Marquis Care At Centennial Hills
6351 N Fort Apache Rd, Las Vegas, NV 89149 · For profit - Corporation · 120 certified beds · (702) 515-3000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- 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 (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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
- 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 |
| Long-stay residentspeople who live here | 4 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 improved from 3 to 5 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 |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.9% | 12.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.8% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.1% | 5.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 1.6% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.8% | 2.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.6% | 13.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 28.9% | 22.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 89.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.9% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.5% | 15.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.4% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.4% | 80.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.3% | 23.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.9% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.58 | 1.85 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.02 | 1.45 | 1.80 | better |
§ 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.
56.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 54 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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
| 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 | 56.5%CMS range 47.6–66.2 | 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 | 14.2%CMS range 11.1–18.0 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 85.2% | 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 | 81.5% | 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 | 75.9% | 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 | 95.1% | 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 | 90.6% | 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 | 100.0% | 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 | 0.0% | 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 | 5.0% | 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 | 7.0%CMS range 3.7–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 95.7 residents a day — about 80% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.33 hrs/resident/day on weekends vs 4.85 on weekdays — 11% thinner on weekends. RN hours go from 1.22 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below 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 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2025-06-27 · 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 interview, record review and document review, the facility failed to ensure a physician's order was clarified and the accurate amount of medication and water was documented per the physician's order for 1 of 21 sampled residents (Resident 10). The deficient practice had the potential for the resident not receiving the maximum therapeutic effect of the medication and inaccurate documentation of the resident's fluid intake. Findings include: Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) and dependence on respirator (ventilator) status. The physician's order dated 12/10/2024, documented Protein Gel/Liquid (medication) 30 milliliters (ml) two times a day, mix in water if administered via enteral tube (G-tube), flush with 30 ml before and after administration. Document total consumed of Protein Gel and water. R10's Medication Administration Record…
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 before2025-06-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 restorative nursing services were provided per therapy recommendations for 1 of 21 sampled residents (Resident 40). The deficient practice had the potential for the resident's further decline in range of motion (extent of movement a joint could perform). Findings include: Resident 40 (R40) R40 was admitted on [DATE], with diagnoses including hemiplegia, tracheostomy status, and bed confinement status. R40's Occupational Therapy (OT) Discharge summary dated [DATE], documented the following: - Discharge Location: Resident discharged to reside in the facility. - Discharge Reason: Need for Skilled Services Ended. - Discharge Recommendations: Equipment / Other Recommendations: Hand rolls and positioning - Follow-Up Programs Established / Trained = Home Exercise Program (HEP) - Program Initiated / Established: Upper Extremity HEP R40's Quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had impairment…
