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Green Valley Health And Wellness Suites

2965 Wigwam Parkway, Henderson, NV 89074 · For profit - Limited Liability company · 124 certified beds · (410) 773-1175 Medicare & Medicaid certified

Call the home — (410) 773-1175 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
8475 S Eastern Ave · (702) 933-0971 · Call to confirm hours
Pharmacy
8579 S Eastern Ave · (702) 792-3777 · Call to confirm hours
Grocery
8500 S. Eastern Ave · (702) 260-6452 · Call to confirm hours
Park
8975 Topaz St · Typically dawn to dusk
Place of worship
8826 S Eastern Ave Ste 107 · (702) 270-7777

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.2%12.6%15.4%worse
Long-stay residents who lose too much weight7.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder2.5%1.6%0.9%worse
Long-stay residents with a urinary tract infection2.5%1.9%2.0%worse
Long-stay residents with depressive symptoms0.4%5.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%2.0%3.3%better
Long-stay residents whose ability to walk worsened22.7%13.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.3%22.2%18.9%typical
Long-stay residents given the seasonal flu vaccine86.8%89.6%95.3%typical
Long-stay residents with pressure ulcers10.8%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control17.5%15.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.9%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%1.8%1.4%worse
Short-stay residents given the seasonal flu vaccine41.9%80.7%79.4%worse
Short-stay residents rehospitalized after admission28.8%23.2%22.6%worse
Short-stay residents with an outpatient ER visit9.7%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.871.851.67worse
Long-stay outpatient ER visits per 1,000 resident days1.531.451.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

53.3% 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 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.3%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
71.7%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 71.7% 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 53 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.3%CMS range 44.1–62.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 9.2–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge73.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting82.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge85.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 4.3–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.141.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.43
RN hours/ resident / day
1.23
LPN hours/ resident / day
1.74
Aide hours/ resident / day
3.40
Total nurse hours/ resident / day
0.26
RN hoursweekends
59.6%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 105.5 residents a day — about 85% occupied, or roughly 18 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.54 on weekdays — 14% thinner on weekends. RN hours go from 0.50 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% 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

7
deficiencies at the latest standard inspection (2026-01-30)
6
at the previous standard inspection (2024-12-20)

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.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-30 · 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, interview, and document review, the facility failed to ensure dishware was sanitized by facility policy in the three-compartment sink of the main kitchen. This deficient practice had the potential to cause spreading foodborne illnesses exposing all residents who received meals from the kitchen.Findings Include:On 01/27/2026 at 7:48 AM, the quaternary ammonium sanitizer solution in the three-compartment sink measured approximately 50-100 parts per million (ppm), indicating the sanitizer solution in the three-compartment sink was low.On 01/28/2026 at 7:30 AM, the Food Service Manager indicated the quaternary ammonium sanitizer solution should be maintained between 200-400 ppm as per most health and food safety standards and manufacturer guidelines. The Food Service Manager stated the proper cleaning process included washing, rinsing, and sanitizing all utensils and equipment. The Food Service Manager stated the three-compartment sink must be tested daily.The facility's policy of titled Manual Cleaning and Sanitizing with a Three-Compartment sink, dated…

    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 · D2026-01-30 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 48 sampled residents (Resident 14). The deficient practice had the potential for the residents to not be informed of risk, benefits, and potential side effects of the medication.Findings include: Resident 14 (R14) was admitted on [DATE] with diagnoses including metabolic encephalopathy, depression, and unspecified mood disorder.A Physician Order dated 01/12/2026 documented Duloxetine (an antidepressant medication) capsule, delayed release, 30 milligrams (mg) twice a day.R14's medical record lacked documented evidence informed consent was obtained prior to the first administration of duloxetine on 01/12/2026.On 01/28/2026 at 4:40PM, the Director of Nursing (DON) confirmed R14's medical record lacked consent for Duloxetine.On 01/29/2026 at 10:34 AM, a Licensed Practical Nurse (LPN) explained a consent for psychotropic medication was required…

