled residents (Resident #4 and #104) dependent on staff for personal hygiene. Failure to provide assistance with hair, oral, and nail care may result in poor hygiene and decreased self-esteem and quality of life. Findings include: The facility failed to provide a policy for activities of daily living. -Observation on 08/11/25 at 4:29 p.m. showed Resident #4's hair uncombed. The resident stated, I only get my hair combed about once a week and teeth brushed occasionally. Review of Resident #4's medical record occurred on all days of survey. The care plan stated, . [Resident #4's name] is not able to perform her own ADL's [activities of daily living] related to weakness and right femur fracture. Grooming/Personal Hygiene: staff assistance of one for assistance at bedside. Encourage [Resident #4's name] to . comb hair Oral hygiene: partials/own teeth. Oral cares bid [twice a day] . Encourage [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 · Dcited before2025-08-14 · 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 — the official record, unedited, may be distressing

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 6 sampled resident (Resident #6) observed during dressing changes. Failure to complete dressing changes as physician ordered placed the resident at risk for delayed wound healing. Findings include:Review of the facility policy titled Skin Management occurred on 08/14/25. This policy, dated December 2022, stated, . Wound Care Guidelines . Floor nurse will observe wound daily . Wound care dressings will be dated and initialed. Floor nurse will document observed wounds . in the resident's EHR [electronic health record].Review of Resident #6's medical record occurred on all days of survey. A physician's order, dated 11/27/24, identified a dressing change to the resident's right leg once a day. Observation on 08/12/25 at 9:30 a.m. showed a nurse (#12) removed a dressing dated 08/10/25 from Resident #6's right leg. The nurse (#12) stated, I don't know what happened. They must have forgot to change the dressing yesterday.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · 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, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to prevent skin breakdown and pressure ulcers for 1 of 4 sampled residents (Resident #4) reviewed with pressure ulcers. Failure to consistently reposition residents for pressure relief may result in delayed healing of current pressure ulcers and/or the development of new pressure ulcers.Findings include:Review of the facility policy titled Skin Management occurred on 08/14/25. This policy, dated December 2022, stated, Once residents are identified at risk of skin breakdown, prevention guidelines will be implemented, including but not limited to: turn schedule .Follow individualized prevention protocols for each resident . Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.Review of Resident #4's medical record occurred on all days of survey. Diagnosis included a pressure…

  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

“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

$75,611 in federal fines across 3 penalties.

• $10,358 — penalty dated 2025-11-19
• $57,584 — penalty dated 2024-07-31
• $7,669 — penalty dated 2023-08-24

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 35 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in ND