Windsor Hills Nursing Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 112 beds and averages 51.4 residents a day — about 46% occupied, or roughly 61 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.12 hrs/resident/day on weekends vs 3.91 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are 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.

28 citations, most serious first. The 13 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · J2025-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  On 05/09/25 at 10:15 a.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for safe smoking and the use of electronic vaping devices. Resident #1 was a known vape device user, in their room with continuous oxygen use. Resident #1 did not have a care plan that addressed the vape device, and the use of the device in their room. Staff confirmed the knowledge of the use of the vaping devices in the room and they charged them. On 05/02/25, Resident #1 while in their room with oxygen on lit a cigarette causing flash burns to his face. Based on observation, record review, and interview, the facility failed to have a system in place to ensure residents were supervised and monitored for safe smoking and the use of electronic vaping devices for 1 (#1) of 4 sampled residents reviewed for smoking and electronic vaping use. Resident #1 lit a cigarette in their room, while oxygen was in use, causing a flash burn to their nostrils and left cheek. The DON identified 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2025-09-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview, the facility failed to ensure a resident was not touched sexually by another resident for 1 (#3) of 3 sampled residents reviewed for abuse. The facility's failure to prevent this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm.The administrator identified 54 residents resided in the facility. On 09/08/25 at 10:43 a.m., Resident #3 was observed lying in bed, with the bed in the low position, with fall mat in place. Their room was clutter free and the trash can was empty. Resident #3's room was next to the nurse's station on hall 300. Resident #3 was unable to appropriately respond to surveyor.On 09/09/25 at 1:08 p.m., Resident #27 was in attendance during resident council.On 09/09/25 at 2:00 p.m., Resident #27 was observed playing bingo in the dining room.On 09/10/25 at 10:25 a.m., LPN #2 and CNA #3 were observed coming out of Resident #3's room. Resident #3 was observed in bed repeating well, well, well, okay, okay, okay. The fall mat was observed in place next to bed. The bed…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-09-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide 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 record review and interview, the facility failed to ensure a physician's order for monthly catheter changes was followed and failed to ensure a resident with a indwelling urinary catheter received services to help prevent urinary tract infections for one (#35) of two sampled residents reviewed for catheters. The deficient practice resulted in a bladder stone. The MDS Resident Matrix, dated 09/23/24, identified four residents with catheters. Findings: A Clinical Supplies in Case of Emergency policy, reviewed 09/17/24, read in part, It is the policy of this facility to establish procedures to ensure that needed clinical supplies are available to maintain continuity of care in the case of emergency. It also read, Par levels of various supplies will be set, base on use, and procedures for reordering will be followed accordingly to ensure availability of supplies on an ongoing basis. Res #35 had diagnoses which included acute kidney failure and retention of urine. The admission assessment, dated 04/29/24,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-11 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to have a designated and trained infection preventionist to oversee the infection control program. The administrator identified 55 residents resided in the facility. Findings: The facility policy title Infection Preventionist, last reviewed 01/18/25, read in part, The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention control program.An undated Windsor Hills Nursing Center key staff list, provided by at the time of entrance conference, did not identify any staff members as an infection preventionist. On 09/08/25 at 10:25 a.m., during the entrance conference the DON and business office manager were asked to identify who the facility infection preventionist was. The DON stated they had been without an infection preventionist since the previous DON resigned. The DON stated they oversee the wounds in the facility and was not trained and certified to be an infection preventionist. On 09/09/25 at 10:12 a.m., the administrator was asked who the designated…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-11 · tag F0569 — pattern
  Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure residents accounts within $200 of the $2,000 resource received notices of the balances for 4 (#3, 12, 34, and #23) of 5 sampled residents reviewed for balances in the and trust accounts. This had the potential for Residents (#3, 12, 34, and #23 to lose their Medicaid eligibility. The facility identified 23 residents with Medicaid as a payor source and had the facility manage their funds. Findings: An undated facility policy Resident Personal Funds, read in part, Notices of Certain Balances. The facility must notify each resident that receives Benefits: when the amount in the resident's account reaches $200 less than the SSI resource limit for one person.and if the amount in the account in addition to the value of the resident's nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid and SSI. 1. An undated face sheet for Resident #3 showed they had a payor source of Medicaid. A trust account ledger balance for Resident #3, dated 09/09/25, showed they 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview the facility failed to develop a care plan for the provision range of motion services for 1 (#6) of 1 sampled resident reviewed for range of motion.The administrator identified eight residents with range of motion deficits. Findings: On 09/08/25 at 12:45 p.m., Resident #6 was observed in their room with his right hand slightly contracted and unable to move his right side. An undated facility policy titled Prevention of Decline in Range of Motion, read in part, Appropriate care planning . Based on the Comprehensive assessment, the facility will provide interventions, exercise and/or therapy to maintain or improve range of motion. An undated admission Record for Resident #6 showed they had diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. An annual assessment for Resident #6, dated 06/19/25, showed they were severely cognitively impaired with a BIMS score of five. The assessment showed Resident #6 had upper and lower range of motion deficits. A care plan for Resident #6, last…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview, the facility failed to implement infection control practices a. for the care of oxygen tubing for 2 (#9 and #36) of 2 sampled residents reviewed for respiratory care, and b. for utilizing EBP during the provision of wound care for 2 (#8 and #12) of 2 sampled residents reviewed for wound care.The administrator identified 14 residents who had orders for oxygen and 18 residents that required the use of EBP. Findings: An undated facility policy Enhanced Barrier Precautions, read in part, It is the policy of this facility to implement enhanced barrier precautions of transmission of multi-drug-resistant organisms.An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds. 1. On 09/08/25 at 2:28 p.m., Resident #12's room was observed. A sign located on the door showed Resident #12 was on EBP. On 09/10/25 at 10:02 a.m., LPN #1 was observed performing Resident #12's wound treatment. LPN #1 gathered supplies, set up a barrier on the bedside table, washed their hands and donned a pair of gloves.…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-11 · tag F0919 — failed to provide a working call system — pattern
  Make 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