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 · D2025-06-27 · 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 failed to ensure Oxygen (O2) was administered according to physician's orders for 1 of 21 sampled residents (Resident 31). The deficient practice had the potential to lead to O2 toxicity and exacerbation of the residents' underlying health conditions. Findings include: Resident 31 (R31) R31 was admitted on [DATE], with diagnoses including peripheral vascular disease, atherosclerotic heart disease, and adult failure to thrive. On 06/24/2025 at 9:31 AM, R31 was lying in bed and receiving O2 via nasal cannula (NC) connected to an Oxygen concentrator (a medical device that separates oxygen from air, providing a higher concentration of oxygen to individuals who need supplemental oxygen therapy). The concentrator was turned on and set at 2.5 liters per minute (LPM). A physician order dated 03/15/2023 documented Oxygen at 2 LPM via NC continuously. R 31's Care Plan dated 05/13/2025, documented R31 had inadequate compromised respiratory…
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 before2025-06-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 received the medication as ordered for 1 of 21 sampled residents (Resident 243). The deficient practice had the potential for the resident having adverse events for not receiving physician prescribed medication. Findings include: Resident 243 (R243) R243 was admitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications and hyperlipidemia. The physician's order dated 06/16/2025 at 8:55 PM, documented Semaglutide Oral Tablet 7 milligrams (mg) by mouth in the morning related to type 2 diabetes mellitus without complications. The start date was 06/17/2025. The order was discontinued on 06/19/2025 at 2:28 PM and the reason was clarification. The physician's order dated 06/19/2025 at 2:28 PM, documented Semaglutide Oral Tablet 7 mg by mouth in the morning related to type 2 diabetes mellitus without complications. The start date was 06/21/2025. The Interdisciplinary (IDT) Progress…
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 before2025-06-27 · 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, interview and document review, the facility failed to discard expired milk stored in a refrigerator located in the kitchen, an ice pack in the first floor nourishment room freezer, and employee food from the freezer located in second floor nourishment room. The deficient practice has the potential to lead to bacterial growth and foodborne illnesses. Findings include: On 06/24/2025 at 8:00 AM, the milk refrigerator located in the kitchen, had a quart of expired silk milk dated 06/13/2025. On 06/24/2025 at 8:20 AM, the nourishment room located on the first floor, had an ice pack placed in the resident freezer. On 06/24/2025 at 8:30 AM, the nourishment room located on the second floor, had employee personal food items inside the nourishment freezer, which included a protein shake and a pizza. On 06/24/2025 at 8:02 AM, the Director of food and nutrition, verified the milk was expired and should have been discarded. On 06/24/2025 at 8:22 AM, the Charge Nurse (CN) stated the ice packs are used for residents if they have pain and expressed the ice packs should not be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0660 — isolatedPlan 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 update discharge instructions and failed to notify the physician of the changes in the discharge plan for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for a resident not to receive the necessary provisions for continuation of care. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 02/18/2025 with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. The physician Discharge summary dated [DATE] documented to discharge R1 home with home health, Registered Nurse (RN), Physical Therapy (PT), and Occupational therapy (OT) for maximizing strength and safety. A discharge order request dated 02/18/2025 documented discharge services of home health, nursing, PT, OT, social worker, bath aide and wound care three times a week for pressure wound on sacrum and right heel. An Interdisciplinary Team (IDT) discharge note 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 · Dcited before2025-02-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to provide documented evidence wound care treatments were provided per the physician's order for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for delayed healing of a wound. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 02/18/2025 with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. A physician's order dated 12/05/2024 documented Silvadene External Cream 1 % (Silver Sulfadiazine) apply to sacrum topically every day shift, every other day for skin impairment. Cleanse stage 3 pressure injury to sacrum with normal saline and pat dry, apply no sting skin prep to surrounding skin, apply Silvadene/ Triad mix to wound bed, cover with calcium alginate then cover with dry dressing. R1's Treatment Administration Record (TAR) for the stage 3 pressure area of the sacrum lacked documented…
