Canyon Vista Post Acute
6352 Medical Center Street, Las Vegas, NV 89148 · For profit - Limited Liability company · 120 certified beds · (702) 541-6200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $35,016 in federal fines (most recent 2025-03-06)
- its facility-reported quality-measure score sits well above its independent inspection score
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 80.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.9% | 23.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.0% | 9.6% | 12.0% | better |
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.
54.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 318 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.4% 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 409 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 1.28 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 69% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.9%CMS range 48.2–60.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 8.7–12.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 81.4% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 83.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 66.3% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 97.2% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 97.1% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 93.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 4.5–8.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 120 beds and averages 114.2 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 4.31 hrs/resident/day on weekends vs 5.23 on weekdays — 18% thinner on weekends. RN hours go from 1.80 to 1.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Kdisputed · IDR2025-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to ensure three of three residents sampled for accidents (Resident 14, 34, and 116) had interventions implemented to identify hazards and risks associated with smoking. The facility failed to ensure: 1) Resident 14 with a lighter and cigarettes did not attempt to put a used cigarette in a trash can within the resident's room, 2) Resident 34 was a documented smoker with an Oxygen Concentrator (a device delivering up to 95 percent Oxygen, Oxygen when in contact with flammable materials through heat can cause severe burns) in the resident's room, and 3) a non-smoking policy and procedure was enforced when Resident 116 (R116) took out a black lighter from the left chest pocket. The deficient practice had the potential to result in fire hazards and compromise the safety of all residents and staff in the facility. During the extended survey, the sample was expanded to include an additional four smoking residents (Resident 188, 189, 190 and 320).…
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.
- Potential for harm · D2026-04-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview record review and document review, the facility failed to ensure:1) medications were not left on a resident's breakfast tray and documented as administered without direct observation of ingestion for 1 of 40 sampled residents (Resident 96);2) medications were not pre-charted as administered prior to actual administration for 1 of 40 sampled residents (Resident 153); and3) nephrostomy care was not documented as completed without actual provision of care for 1 of 40 sampled residents (Resident 77).The deficient practice had the potential to compromise quality of care provided to residents.Findings include:1)Resident 96 (R96) was admitted on [DATE], with diagnoses including transient cerebral ischemic attack and polyneuropathy.On 04/07/2026 at 8:34 AM, R96 sat up in bed eating breakfast, a medication cup containing eight pills was observed on the meal tray. R96 indicated the nurse left it there so R96 could take the medication when they were ready. R96 stated, I know they are busy…
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.
- Potential for harm · Dcited before2026-04-10 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide 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 observation, interview, record review, and document review, the facility failed to ensure care orders for nephrostomy tubes were followed for 1 of 40 sampled residents (Resident 77). The deficient practice placed the resident at risk for infection.Findings include: 1)Resident 96 (R96) was admitted on [DATE], with diagnoses including transient cerebral ischemic attack and polyneuropathy.On 04/07/2026 at 8:34 AM, R96 sat up in bed eating breakfast, a medication cup containing eight pills was observed on the meal tray. R96 indicated the nurse left it there so R96 could take the medication when they were ready. R96 stated, I know they are busy and I am still eating my breakfast.On 04/07/2026 at 8:37 AM, the Registered Nurse (RN1) assigned to R96 acknowledged leaving the medication cup on R96's meal tray and identified the pills including:Aspirin, Vitamin B complex, Biotin, Carvedilol, Duloxetine, Ezetimibe, Lisinopril, and Multivitamins and minerals.RN1 displayed R96's electronic health record (EHR) 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.