    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 before2026-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a comprehensive person-centered care plan for activities was created for 1 of 48 sample residents (Resident 1). The deficient practice had the potential for residents not to receive care and services in accordance with assessed needs. Findings include:Resident 1 (R1) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pleural effusion, and hypothyroidism. R1 was on contact isolation.On 01/27/2025 in the morning, R1 enjoyed working on puzzles. R1 had not attended activities and was unaware of what activities the facility offeredR1's medical record lacked a care plan for activities which outlined specific interventions with measurable goals to promote R1's quality of life.On 01/30/2026 at 9:30 AM, an Activity Aide completed an activity assessment for R1 upon admission. The Activity Aide was unaware of the staff member responsible for completing the activity care plan.On 01/30/2026…

    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 before2026-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to obtain a physician order for the use of a knee brace for 1 of 48 sampled residents (Resident 14). The deficient practice had the potential to result in discomfort, impaired circulation or skin breakdown.Findings include:Resident 14 (R14) was admitted on [DATE] with diagnoses including metabolic encephalopathy, depression, displaced transverse fracture of left patella, and unspecified mood disorder.On 01/27/2026 in the morning, R14 had knee brace lying on top of the dresser located at the foot of R14's bed.A Physician Order dated 11/24/2025 documented Restorative Nursing Services: passive range of motion to left lower affected side, non-weight bearing left lower side, active range of motion to upper extremities and to unaffected lower right side, at least 6 days per week.On 01/30/2025 at 9:18 AM, the Restorative Nurse Assistant (RNA) explained R14's knee brace originally came from physical therapy, and the brace was applied…

    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 · D2026-01-30 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for 2 of 48 sampled residents (Resident 74 and Resident 86). The deficient practice posed a potential risk of injury or harm to the residents.Findings include:On 01/29/2026 in the morning, a Medication Administration Pass observation was performed with 28 opportunities observed with two errors. The medication error rate was 7.14%.1) Resident 74 (R74) was admitted on [DATE] with diagnoses including displaced fracture of lateral condyle of left femur, unspecified protein calorie malnutrition, and atrial fibrillation.On 01/29/2026 at 7:50AM, during the Medication Administration Pass observation the Licensed Practical Nurse (LPN) prepared and administered R74's scheduled morning medications.A Physician Order dated 01/07/2026 documented Azelastine spray 137 micrograms (mcg), two nasal sprays once a day at 8:00AM.R74's Azelastine spray was not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0761 — failed to label and store drugs safely — isolated
    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, interview, record review and document review the facility failed to 1) ensure medications were secured for 1 of 48 sampled residents (Resident 67) and 2) expired multi-dose vial of medication was disposed. The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility and potential for the facility staff to administer expired medications.Findings include:1) Resident 67 (R67) was admitted on [DATE] with diagnoses including recurrent dislocation of right hip, acute osteomyelitis of right femur, and fibromyalgia.On 01/27/2026 at 7:52 AM, R67 had one 10-ounce (oz) spray bottle of 91 percent (%) Isopropyl alcohol, a spray bottle of Hydrogen Peroxide, and one 10 oz bottle of Mylanta on the overbed table.On 01/30/2026 at 7:48 AM, R67 had one 10oz spray bottle of 91% Isopropyl Alcohol, a 10oz bottle of Mylanta, and one tube of Neosporin on top of the overbed table. R67 explained being able to use the Isopropyl Alcohol and Neosporin…

    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 · D2026-01-30 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee included the Medical Director. The deficient practice had the potential to delay quality improvement actions leading to problems going unaddressed, delayed correction actions or risks not being mitigated.Findings include:The Quality Assessment and Assurance Meeting Minutes documented the Medical Directed did not attend on 01/16/2025, 03/27/2025, 04/25/2025, 05/22/2025, 06/24/2025, 08/28/2025, 10/16/2025 and 01/15/2026.On 01/30/2026 at 11:30 AM, the Administrator confirmed the Medical Director had not been attending the QAPI meetings. The Administrator explained the Medical Director had scheduling conflicts and did not attend the meetings at least quarterly.The facility's policy titled Leadership Framework revised 12/03/2019 documented the facility (QAA) committee team will meet at least monthly to meet the demands of identified facility needs and will be composed of at a minimum, the Administrator, Director of Nursing, Medical Director or Designee,…