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 before2025-02-20 · 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 interview, record review and document review, the facility failed to provide documented evidence a resident's midline (a long, thin, flexible tube inserted into a large vein of the upper arm used to administer medication into the bloodstream) was removed, and a site assessment was performed upon discharge for 1 of 4 sampled residents (Resident 1). This deficient practice had the potential for an increased risk of infection and to compromise the residents' health. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 02/18/2025 with diagnoses including urinary tract infection, atrial fibrillation, and unstageable pressure ulcer site unspecified. A physician's order dated 02/18/2025 documented to discontinue midline related to completion of intravenous (IV) medication regimen. On 02/20/2025 at 2:35 PM, a Registered Nurse (RN) stated when an order for the midline removal was received from the physician, the removal was documented in the progress notes and was to include an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-26 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 assessment for the use of bilateral mitten restraints for a resident was completed accurately and consent for the mitten restraints was obtained from the resident or the appropriate representative for 1 of 20 sampled residents (Resident #44). The deficient practice had the potential to cause physical and psychosocial harm to the resident. Findings include: Resident #44 (R44) Resident # 44 was admitted on [DATE], with diagnoses including acute respiratory failure, anxiety disorder, type 2 diabetes mellitus, dementia, nontraumatic intracerebral hemorrhage, hypoxemia, tracheostomy, and gastrostomy. Assessment: On 07/23/2024 at 3:21 PM, Resident #44 was observed wearing bilateral hand mitts (a restrictive type of mitten to prevent residents from pulling out invasive devices such as intravenous lines, feeding or airway tubes). The active care plan details Resident #44 was ventilator dependent, at risk for skin…
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 · D2024-07-26 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 20 sampled residents (Resident #36). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Resident #36 (R36) R36 was re-admitted on [DATE], with diagnoses including pulmonary edema, acute respiratory failure with hypoxia, anxiety disorder, mood disorder, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder. On 07/23/2024 in the afternoon, R36 was sitting on the bed. R36 stated had been at the facility for about 8 years and the care and services at the facility were good. A PASARR level one document dated 12/27/2016, revealed R36 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility…
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 16 citations
- Potential for harm · D2024-07-26 · 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 observations, interviews, record reviews, and document reviews, the facility failed to ensure documentation accurately reflected medications and treatment services were provided. Specifically, this pertained to 1) wound care treatment; 2) ACE wrap (elastic bandage); 3) Oxygen (O2) therapy; and 4) diuretic medication . This deficient practice could potentially have led to severe harm, including ineffective wound management, an increased risk of respiratory complications, inadequate compression therapy, and compromised medication management. Findings include: A facility policy titled Administering Medications dated 04/08/2019, medications should be administered in a safe and timely manner and as prescribed. Medications or treatments must be administered in accordance with the orders, including any required time frame. Resident 48 (R48) R48 was admitted on [DATE], and readmitted on [DATE], with diagnoses including edema, anemia, congestive heart failure, effusion, chronic obstructive pulmonary disease…
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 before2024-07-26 · 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, interview, record review, and document review, the facility failed to ensure: 1) the wound care treatment was provided as ordered to treat impaired skin; 2) the ACE wrap (elastic bandage) was applied as ordered to treat edema; and 3) the Oxygen flow meter rate was administered as ordered to treat chronic obstructive pulmonary disease (COPD) for 1 of 20 sampled residents (Resident 48). These deficient practices had the potential to cause delayed wound healing, increased risk of complications related to poor circulation and compromised respiratory function. Findings include: Resident 48 (R48) R48 was admitted on [DATE], and readmitted on [DATE], with diagnoses including edema, anemia, congestive heart failure, effusion, COPD, atrial fibrillation and heart failure. The Brief Interview of Mental Status dated 07/13/2024, documented a score of 15/15, which indicated R48's cognitive status was intact. 