- Potential for harm · Dcited before2026-04-10 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 and interview, the facility failed to ensure food items were not expired, properly dated, labeled, and discarded as required from the refrigerator for 3 of 4 nourishment rooms inspected. This deficient practice had the potential to result in foodborne illness, affecting the health and safety of residents. Findings include: On 04/07/2026 at 8:30 AM, an inspection of the 400-hall nourishment room refrigerator revealed resident food items with an expiry date of 03/03/2026. On 04/07/2026 at 8:32 AM, an inspection of the 100-hall nourishment room, refrigerator revealed resident food an expiry date of 04/03/2026 and an unlabeled resident food item.On 04/07/2026 at 8:35 AM, an inspection of the hall-200 nourishment room, refrigerator revealed six milk cartons expiry date of 03/05/2026. On 04/07/2026 at 11:47 AM, the Assistant Director of Nursing (ADON), verified the resident food had expired and should have been discarded. The ADON confirmed the additional resident food items did not have a label and expressed that the food items should have been labeled before 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.
- Potential for harm · D2026-04-10 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
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 the trash compactor was sealed, in good repair, and free of leaks, foul odors, and accumulated liquid waste. The deficient practice created the potential for unsanitary conditions, foul odors and pest infestation. Findings include: On 04/07/2026 at 8:10 AM, an inspection of the facility's kitchen revealed a trash compactor with a foul smell and various leaks that traveled throughout the side and bottom of the trash compactor. On 04/07/2026 at 8:16 AM, the head cook confirmed the compactor had a known leak and verbalized the area needed to be cleaned due to a safety hazard and a present foul odorOn 04/07/2026 at 8:22 AM, the Maintenance Director verified the trash compactor had a leak and confirmed the trash compactor needed to be replaced. On 04/08/2026 at 1:48 PM, the Assistant Director of Nursing (ADON), confirmed the trash compactor was not in sanitary condition and had a leak with a present odor, which would cause a pest concern. The facility policy titled Sanitization (undated) documented, areas…
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.
- Potential for harm · D2026-04-10 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 appropriate personal protective equipment (PPE) was available in the laundry room for staff handling soiled linens. This deficient practice had the potential to expose staff and residents to contaminants from soiled linens and increased the risk of transmission of infectious organisms in a facility with active resident infections.Findings include:A Daily Overview Summary Report (undated) listed 18 confirmed, current resident infections in the facility, including Clostridioides difficile (C. diff), wound infections, and cellulitis.On 04/08/2026 at 2:36 PM, an inspection of the laundry room revealed gowns (PPE) were not available for staff use.On 04/08/2026, a laundry aide, confirmed that gowns were not available in the laundry room for staff use. The laundry aide indicated gowns would need to be obtained from another area of the facility and pointed toward the resident room areas and hallways. On 04/06/2026 at 2:26 PM, the Infection Preventionist (IP), confirmed gowns were not available in the laundry…
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.
- Potential for harm · D2025-12-05 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 Release of Information policy included a defined time frame for providing resident medical records when requested. The deficient practice had the potential to delay access to a resident's medical records.Findings include: A home health agency (HHA) requested medical records on 05/01/2025 for resident 4 (R4). A second request was made on 05/20/2025. Medical records were electronically sent to the HHA on 05/20/2025 and 05/21/2025. On 12/05/2025 at 9:37 AM, the Medical Records Director explained no medical records would not have been released without a request. Once a request was received, staff documented a note in the including details of the portion of the record provided. The Medical Records Director was unsure if other staff had documented the requests. Medical records were usually provided the same day they were requested. The Medical Records Director indicated there were no documented requests for medical records, and no phone calls from a HHA regarding R4. The Medical Records Director confirmed that both…
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.
- Potential for harm · D2025-12-05 · tag F0628 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and documentation review, the facility failed to ensure a copy of the discharge medication list and education about the medication was provided for 1 of 6 sampled residents (Resident 5). This failure had the potential to lead to medication errors and adverse drug reactions causing resident harm. Findings include: Resident 5 (R5) was admitted to the facility on [DATE] and discharged on 06/20/2025, with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis. The facility was unable to provide documentation of a discharged medication list or education regarding the medications released to R5 upon discharge. On 12/05/2025 at 9:37AM, the registered nurse indicated residents could ask their pharmacy or call the facility back if they were unsure of their medications or prescriptions after discharge. On 12/05/2025 at 9:54AM, the social services assistant explained it was 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.