    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 · D2025-11-24 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure a resident was not involuntarily discharged without a valid reason, when a resident returned to the facility after a therapeutic leave and was not allowed to reenter the facility, for one of two sampled residents (Resident 2). The deficient practice had the potential to cause residents to experience adverse effect such as mental distress and unmet medical needs. Findings include:The facility policy titled Against Medical Advice (AMA) -Day Outing/Therapeutic Leaves of Absence indicated a resident may leave for a day outing or therapeutic leave of absence (LOA) with family and friends at any time during their stay with written permission from their physician. If the physician denied permission, then the patient may elect the right to sign out against medical advice. The facility policy titled Discharge /Transfer, dated 10/23/2019, indicated for involuntary discharge, the facility would develop a safe discharge plan, including but…

    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 · D2025-05-07 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident grievances were investigated and a determination, and/or resolution, was provided to the residents. This deficient practice had the potential to result in a resident having unresolved complaints/grievances. Findings include: On 04/17/2025 in the afternoon, the Social Worker (SW) verbalized the Activity Director takes the issues presented in the Resident Counsel Meeting Minutes and turns them into Grievances by inputting them into the Grievance program on the computer. Since there were a lot of new staff, not everyone had access to go into the computer to input the investigation and resolutions of the grievances. The SW also stated there was no documentation of investigations and/or resolutions for the grievances which needed to be inputted into the Grievance computer program. The Resident Council Meeting Minutes dated 02/19/2025, documented unresolved old issues of night shift not doing rounds every two hours and staff being…

    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 · D2025-05-07 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure a resident who had functional impairments was appropriately discharged for 1 of 4 sampled residents (Resident 4). This failure could potentially lead to medical complications or adverse events which could result in hospitalization, prolonged illness, or even death. Findings include: Resident 4 (R4) R4 was admitted to the facility on [DATE] and discharged home on [DATE], with diagnoses including fracture of shaft of humerus of right arm, chronic obstructive pulmonary disease, cerebral infarction, and chronic atrial fibrillation. A Notice of Medicare Non-Coverage (NOMNOC) document was issued to R4 on 12/09/2024. Neither the family of R4 or R4 themselves, had filed an appeal at this time. On 04/17/2025 at 08:15 AM, a Case Manager (CM) stated responsible for the resident discharges. The CM revealed had gone to R4 on 12/9/2024 to explain the NOMNOC to R4 and to get R4 to sign the document. R4 declined the appeal process as R4 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2025-05-07 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure a discharge summary was completed for 1 of 4 sampled residents (Resident 2). The deficient practice had the potential for the facility failing to provide the necessary information to continuing care providers pertaining to the course of treatment while the resident was at the facility and the resident's plan of care after discharge. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and discharged on 03/31/2025 with diagnoses including Friedreich ataxia, unspecified symptoms and signs involving cognitive functions and awareness, and functional quadriplegia. A progress noted dated 03/31/2025 documented 911 was called to the building to transfer resident, asking if R2 had a place to go when discharged and R2 stated did not want to return to this facility. The ambulance attendants were given R2's face sheet and list of medications. R2 was transferred to hospital. R2's medical record lacked documented evidence a discharge…

    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 before2025-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medication was administered per physician order for 1 of 4 sampled residents (Resident 2). The deficient practice had the potential for the resident not achieving the therapeutic effect (specific and desired effect) of the medication. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and discharged on 03/31/2025 with diagnoses including Friedreich ataxia, unspecified symptoms and signs involving cognitive functions and awareness, and functional quadriplegia. A physician order dated 03/25/2025 documented Clonazepam 0.5 milligrams (mg) one tablet oral twice a day at 8:00AM and 8:00 PM. The Medication Administration Record for 03/25/2025 at 9:21PM documented Clonazepam 0.5 mg one tablet oral twice a day at 8:00 AM and 8:00PM not administered: drug/item unavailable Comment: New admit. Awaiting delivery from pharmacy. Will give upon arrival per hospice. On 04/17/2025 at 11:26 AM, a Pharmacist confirmed the pharmacy received the Clonazepam…