1) Wound Care Treatment The admission Skin Integrity Report dated 07/07/2024 documented R48 had 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 before2024-07-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to implement floating heels to prevent pressure ulcers for 1 of 20 sample residents (Resident #11). The deficient practice had the potential to expose the resident to an avoidable skin injury. Findings included: Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including hypertension, diabetes, epilepsy, CVA, and chronic hypoxia. A physician order dated 04/26/2024 documented floating heels while in bed for skin integrity. A Braden Scale for predicting pressure sore risk assessment dated [DATE] indicated R11 had moderate risk for pressure sore. On 07/23/24, at 10:00 AM, R11 was in bed without any heel protectors, and the heels were not floating. A registered nurse confirmed the observation and explained the bed should have been in a position to allow heels to float. The bed was in a flat position, which did not prevent the heels from coming into direct contact with the mattress. On 07/25/2024 at 2:00 PM, R11 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 · Dcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to complete a post fall assessment and neurological checks after an unwitnessed fall for 1 of 20 residents (Resident 38). The failed practice could have contributed to increased pain and a delay of necessary medical interventions. Findings include: Resident 38 (R38) R38 was admitted on [DATE] with diagnosis including polyneuropathy, unilateral primary osteoarthritis of right hip, dizziness and giddiness. A Care Plan initiated 02/11/2024, documented R38 was at risk for falls due to muscle weakness and history of falls. A Fall/Post Fall assessment dated [DATE] documented a history of falls, and R38 remained at risk for falls related to unsteady gait with poor safety awareness. On 07/23/2024 at 9:51 AM, R38 reported fell asleep sitting on bed and fell on the floor approximately one week before. R38 reported had right hip pain after the fall. A Fall Note dated 07/09/2024, documented R38 reported fell asleep while lying down on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-26 · 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 2) Resident 39 (R39) R39 was admitted to the facility on [DATE], with diagnoses including infection of tracheostomy stoma, chronic pain, nontraumatic intracerebral hemorrhage, unspecified intestinal obstruction, acute embolism and thrombosis, and bed confinement. R39's Weight Summary report, documented a January weight of 218.7 pounds (lbs.) on 01/12/2024. No weights were tracked or monitored for April 2024. According to the weight task history, R39 was on monthly weights from 01/10/2024 until 05/15/2024 when the resident was switched to weekly weights due to weight loss. R39's Weight Report documented weights from January 2024 through July 2024 as follows: -07/22/2024: 198.4 lbs. -07/15/2024: 197.0 lbs. -07/08/2024: 196.8 lbs. -07/01/2024: 196.2 lbs. -06/17/2024: 198.4 lbs. -06/10/2024: 196.4 lbs. -06/03/2024: 196.0 lbs. -05/27/2024: 196.4 lbs. -05/13/2024: 195.8 lbs. -05/12/2024: 194.0 lbs. -03/12/2024: 220.0 lbs. -02/12/2024: 216.8 lbs. -01/12/2024: 218.7 lbs. On 07/24/2024 at 10:43 AM, the Dietician (E14)…
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 · D2024-07-26 · 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 adequate tube feeding (TF) formula was provided as ordered to a resident who was TF-dependent or to notify the physician when it could not be carried out in a timely manner for 1 of 20 sampled residents (Resident 188). This deficient practice had the potential to compromise the resident's nutritional status and overall health, leading to malnutrition, dehydration, and an increased risk of infection. Findings includes: Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and gastrostomy. The Nursing admission assessment dated [DATE], documented R188's short and long memory as intact. R188 had a gastric feeding tube in place. A Care Plan dated 07/23/2024, documented R188 required TF in maintaining or improving nutritional status related to chewing problems and swallowing impairment. The goal included providing the TF as ordered, monitoring, and reporting formula…
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 before2024-07-26 · 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, interview, and document review, the facility failed to ensure food products were labeled with the date when they were opened, and failed to dispose of fruits showing signs of spoilage. The deficient practice could have exposed the residents to potential health risk associated with contaminated food. Findings included: 07/23/24 08:19 AM, inspection was conducted in the kitchen with the Kitchen Manager. The following issues in the walk-in refrigerator were identified: - A 1 Lb. container of beef base open and not dated. - Staff beverage stored in the walk-in refrigerator - 1 gallon container of coleslaw dressing open and not dated. - 5 Lb. container of low fat cottage cheese open and not dated. - 8.44 Lb. container of mild chunky salsa open and not dated - 1 gallon container of golden Italian dressing open and not dated - 11 Cantaloupes and one watermelon with black spots and white patches on the skin, showing signs of spoilage, with softness and mushiness at the touch. The Kitchen Manager confirmed the observation and indicated open containers of food products…