- Potential for harm · Ecited before2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 that opened items in the refrigerator and freezer were properly labeled and discarded upon expiration per policy. This deficient practice had the potential to result in the serving of expired or improperly stored food items to residents, potentially leading to foodborne illness. Findings include: On 02/25/25 at 7:51 AM, during an initial brief inspection of the kitchen, the surveyor, accompanied by the Director of Dietary Services, observed the following inside the walk-in refrigerator: a large bin of chopped onions dated 02/17/2025, a half-cut large tomato wrapped in plastic wrap without a label, and a large plastic bin of canned fruits that was unlabeled. The Director of Dietary Services confirmed the observation and indicated the opened items should have been discarded within five days but had not been removed as required. An inspection of the walk-in freezer revealed an undated chocolate cream pie in a foil container had been opened and cut in half. The Director of Dietary Services confirmed 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.
- Potential for harm · D2025-03-06 · tag F0655 — isolatedCreate 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 develop and implement baseline care plan for: 1) safety interventions for the care of 4 of 5 residents who smoke (Residents # 188, 189, 190, and 320), 2) interventions to address communication issues for 2 resident with communication deficit related to language barrier (Resident #171 and 324), and 3) interventions for the care of a peripheral intravenous (IV) catheter (Resident #325). Findings include: Resident #188 (R188) R188 was admitted on [DATE], with diagnoses including nicotine dependence and major depressive disorder. admission Minimum Data Set (MDS) assessment dated [DATE], indicated R188 had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS assessment documented R188 was a tobacco user. R188 medical record lacked documented evidence a baseline care plan was developed and implemented to address R188's smoking habits. Resident #189 (R189) R189 was admitted on [DATE], with diagnoses…
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.
- Potential for harm · D2025-03-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 develop comprehensive care plans to reflect new interventions, specifically, a smoking care plan for 3 of 3 sampled residents (Residents 14, 34, and 116). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being. Findings include: Resident 14 (R14) R14 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a serious mental condition affecting thought, resulting in a mix of disorganized thinking and behavior), depression (a mental disorder resulting in loss of pleasure or interest in activities, hopelessness about the future, or thoughts of dying or suicide), and suicidal ideations (thoughts or ideas centered around death or suicide). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/2025, indicated R14 was moderately impaired with a Brief Interview for Mental Status (BIMS)…
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.
Show the remaining 15 citations
- Potential for harm · D2025-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, record review, document review, and interview, the facility failed to respond to resident call lights in a timely manner for 1 of 41 sampled residents (Resident 17), and 2 unsampled residents. The failed practice had the potential to cause delay in resident care and needs. Findings include: 02/26/25 at 8:38 AM, the call light at the door in room [ROOM NUMBER] was observed activated. At the same time a staff member was sitting at nursing station while an audible alarm from the call light system could be heard. 02/26/25 at 8:44 AM, the call light continued activated in room [ROOM NUMBER]. Two staff members wearing scrubs passed by but did not answer the call light. 02/26/25 at 9:00 AM, the resident in 220 verbalized the call light was activated to request the room temperature be adjusted since it was cold. Resident verbalize had been waiting for a long time for somebody to respond. 02/26/25 at 9:03 AM, a Certified Nursing Assistant (CNA) answered the call light and addressed resident'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.