    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 before2025-05-07 · tag F0761 — failed to label and store drugs safely — isolated
    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, interview and document review, the facility failed to ensure that medications were secured for 1 of 3 unsampled residents (Resident 5). The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility. Findings include: Resident 5 (R5) R5 was admitted on [DATE] with diagnoses including cellulitis of right lower limb, type 2 diabetes mellitus with hyperglycemia, and difficulty in walking. A physician order dated 11/02/2024 documented Latanoprost drops 0.005% administer one drop to both eyes at bedtime. On 04/17/2025 at 7:57 AM, R5 had a prescription bottle on the bedside table labeled Latanoprost 0.005% with directions to apply one drop to both eyes at bedtime. R5 explained the nurse had left the medication on the bedside table the previous night. On 04/17/2025 at 8:05 AM, a Licensed Practical Nurse (LPN) confirmed the medication was present at R5's bedside and removed the medication from the resident's room explaining 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure infection control practices were maintained for 2 of 3 unsampled residents (Resident 6 and Resident 7). The deficient practice had the potential to increase risk of cross-contamination, spread infectious diseases, and compromise health and safety for residents. Findings include: Resident 6 (R6) On 04/17/2025 at 8:28 AM a Certified Nurse Assistant 1 (CNA) was inside R6's room with gloves on picking food off R6's chest and placing it onto a meal tray. The CNA 1 picked up the meal tray and exited R6's room. R6 had a sign posted to the left of the door which documented the following: -Contact Precautions providers and staff must: put on gloves and gown before room entry and discard gloves and gown before room exit. The CNA 1 acknowledged the posted sign and explained not having had education on infection control and was just entering the room quickly to pick up the meal tray. The CNA 1 explained being unsure of what infection R6 had and explained a gown should have also been worn as indicated on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review, the facility failed to implement a person-centered care plan for the utilization and maintenance protocol of a peripherally inserted central catheter (PICC) line for 1 of 3 sampled residents (Resident 2). This deficient practice posed a potential risk of improper care, including inadequate dressing changes and improper flushing, which could lead to complications such as infection, catheter occlusion, thrombus formation, or other adverse health outcomes. Findings include: Resident 2 (R2) R2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), dementia, protein-calorie malnutrition, and failure to thrive. The PICC Procedural Note dated 12/03/2024, documented the PICC line was inserted in R2's right upper arm for total parenteral nutrition (TPN) and antibiotics administration. A physician's order dated 12/03/2024, documented the Clinimix TPN was to be infused through the PICC line only, with a bag 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when 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 observation, interview, record review, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing care was changed for 1 of 3 sampled residents (Resident 1), and a physician order for flushing protocol was obtained, transcribed, and implemented for 1 of 3 sampled residents (Resident 2). The deficient practice had a potential for a resident to develop an infection from poor maintenance of an intravenous site and a potential for catheter occlusion. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including diabetes mellitus and chronic hepatitis. The admission Minimum Data Set for Brief Interview for the Mental Status dated 01/17/2025, documented a score of 15/15, which indicated R1's cognitive status was intact. On 02/04/2025 at 11:21 AM, R1 was seated in a wheelchair with a PICC line in the right upper arm. The dressing was undated, peeling, and soiled with dried, reddish-brown blood-like residues. R1's medical records…

    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 · D2024-12-20 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure an initial Preadmission Screening and Resident Review (PASRR) was completed prior to a resident's admission for 1 of 18 sampled residents (Resident 2). The deficient practice had a potential for a newly admitted resident not to receive the necessary screening for the appropriateness to be admitted to a skilled nursing facility. Findings include: Resident 2 (R2) was admitted on [DATE], with diagnoses including depression and anxiety disorder. On 12/17/2024 at 10:46 AM, R2 was observed lying in low bed and remained quiet when being interviewed. There was a one to one (1:1) staff at the bedside and stated the resident could get very anxious when being left alone. The 1:1 staff member indicated the resident does not have any history of falls but wonders around the hallways and gets very anxious. Review of R2's progress notes from admission to current revealed the resident at most times would require 1:1 monitoring due…

