St. Joseph Villa Nursing 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.

47.5% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 47.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 184 beds and averages 153.1 residents a day — about 83% occupied, or roughly 31 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 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 3.67 hrs/resident/day on weekends vs 3.94 on weekdays — 7% thinner on weekends. RN hours go from 0.35 to 0.25 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 below 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.

34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · J2023-07-21 · 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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interviews, record review, and facility document and policy review, the facility failed to protect the residents' right to be free from sexual abuse by a resident. Specifically, the facility failed to ensure 2 (Resident #141 and Resident #142) of 4 residents reviewed for abuse who resided on the memory care unit (MCU) and were cognitively impaired were free from sexual abuse. The facility census was 147. Findings are: Review of a facility policy titled, Abuse, Neglect and Exploitation, Freedom From, last revised in 09/2022, indicated, It is the policy of [the facility] to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment involuntary seclusion and misappropriation of property. The policy indicated sexual abuse is non-consensual sexual contact of any type with a resident which includes, but is not limited to,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-10 · 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 Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement intervention to prevent the potential for hot liquid burns on 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 156. Findings are:A record review of the facility's undated Precautions for Handling Hot Beverages education prior to this incident revealed staff shall monitor, serve, and hold hot beverages in a safe manner to prevent burns. The temperature (temp) of any hot beverage would be allowed to cool to 130 degrees Fahrenheit (F). Additional precautions may be implemented based on the needs and make-up of the residents served. These precautions may include: Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensuring staff monitors the identified high-risk residents at mealtimes and when hot beverages were served. Utilizing specialized spill proof lids and cups for those residents identified at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-22 · 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 LICENSE REFERENCE NUMBER NAC 12.006.09(I) Based on record review and interview; the facility staff failed to transfer 1 (Resident 9) of 1 residents in a manner to prevent injury. The facility staff identified a census 159. Findings are: Record review of Resident 9's Electronic Health Record (EHR) titled Census Sheet revealed Resident 9 was admitted to the facility on [DATE]. Record review of Resident 9's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6-06-2024 revealed the following: -Resident 9 had short term and long-term memory problem. -Dependent for eating, bed mobility, transfers, and toileting. -Has a diagnosis of Alzheimer's and dementia with behavioral disturbance. Record review of Resident 9's Comprehensive Care Plan (CCP) with a last conference date of 6-05-2024 revealed Resident 9 required extensive to total assistance with Activities of Daily living (ADL's). According to Resident 9's CCP dated 7-06-2016 revealed 2 staff were to transfer Resident 9 using a…

  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 · F2026-01-08 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.07(C) Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 148. Findings are:A record of the facility's Quality Assessment and Assurance (QAA) policy with a revised date of 7/21 revealed the purpose of the policy was to assist in improving quality of care and quality of life to each of the facility's residents. To identify and respond to quality deficiencies and develop positive outcomes that are sustainable (maintained) over time. During the recent survey with an exit date of 01/08/2026 the following deficiencies and repeat deficiencies were identified: F580 - The facility failed to notify the resident's representative and medical practitioner of a change in AIMS scale…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-08 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 Licensure Reference Number 175 NAC 12-006.09(H) & 12-006.09(H)(iii)(3). Based on observation, interview and record review the facility failed to ensure fluid intakes and daily weights were monitored according to practitioner orders for Resident 128, failed to ensure an air mattress was functioning to promote healing of diabetic wounds for Resident 16, failed to follow up on requested lab work for recurrent urinary tract infections for Resident 47, failed to ensure weekly weights were completed for Resident 2 and failed to complete neurological assessments after an unwitnessed fall for Resident 71. The facility census was 148. The findings are:Licensure Reference Number 175 NAC 12-006.09 (H) & 12-006.09 (H)(iii)(3). Based on observation, interview and record review the facility failed to ensure fluid intakes and daily weights were monitored for Resident 128, failed to ensure an air mattress was properly functioning to promote healing of diabetic wounds for Resident 16, failed to follow up on requested lab work…

  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 · E2026-01-08 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to ensure food was maintained at a palatable temperature for food delivered to residents rooms. This had the potential to affect 40 residents who receive room trays. The facility staff identified a census of 148.Findings are:Interview on 1/06/2026 at 10:30 AM with Resident 15 revealed food was cold and not warm enough. Resident 15 confirmed they ate meals in the residents room.Observation on 1/6/26 at 12:33 PM of a test tray taken to hall 900 by the Dietary Manager (DM).Using the facility thermometer, the DM obtained the following temperatures;-tomato soup was 108.3 degrees-philly steak sandwich was 107 degrees-tater tots were 119 degrees-peaches were 43 degrees Interview with the DM on 1/6/25 at 12:35 PM confirmed the temperature for the tomato soup, philly steak sandwich and tater tots should have been above 135 degrees and the temperature for the peaches should have been below 41 degrees. The DM confirmed the facility did not have plate warmers or insulated plate covers. Interview on 01/07/2026 at 10:00 AM Resident 106…

  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 · E2026-01-08 · 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

  Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility staff failed to perform hand hygiene between residents while assisting 16 (Residents 43, 107, 145, 149, 2, 97, 70, 163, 82, 110, 66, 143, 37, 30, 142, and 87) of 27 sampled residents with eating in a manor to prevent cross contamination. The facility census was 148. Findings are: A record review of the facility's Feeding a Resident policy with a reviewed date of 6/21 revealed staff should wash hands before and after assisting the residents with meals. A. An observation on 01/06/2026 at 8:16 AM revealed that Nursing Assistant (NA)-P was assisting Residents 163 and 82 and NA-Q was assisting Residents 97 and 70 with eating their meals going back and forth between residents with the same hand and touching the residents and the resident's silverware without performing hand hygiene (cleaning) between residents. An observation on 01/06/2026 at 8:29 AM revealed NA-D was assisting Residents 66 and 110 with their meal while touching the Resident's clothing, plate, and the…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-08 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to inform the physician and resident representative of a change in Abnormal Involuntary Movements Scale (AIMS) score for 1 (Resident 7) of 5 sampled residents. The facility census was 148. The findings are:Record review of the facility policy titled Abnormal Involuntary Movements Scale (AIMS) dated 02-2021 revealed the AIMS is a rating scale designed to measure involuntary movements known as Tardive Dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment of antipsychotic medications. A score of 2 or higher on the AIMS scale is evidence of TD. If the patient has mild TD in two areas, or moderate movements in one area, then he or she should be considered for a diagnosis of TD and the results discussed with their physician. If a resident's score on the AIMS suggests the diagnosis of TD, the clinician must consider whether the resident still needs to be on an…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-08 · 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 and interview, the facility failed to communicate with the hospital and failed to provide transfer documentation during a hospital transfer for 2 (Residents 6 and 154) of 4 sampled residents. The facility staff identified a census of 148.The findings are: A. A record review of a facility policy entitled Transfer Resident to Hospital dated Revised 1/2021 revealed: -Purpose: To provide prompt and safe transfer of resident from the facility and to ensure continuity of care through provision of pertinent resident information. -9. INTERACT Nursing Home to Hospital Transfer Form Observation. -10. Nurse will contact emergency department nurse to give report to include Resident's COVID-19 status. -11. Document in the Resident's Progress Notes the basis for the transfer, conversations with the physician/nurse practitioner, family and hospital nurse. -13. Nurse will complete documentation in HER to include but no limited to: -a. Physician Discharge Order in Resident Orders -b. Progress Notes -c. Disposal/returned medications (if applicable) -d. Diagnosis at time 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 · D2026-01-08 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 and interview, the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) referral had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 10) of 1 reviewed for PASRR. The facility census was 148.Findings are:Record review of a facility policy entitled Preadmission Screening and Resident Review (PASRR) Program dated August 2023 revealed the following information: The facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under the state approved Medicaid program. Coordination includes:b. Referring all level 2 residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level 2 resident review upon a significant change in status assessment. 5. A nursing facility must notify the state mental health authority or state…

  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 before2026-01-08 · 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, interview, and record review, the facility failed to assist with or offer oral hygiene during the morning routine for 1 (Resident 17) of 3 sampled residents. The facility staff identified a census of 148.The findings are:Record review of a facility policy entitled Oral Hygiene reviewed 5/2021 revealed the following: - Purpose: To ensure cleanliness; to prevent odor; to improve appetite; to prevent cavities, tartar buildup and gum disease; to stimulate circulation of blood in the gums. - Frequency: Every morning and bedtime.A record review of Resident 17's Face Sheet showed the facility admitted Resident 17 on 12/30/2024. Further review of the face sheet revealed Resident 17 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing), and dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]).A record review of Resident 17's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-08 · 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 Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1). Based on observation, interview and record review the facility failed to ensure the proper functioning of an air mattress for 1 (Resident 123) of 1 residents sampled. The facility census was 148. The findings are: Record review of Resident 123's Minimum Data Set, dated [DATE] (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-had a diagnosis of malnutrition, and Inclusion Body Myositis (IBM: a slow-progressing inflammatory, muscle disease that causes the gradual weakening of the muscles).-Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with eating, dressing, hygiene, toileting, bathing, transfers and bed mobility.-was always incontinent of bowel and bladder.-had a recent weight loss-current body weight was 93 pounds.-was at risk of developing a…

  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 before2026-01-08 · 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 Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to complete quarterly bed assist devices assessments and regular preventive maintenance checks on 1 (Resident 5) of 1 sampled resident's bed assist device. The facility census was 148. Findings are:A record review of the facility's Bed Mobility Assist Devices policy dated February 2021 revealed A Bed Mobility Device Evaluation should be completed upon assessed need and reviewed quarterly, annually, and with significant change thereafter. Environmental staff would install and inspect for safety prior to use and preventative maintenance would be done bi-monthly and as needed. A record review of Resident 5's Resident Census dated 01/08/2026 revealed the resident was admitted on [DATE]. A record review of Resident 5's Face Sheet dated 01/07/2026 revealed the resident had diagnoses of Epilepsy (a brain disorder causing recurring seizures), Unspecified Dementia (confusion of unknown cause),…

  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

$12,048 in federal fines across 1 penalty.

• $12,048 — penalty dated 2024-08-22

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 DELMAR GARDENS — 12 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 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.5M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 NE