- Potential for harm · D2025-03-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 the Foley catheter was properly assessed and the correct Foley size was inserted or clarified and appropriately documented in the medical record for 1 of 41 sampled residents (Resident 104). This deficient practice had the potential to result in complications such as discomfort, urinary tract injury, bladder trauma, or obstruction. Findings include: Resident 104 (R104) R104 was admitted on [DATE] and readmitted on [DATE], with diagnoses including acute kidney failure and obstructive and reflux uropathy. On 02/25/2025 at 9:09 AM, R104 was in bed with eyes closed. R104's Foley catheter was visible from the door, uncovered, with sediments and red-tinged urine. R104's Foley catheter in place was a size 16 French by 10 milliliters (ml) water balloon. R104 indicated had been readmitted with a Foley catheter. A Licensed Practical Nurse (LPN) confirmed R104's indwelling catheter 16 French by 10 ml water balloon with 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.
- Potential for harm · Dcited before2025-03-06 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide 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 a nephrostomy tube (a tube inserted directly into the kidney to drain urine) insertion site care was documented in the medical record for 1 of 9 sampled residents (Resident 1). The deficient practice made it uncertain if site care including periodic cleaning and application of a dressing had been provided; and could have contributed to infections in R1's skin and tissue adjacent to both nephrostomy tube insertion sites. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and with diagnoses including prostate and bladder cancer. A wound care progress note dated 01/17/2025 documented the resident had bilateral nephrostomy tubes. Physician orders dated 01/17/2025 indicated to monitor bilateral nephrostomy tube sites for signs and symptoms of infection, swelling, redness, or pain every shift and notify MD, and to measure and record output from right and left nephrostomy tubes, each shift. A progress note dated 02/20/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 interview, record review, and document review, the facility failed to ensure that an impaired nutrition assessment or a comprehensive nutritional assessment was completed upon admission and failed to address the resident's severe weight loss (over 5 percent) with interventions for undesirable weight loss for 1 of 41 sampled residents (Resident 121). The deficient practice had the potential to result in continued weight loss and malnutrition, impacting Resident 121's overall health and well-being. Findings include: Resident 121 (R121) Review of the admission record revealed R121 was admitted on [DATE] and discharged on 09/04/2024, with diagnoses including acute kidney failure, type 2 diabetes, and local infection of the skin and subcutaneous tissue. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, indicated R121 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of the Comprehensive Care Plan did not include…
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.
- Potential for harm · D2025-03-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure the tube feeding order was followed, the actual total dose volume consumed was monitored, and the daily enteral feed and caloric intake were documented for 1 of 41 sampled residents (Resident 271). This deficient practice could have the potential to result in inadequate nutrition, dehydration, weight loss, and improper tube feeding administration. Findings include: Resident 271 (R271) R271 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy. On 02/25/2025 at 10:24 AM, R271 was in bed, incoherent but verbally responsive. The enteral pump at the bedside with no tube feeding (TF) formula infusing. The percutaneous endoscopic gastrostomy (PEG) tube site had a dressing in place, undated. The History and Physical dated 01/09/2025 documented R271 developed aspiration pneumonia due to dysphagia, and a percutaneous endoscopic gastrostomy (PEG) tube was placed. The Nutritional…
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.
- Potential for harm · D2025-03-06 · tag F0694 — isolatedProvide 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 obtain a physician's order for the use of an intravenous (IV) access or heplock, including assess and monitor the site, identify whether an IV was present upon admission, and document for 2 of 32 sampled residents (Residents 104 and 325). This deficient practice had the potential to cause complications such as infection, infiltration, phlebitis, or impaired venous access. Findings include: A facility policy titled Peripheral IV Catheter Insertion (undated), documented a physician's or provider's order was necessary for this procedure. The information should have been recorded in the resident's medical record, including the date and time of the procedure, the number of venipuncture attempts (with a maximum of two), the condition of the site, the location of the insertion, and the resident's response to the procedure. Resident 104 (R104) R104 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anemia…
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.