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 before2024-01-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 and record review, the facility failed to ensure a resident who required a one-person physical assist in toilet use and had history of falls was not left alone while using the toilet resulting in a fall for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for severe injury due to lack of assistance provided. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 10/06/2023, with diagnoses including syncope and collapse, fall on same level from slipping, tripping, and stumbling without subsequent striking against object, chronic pain syndrome, and dementia. R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented the following: - R1 required limited assistance and one-person physical assist for toilet use. - R1 was not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking (with assistive device if used), moving on and off toilet, 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 before2024-01-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 account for narcotic medications signed out on the controlled drug record (narcotic log) for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to delay a resident's pain management and increase risk for physical and psychosocial harm. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on 10/06/2023, with diagnoses including syncope and collapse, fall on same level from slipping, tripping, and stumbling without subsequent striking against object, chronic pain syndrome, and dementia. A Physician Order dated 06/23/2023, documented Oxycodone Hydrochloride (HCl) oral tablet 30 milligram (mg) give 0.5 tablet by mouth every four hours as needed for moderate to severe pain. Hold for sedation. R1's Controlled Drug Record documented Oxycodone 0.5 tablet (15 mg) was signed out to be administered on 09/03/2023 at 12:07 PM and 4:00 PM; and on 10/01/2023 at 4:00 PM. R1's medical record lacked…
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 · D2023-07-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 resident right of dignity was honored for 1 of 23 sampled residents (Resident 19). The deficient practice had the potential to cause a negative psychosocial outcome. Findings Include: Resident 19 (R19) R19 was admitted on [DATE] with diagnosis of Parkinson's disease. A facility report indicated on 04/10/2023, R19 was placed near the nurse's station on a shower chair with bucket under the chair for the resident to defecate. On 07/25/2023 at 1:15 PM, a Certified Nursing Assistant (CNA) was familiar with incident and confirmed the incident did occur. The CNA explained while making rounds, the CNA noticed the resident close to the nurse's station and immediately advised nurse and CNA responsible for placing the resident at the nurse's station, so the resident could be returned to room. On 07/27/23 at 11:14 AM, the Administrator verified incident occurred with resident. Neither abuse nor neglect were identified during 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 · D2023-07-27 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 for self-administration was obtained and an assessment was completed before allowing a resident to self-administer medications. The deficient practice had the potential to lead to medication errors impacting the well-being of the resident. Findings include: Resident 63 (R63) R63 was admitted on [DATE] with medical diagnoses including pain in the right and left hip. On 07/25/2023 at 8:29 AM, a Lidocaine Patch 4% (medication used for pain) was observed on the bed of R63. R63 indicated the Lidocaine Patch belonged to the resident and it was used to alleviate pain at the right hip. R63 explained nursing staff left the patch for the resident to apply it on their own. R63 then reached for the Lidocaine patch and applied it to their right hip. On 07/26/23 at 11:26 AM, a Licensed Practical Nurse (LPN) explained R63 did not let nursing staff apply the Lidocaine Patch. The LPN confirmed nursing staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-27 · 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, interview, record review and document review, the facility failed to ensure medications were administered per physician's order for 2 of 23 sampled residents (Resident 144 and Resident 20). Specifically, 1) two intravenous (IV) antibiotic medications were not given as scheduled for a resident with pneumonia (Resident 144) and 2) a phosphate binder was not administered with meals for a resident with end stage renal disease (Resident 20). The deficient practice placed Resident 144 at risk for unresolved infection and potentially contributed to Resident 20's hyperphosphatemia (elevated Phosphorus in the blood). Findings include: Resident 144 (R144) R144 was admitted on [DATE], with diagnoses including pneumonia and acute respiratory failure with hypoxia. On 07/25/2023 at 11:32 AM, R44 laid in bed with eyes opened and was non-verbal. Two empty intravenous (IV) bags were observed hanging on a pole on the right side of the resident's bed. The IV medication bags were labeled Zosyn and Vancomycin…
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 before2023-07-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 evaluate and provide appropriate interventions for hand contractures for 1 of 23 sampled residents (Resident 52). The deficient practice had the potential for the resident to develop further decline or decrease in physical functioning. Findings include: Resident 52 (R52) R52 was admitted on [DATE], with diagnoses including quadriplegia and anoxic brain damage (occurred when the brain was deprived of oxygen). The admission and Quarterly Minimum Data Set (MDS) dated [DATE] and 06/02/2023, respectively, documented R52 had functional limitation in range of motion (ROM) with impairment on both sides of upper and lower extremities. The Nursing admission Assessment form dated 08/26/2022, documented R52 had contractures to all extremities. On 07/25/2023 at 12:20 PM, R52 was observed with left and right hand contractures, with no interventions in place such as a carrot splint (positioned the fingers away from the palm to protect…