    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 · D2024-12-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure incontinent care was provided to a dependent resident who was soiled, wet, and had requested assistance for 1 of 30 sampled residents (Resident 229). This deficient practice had the potential to result in skin breakdown, infections, discomfort, and a diminished quality of life. Findings include: Resident 229 (R229) was admitted on [DATE], with diagnoses including overactive bladder, cramp and spasm, and pain. On 12/17/2024 at 9:33 AM, R229 was verbally alert and oriented but totally dependent on assistance for care due to a spinal injury. A suprapubic catheter was observed in place, draining yellow urine, with the urinary catheter bag lowered and placed in a basin. R229 verbalized although had the catheter, had intermittently been able to urinate through the urethra. R229 reported an incident had occurred on December 12, 2024, having urinated in bed twice due to a bladder spasm and pressed the call light for help,…

    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 · D2024-12-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure: nutritional assessments were completed and interventions were implemented when a significant weight change occurred for 1 of 18 sampled residents (Resident 14), and residents' weights were obtained as scheduled for 3 of 18 sampled residents (Residents 14, 16 and 39). The deficient practices could have had the potential to delay interventions, increase the risk of health complications, and negatively impact residents' overall health and well-being. Findings include: 1) Resident 14 (R14) was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, dysphagia (difficulty swallowing) and anxiety disorder. The Observation Details List dated 05/09/2024, documented R14 was at risk for malnutrition. R14's Weight Summary documented the following: - 12/05/2024: 131 pounds (lbs.), Routine body mass index (BMI): 26.46 (Height: 4'7) - 11/01/2024: 132 lbs., Routine BMI: 26.66 - 10/08/2024: 130.6 lbs.,…

    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 before2024-12-20 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when 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 observation, interview, record review and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing care and maintenance was completed for 1 of 18 sampled residents (Resident 35). The deficient practice had a potential for a resident to develop an infection from poor maintenance of an intravenous site. Findings include: Resident 35 (R35) was admitted on [DATE] and a recent re-admission on [DATE], with diagnoses including hemiplegia and cellulitis of the abdominal wall. On 12/17/1024 at 11:04 AM, R35 was observed with a right upper arm PICC line, the dressing on the PICC line was dated 11/21/2024. R35's family member indicated the resident had no intravenous antibiotics or fluids given for more than a month. On 12/17/24 at 2:24 PM, a Registered Nurse (RN) indicated a PICC line dressing should be changed every week by nursing. The RN confirmed the date on R35's PICC line and acknowledged the dressing should have been changed. The RN indicated all 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-20 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure dialysis communication and post treatment assessments were completed for 2 of 18 sampled residents (Resident 5 and 8). The deficient practice had a potential for residents not to have good communication with dialysis provider impairing continuity of care and not to be assessed post dialysis treatment for adverse reactions. Findings include: 1.) Resident 5 (R5) was admitted on [DATE], with diagnoses including end stage renal disease and generalized anxiety. R5's medical record documented Dialysis Tuesday, Thursday and Saturday at 5:10 AM. A Review of the completed Hemodialysis Communication Record from admission to current, revealed the resident attended dialysis treatment 24 times The communication record revealed the following: On 8 days there was a completed record. There were 8 days where the record was missing. There were 6 days where the record was missing return vital signs and/or dialysis site. There were two days where…

    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 · D2024-12-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain informed consents, monitor behaviors, and document non-pharmacological interventions for the use of psychoactive medications, for 2 of 18 sampled residents (Residents 46 and 38). The deficient practices had the potential to cause residents to use an unnecessary medication with possible adverse effects. Findings include: 1.) Resident 46 (R46) was admitted on [DATE] with diagnoses including schizoaffective disorder, insomnia, and depression. A Physician Order dated 09/17/2024 indicated to take Zoloft (an anti-depressant medication) 25 milligrams (mg) once daily for depression. A Psychiatric Note dated 12/12/2024 indicated the patient had been taking Zoloft 25 mg by mouth daily for depression. The record lacked evidence of a physician order to monitor behavior or side effects for Zoloft; ongoing monitoring for behavior or side effects of Zoloft; and an informed consent for the use of Zoloft had been obtained from R46 prior to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-18 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure a baseline care plan was developed for an ileostomy (a surgical opening constructed by bringing the end or loop of the small intestine out onto the surface of the skin) for 2 of 4 sampled residents (Residents 1 and 3). The deficient practice placed the residents at risk for complications such as stoma (surgical opening) infection, skin irritation, leakage of fecal contents and patient discomfort. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including malignant neoplasm of the endometrium and ileostomy. An initial encounter provider note dated 03/08/2024, documented R1 was admitted for pain management and rehabilitation following partial colectomy and ileostomy creation. The medical record lacked documented R1's baseline care plan included care and management interventions for R1's ileostomy. Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including alcohol abuse and ileostomy creation. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-18 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure care orders were entered and carried out for an ileostomy (a surgical opening constructed by bringing the end or loop of the small intestine out onto the surface of the skin) for 2 of 4 sampled residents (Residents 1 and 3). The deficient practice placed the residents at risk for complications such as stoma (surgical opening) infection, skin irritation, leakage of fecal contents and patient discomfort. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including malignant neoplasm of the endometrium and ileostomy. An initial encounter provider note dated 03/08/2024, documented R1 was admitted for pain management and rehabilitation following partial colectomy and ileostomy creation. The medical record lacked documented evidence care orders were transcribed and carried out for R1's ileostomy. Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including alcohol abuse and ileostomy creation. A hospital…