- Potential for harm · D2025-03-06 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 observation, interview, record review, and document review, the facility failed to ensure the resident's pain was consistently assessed or reassessed, managed, and documented in a timely manner in the Medication Administration Record (MAR) for 2 of 41 sampled residents (Residents 273 and 17). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management. Findings include: Resident 273 (R273) A facility policy titled Pain Assessment and Management revised October 2022, documented acute pain should be assessed every 30-60 minutes after the onset and reassessed as indicated until relief was obtained. On 02/25/2025 at 10:54 AM, R273 was in bed, verbally alert and oriented. R273 verbalized having back surgery and feeling frustrated when requesting help for pain medication, but the request was ignored. R273 verbalized the pain scale was at 8/10, with discomfort in the hip, back, elbow, and foot. R273 verbalized the pain medication was insufficient and 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.
- Potential for harm · D2025-03-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, and record review, the facility failed to ensure a medication error rate of less than 5% during medication pass. There were 25 opportunities observed, which revealed two errors. The medication error rate was 8%. Findings include: Resident 274 (R274) On 02/27/2025 at 8:40 AM, a Licensed Practical Nurse (LPN) prepared and administered five medications, including Folic Acid 400 micrograms (mcg) (0.4 milligram), one tablet by mouth. A Physician order dated 02/24/2025, documented Folic acid oral tablet 1 milligram (mg) to give one tablet daily for a supplement. The Medication Administration Record dated 02/27/2025, documented the Folic acid 1 mg tablet was administered successfully. On 03/05/2025 at 10:39 AM, a Licensed Practical Nurse (LPN) confirmed the Folic acid order was for 1 mg or 1000 mcg, but 400 mcg had been administered. The LPN explained there were two bottles of Folic acid available. The LPN indicated the medication dosage should have been double-checked and enumerated…
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.
- Potential for harm · D2025-03-06 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 a safe and functional environment was provided for residents in the 200 hall by not maintaining a functioning call light system. The failed practice placed the residents at risk of not having call lights answered in a timely manner, delayed response to resident's needs and increased accidents risk. Findings include: 02/26/25 at 8:38 AM, the call light at the door in room [ROOM NUMBER] was observed activated. At the same time a staff member was sitting at nursing station while an audible alarm from the call light system could be heard. 02/26/25 at 8:44 AM, the call light continued activated at room [ROOM NUMBER]. Two staff members wearing scrubs passed by but did not answer the call light. 02/26/25 at 9:00 AM, the resident in 220 verbalized the call light was activated to request the room temperature be adjusted since it was cold. Resident verbalize had been waiting for a long time for somebody to respond. 02/26/25 at 9:03 AM 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.
- Potential for harm · E2024-03-29 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and document review, the facility failed to document a response to concerns raised by the Resident Council group, and report actions taken and their rationale to the Resident Council. The deficient practice had the potential to adversely affect resident quality of life. Findings include: The policy and procedure titled Resident Council, revised 04/2017, indicated Resident Council meetings were scheduled monthly. The policy indicated the purpose of the Resident Council was to provide a forum for discussion of concerns and suggestions for improvement. The policy indicated a Resident Council Response Form would be utilized to track issues and their resolution. The policy indicated the facility department related to any issues would be responsible for addressing the item(s) of concern. On 03/27/2024 at 9:01 AM, monthly Resident Council meeting minutes indicated the following: The resident council meeting dated 09/2023 was attended by 6 residents. One resident verbalized a need to remind staff to speak to English in patient care areas (ongoing reminders). The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 label and date food items and maintain clean floors. The deficient practice posed a potential risk to safety and health standards as it could lead to contamination, inadequate storage, or place the residents at risk for foodborne illness. Findings include: On 03/26/2024 at 7:46 AM, an initial kitchen tour was conducted with the Dietary Director. The following concerns were identified: Food items in the walk-in refrigerator not labeled and/or dated: -a bag of diced yellow onion -a bag of diced red onion -a bag of diced green and red peppers -a bag of diced celery Food items in the walk-in refrigerator not labeled with an open date: -a gallon container of milk (half full) -a five pound container of teriyaki sauce (half full) Food items in the walk-in freezer not labeled and/or dated: -a half bag of chicken fingers - one and a half bag of potato wedges One-gallon bottles stored in the dry storage room not labeled with an open date:…
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.