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 before2023-07-27 · 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 1) ensure a peripherally inserted central catheter (PICC) dressing was changed per the physician's order or facility's policy for 1 of 4 residents (Resident 83) and 2) ensure a midline complication was reported to the charge nurse and physician for 1 of 4 sampled residents (Resident 144).The deficient practice had the potential for the resident to develop an infection and interrupted another resident's intravenous (IV) antibiotic therapy. Findings include: Resident 83 (R83) R83 was readmitted on [DATE] with diagnoses including sepsis. The physician's order dated 07/15/2023, documented a PICC line insertion for R83. The Vascular Insertion Documentation form documented R83's PICC line was inserted in the left upper arm on 07/15/2023. The physician's order dated 07/17/2023, documented IV central line dressing change every seven days in the morning. On 07/25/2023 at 2:14 PM, R83 was lying in bed, alert, and oriented. 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 · D2023-07-27 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) had documented evidence of competency skill sets for 1 of 6 sampled nursing staff members. The deficient practice had the potential to impact the safety of the residents. Findings include: A Facility Report dated 04/29/2023, documented an agency CNA completed an improper transfer for a resident. The resident was assessed to require two persons for transfer using a lift device. The CNA attempted to transfer the resident on their own using the lift device and in the process of transferring had to lower the resident to the floor. The CNA then left the resident and stepped out into the hallway to ask other staff members for assistance. On 07/26/2023 in the afternoon, the Administrator was asked about the record keeping for the trainings and competencies of agency staff. The Administrator indicated trainings and competencies were kept by the staffing agency. On 07/27/2023 at 8:52 AM, the Director of Nursing (DON) indicated training on transfers and transfers with…
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 before2023-07-27 · 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 observations, interviews, and document review, the facility failed to ensure (1) food items in the refrigerator were labeled and dated, personal food items were not placed in resident only refrigerators in the nourishment room and family dining room, and (2) resident food was covered prior to transport to individual units, and meal trays were covered to prevent cross contamination. The deficient practices had to the potential to place all residents at risk for a food-borne illness. 1) On 07/25/2023 at 7:58 AM, the refrigerator in main kitchen contained three food items on shelf in clear plastic bags which were not labeled or dated. On 07/25/2023 at 8:03 AM the Director of Food and Nutrition Services (DNS) indicated all items outside of the manufacturer's box should be labeled and dated and indicated the three bags did not contain a label or date and should be discarded. On 07/27/2023 at 9:25 AM, there was a styrofoam container with initials on it in the refrigerator on the first floor, unit one nourishment room. On 07/27/2023 at 9:27 AM, the DNS verbalized the refrigerator…
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.
- 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
No federal fines in the current CMS record.
Part of a chain
This home belongs to MARQUIS COMPANIES — 15 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 | 4.3 | -0.3 vs chain |
| Health inspection | 3 of 5 | 3.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 3.2 | +1.8 vs chain |
The other 14 homes this chain runs (chain average 4.3★, per CMS)
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 |
|---|---|---|---|---|
| MARQUIS COMPANIES I, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/10/2010 |
| FOGG, PHILLIP | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 08/16/2010 |
| ATWOOD, JACOB | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/06/2018 |
| FOGG, STEVEN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 08/16/2010 |
| SPRANDO, ERIN | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/10/2015 |
| TONE, STACI | Individual | W-2 MANAGING EMPLOYEE | — | since 08/16/2010 |
CMS files one row per role, so the 11 rows in the source record cover these 6 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.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $598K 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 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 295089. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, 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 →
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