    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 before2023-11-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review the facility failed to ensure a physician order was followed during medication administration for one unsampled resident (Resident 16). The deficient practice had the potential to impact therapeutic levels of the medication. Findings include: Resident 16 (R16) R16 was admitted on [DATE] with diagnoses including Vitamin B12 deficiency anemia. On 11/15/2023 at approximately 9:01 AM, Licensed Practical Nurse 1 (LPN1) administered one tablet of Cyanocobalamin (Vitamin B-12) 500 Micrograms (mcg) to R16. A Physician Order with a start date of 11/06/2023 documented Cyanocobalamin (Vitamin B-12), 5 tablets, oral, for a total of 2,500 mcg for Vitamin B12 deficiency anemia. The Medication Administration Record for 11/2023 revealed LPN1 documented Vitamin B-12, 2,500 mcg was administered to R16. On 11/15/2023 at approximately 1:35 PM, LPN1 reviewed the physician order for Vitamin B12. LPN1 did not recall the order specifying 5 tablets. On 11/16/2023 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
  • Potential for harm · D2023-11-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review the facility failed to ensure the medication regimen review was completed monthly for 3 of 14 sampled residents (Resident 10, 25, and 26). The deficient practice had the potential for medication errors, adverse drug reactions, ineffective management of medications and compromised quality of care. Findings include: The facility policy titled Medication Regimen Review revised on 04/01/2022 documented residents would receive a consultant pharmacist medication review at least monthly. Resident 10 (R10) R10 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, congestive heart failure, and muscle weakness. The medical record lacked documented evidence that a medication regimen review (MRR) was conducted by the consultant pharmacist from May 2023 through July 2023. Resident 25 (R25) R25 was admitted on [DATE] with diagnoses schizophrenia and anxiety. The medical record lacked documented evidence that a medication regimen review was conducted…

    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 · Dcited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to 1.) implement proper labeling and storage of perishable food items located in the kitchen and nourishment room [ROOM NUMBER].) discard perishable items by their use by date and 3.) ensure sanitary conditions in 1 of 2 nourishment rooms. The deficient practice had the potential to expose food sources to cross contamination and foodborne pathogens. Findings include: On 11/14/23 at 7:50 AM, the facility kitchen refrigerator contained: undated salad, undated and uncovered gelatin cups, undated and unlabeled mince garlic, a container labeled country gravy with a use by date of 11/13/2023, and a container of beans with a use by date of 11/12/2023. On 11/14/2023 at 8:05 AM, red liquid was observed on the beverage center countertop and reddish-brown stains were located on the floor of the room. On 11/14/2023 at 8:10 AM, resident food located in the nourishment room refrigerator was undated. On 11/14/2023 at 8:20 AM, the Assistant Dietary Manager…