- Potential for harm · D2024-03-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 resident's request for a change in shower schedule was honored for 1 of 24 sampled residents (Resident 3). The deficient practice deprived the resident of the right to self-determination. Findings include: The Resident's rights policy revised December 2016, documented employees shall treat all residents with kindness, dignity and respect and guarantee their basic rights such as the right to self-determination. Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including heart failure and generalized muscle weakness. On 03/26/2024 at 8:50 AM, R3 indicated being in the facility for a month and showers were scheduled on Wednesday and Saturday nights. R3 indicated not wanting showers done in the evening because the resident did not want to sleep with wet hair and there had been a few occasions where staff had woken up the resident from sleep for a shower. R3 indicated requesting to change shower schedule from…
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.
- Potential for harm · D2024-03-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care 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 lacked documented evidence a respiratory therapeutic device was consistently monitored and cared for per physician order for 1 of 24 sampled Residents (Resident 221). The deficient practice had the potential for a resident's therapeutic drain's output to be routinely monitored and recorded. Findings include: Resident 221 (R221) R221 was admitted on [DATE] with diagnoses including pleural effusion and acute respiratory failure. A Physicians Order dated 03/07/2024, documented Aspira drain (a tunneled, long-term catheter used to drain accumulated fluid from the pleural cavity to relieve symptoms associated with pleural effusion): Check drainage bag every shift, drain as needed. measure and record output. The order was transcribed onto the Medication Administration Record (MAR) to ensure nursing would be aware of the order and sign off accordingly of the drainage amount or the other interventions provided. MAR Staff Administration Legend…
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.
- Potential for harm · D2024-03-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation, interview and document review the facility failed to ensure resident specific medication was labeled accordingly with resident's name and vial open date for 1 of 4 medication rooms. The deficient practice could result with cross contamination of resident medication and administration of a sub-potent medication. Findings include: On 03/28/2024 at 1:45 PM, inside the 300 Hall medication room refrigerator was a Lantus Insulin vial 100 units/milliliter with a lot number 2F055C, manufacturer's expiration of 06/30/2025. The vial of medication was not labeled specifically to a resident. The prelabeled area for date opened on the vial was not filled in and was left blank. The license practical nurse confirmed a vial of Lantus medication was resident specific medication and should have been kept inside a pharmacy labeled bag. The nurse indicated the vial should have been labeled with an open date. On 03/28/2024 at 3:54 PM, the director of nursing confirmed the Lantus vial should have been in an independent pouch with the resident's name and the date open should have…
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.
- Potential for harm · D2023-08-18 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, employee file review, and document review, the facility failed to implement their written procedures for screening potential employees for a history of abuse, neglect, and exploitation for one of one employee files reviewed (Employee 1). The deficient practice had the potential to expose residents to interaction with a harmful person. Findings include: The facility policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicated residents had the right to free from abuse, neglect, misappropriation of property and exploitation. The policy indicated background checks were conducted for each prospective employee to ensure the employee had not been found guilty of abuse or neglect, and who did not have a finding entered into the state nurse aide registry regarding abuse or neglect. The facility policy and procedure titled Hiring, revised January 2008, indicated the Human Resources Director would conduct background investigations on prospective new employees. On 08/09/23 at 9:33 AM, a review of one…
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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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.
Fines & penalties
$35,016 in federal fines across 1 penalty.
- $35,016 — penalty dated 2025-03-06
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 PACS GROUP — 274 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEVADA OPCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/05/2021 |
| PROVIDENCE GROUP NH, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 06/30/2023 |
| JOSHI, RITU | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 07/01/2015 |
| ZOLLINGER, ADAM | Individual | W-2 MANAGING EMPLOYEE | — | since 06/01/2022 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NV
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.
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 295093. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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 →
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