    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 before2023-11-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure transmission-based precaution (TBP) protocol was followed for 1 of 14 sampled residents (Resident 237). The deficient practice had the potential to lead to the spread of the organism and impacting the wellbeing of residents. Findings include: Resident 237 (R237) R237 was admitted on [DATE] with medical diagnoses to include enterocolitis due to clostridium difficile (C-Diff a bacteria causing infection/inflammation of the colon). On 11/14/2023 at 9:59 AM, R237's room was observed with a contact precaution sign posted outside of the room. On 11/14/2023 at 10:11 AM, a Licensed Practical Nurse (LPN) confirmed the contact sign was posted outside R237's room due to the resident having C. Diff. The LPN explained it was okay to enter the room without personal protective equipment (PPE) as the resident had completed treatment and was in the process of having contact precautions discontinued. The LPN indicated the appropriate…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to FUNDAMENTAL HEALTHCARE — 66 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 →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 65 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Avir at MemorialDenison, TX 1 of 5Bennettsville Health And Rehabilitation CenterBennettsville, SC 1 of 5Calhoun Convalescent CenterSaint Matthews, SC 1 of 5Corinth Rehabilitation Suites on the ParkwayCorinth, TX 1 of 5Forest Haven Nursing And Rehabilitation CtrCatonsville, MD 1 of 5Julia Manor Nursing And Rehabilitation CenterHagerstown, MD 1 of 5Lake Emory Post Acute CareInman, SC 1 of 5Magnolia Manor - GreenwoodGreenwood, SC 1 of 5Magnolia Manor - InmanInman, SC 1 of 5Magnolia Manor - Rock HillRock Hill, SC 1 of 5Northampton Manor Nursing And Rehabilitation CenteFrederick, MD 1 of 5Oakbrook Health And Rehabilitation CenterSummerville, SC 1 of 5Oakland Nursing & Rehabilitation CenterOakland, MD 1 of 5Physical Rehabilitation And Wellness Center Of SpaSpartanburg, SC 1 of 5Riverside Health and RehabCharleston, SC 1 of 5San Gabriel Rehabilitation and Care CenterRound Rock, TX 1 of 5Springdale Healthcare CenterCamden, SC 2 of 5Berlin Nursing And Rehabilitation CenterBerlin, MD 2 of 5Bremond Nursing and Rehabilitation CenterBremond, TX 2 of 5Fairfield Nursing & Rehabilitation CenterCrownsville, MD 2 of 5Faith Healthcare CenterFlorence, SC 2 of 5Falcon Ridge RehabilitationHutto, TX 2 of 5Hillside Heights Rehabilitation SuitesAmarillo, TX 2 of 5Horizon Health And Rehabilitation CenterLas Vegas, NV 2 of 5Lancaster Health and RehabilitationLancaster, SC 2 of 5Las Ventanas De SocorroSocorro, TX 2 of 5Magnolia Manor - GreenvilleGreenville, SC 2 of 5Midlands Health & Rehabilitation CenterColumbia, SC 2 of 5Mira Vista CourtFort Worth, TX 2 of 5Moran Nursing And Rehabilitation CenterWesternport, MD 2 of 5North Las Vegas Care CenterNorth las Vegas, NV 2 of 5Pavilion at Glacier ValleySlinger, WI 2 of 5Sandy Lake Rehabilitation And Care CenterCoppell, TX 2 of 5Southpointe Healthcare and RehabilitationGreenville, SC 2 of 5Spanish Hills Wellness SuitesLas Vegas, NV 2 of 5Terra Bella Health and Wellness SuitesHouston, TX 2 of 5The Pavilion At CreekwoodMansfield, TX 2 of 5Villa Rosa Nursing And Rehabilitation, LLCMitchellville, MD 3 of 5Bridgecrest Rehabilitation SuitesHouston, TX 3 of 5Crimson Heights Health & WellnessHumble, TX

Showing 40 of 65; lowest-rated first.

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

Owner / managerTypeRoleShareSince
THI OF NEVADA LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/30/2013
COOK, DARRINIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/27/2023
BOSTON, CHRISTINEIndividualCORPORATE OFFICERsince 06/27/2023

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$7.4M
Net patient revenuemost recent cost report
-57.6%
Operating marginrevenue minus expenses
$388K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 33%Other / private 18%

This home reported $388K 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

$790per resident / day
operating cost
$24,014per month
≈ monthly operating cost
$501per day
avg. revenue, all payers

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 NV

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nevada Medicaid page.

Typical monthly cost in Nevada
$11,786/mo
Nursing home (semi-private)
$14,463/mo
Nursing home (private)
$6,241/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 295110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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