  Based on observation, record review, and interview, the facility failed to ensure call lights were within reach for 2 (#10 and #19) of 23 sampled residents reviewed for call light accessibility.The administrator identified 55 residents resided in the facility.Findings:A Call Lights: Accessibility and Timely Response policy, copyright date 2024, read in part, Staff will ensure the call light is within reach of each resident and secured, as needed. 1. On 09/08/25 at 10:24 a.m., Resident #19s call light button was observed on the floor. An annual assessment, dated 08/05/25, showed Resident #19 had a BIMS of 15, indicating no cognitive impairment. The assessment showed Resident #19 was dependent on staff for dressing, toileting, bathing, transferring, and bed mobility. On 09/08/25 at 10:28 a.m., LPN #2 stated I don't know how the call light got in the floor (for Resident #19), it should not be, it is supposed to be in the resident's reach at all times. 2.On 09/08/25 at 10:48 a.m., Resident #10's call light was observed at the foot of the bed, out of reach of resident. A quarterly…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility failed to ensure care plans were updated to reflect the current status of medications for 1 (#53) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 35 residents received psychoactive medications. Findings: An undated admission record for Resident #53 showed they had diagnoses which included respiratory disorders in disease classified elsewhere, chronic pain, constipation, sleep apnea, ventricular fibrillation, atrial fibrillation, insomnia, anxiety, adjustment disorder with mixed anxiety, and depression. Resident #53's orders for Buspirone (an anti-anxiety medication) showed the medication was discontinued on 07/13/25. Resident #53's orders for trazadone (an antidepressant) showed the medication was discontinued on 07/13/25. A care plan for Resident #53, last updated 07/23/25, showed the resident was currently taking Trazadone and Buspirone. On 09/09/25 at 2:28 p.m., MDS coordinator #1, stated they were responsible for updating care plans for the residents. They stated Resident #53's Trazadone…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide 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

  Based on observation, record review, and interview the facility failed to provide range of motion services for 1 (#6) of 1 sampled resident reviewed for range of motion services. The administrator identified eight residents with range of motion deficits. Findings: On 09/08/25 at 12:45 p.m., Resident #6 was observed in their room with his right hand slightly contracted and unable to move his right side. An undated facility policy titled Prevention of Decline in Range of Motion, read in part, Appropriate care planning . Based on the Comprehensive assessment, the facility will provide interventions, exercise and/or therapy to maintain or improve range of motion. An undated admission Record for Resident #6 showed they had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. An annual assessment for Resident #6, dated 06/19/25, showed they were severely cognitively impaired with a BIMS score of five. The assessment showed Resident #6 had upper and lower range of motion deficits. A care plan for Resident #6, last reviewed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-09 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview the facility failed to ensure care plans were developed and revised for smoking and the use of electronic vaping devices for 1 (#1) of 4 sampled residents reviewed for smoking and electronic vaping use. The DON identified one resident who vaped, three unsupervised smokers and nine supervised smokers. Findings: On 05/06/25 at 10:20 a.m., Resident #1's room was observed with a cup filled with brown liquid substance from chewing tobacco on the sink counter. Next to the bed was a plastic container on the over bed table that contained four various colored vaping devices. An oxygen concentrator was observed against the wall. A policy, Resident Smoking, revised 01/08/25, read in part, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking.Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include but are…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-27 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to ensure the advance directive acknowledgement forms were completed for two (#7 and #23) of three sampled residents reviewed for advance directives. The Administrator identified 58 residents resided in the facility. Findings: Resident #7 admitted to the facility 04/11/23. There was no advance directive form found in their electronic health record or their admission packet designating the decision by the resident or the resident's representative. Resident #23 admitted to the facility 05/06/23. There was no advance directive form found in their electronic health record or their admission packet designating the decision by the resident or the resident's representative. On 09/24/24 at 12:56 p.m., social services stated there was no advanced directive found in the admission packet or electronic health record with the decision of the resident or resident representative about advance directives for resident #7 and resident #23.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-27 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure an accurate comprehensive care plan was developed and implemented for three (#7, #23, and #53) of 24 sampled residents who were reviewed for accurate comprehensive care plans. The Administrator identified 58 residents resided in the facility. Findings: Resident #7 admitted to the facility 04/11/23. They had a diagnosis of vascular dementia with behavioral disturbances, but there was no care plan to address their needs. Resident #23 admitted to the facility 05/06/23. They had an illeostomy, but there was no care plan to address their needs. Resident #53 admitted to the facility 05/10/24. The resident was dependent on staff to provide incontinent care, but the care plan documented, .daily care .toileting .I need staff assistance to use the bathroom .including help transferring on/off toilet . On 09/27/24 at 1:45 p.m., CNA #6 stated they do not toilet (resident #53) on the commode, they can not put on or take off their shoes or pants, and has not changed since they were hired. On 09/27/24 at 1:55 p.m., RN #2 stated…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$29,472 in federal fines across 2 penalties.

• $13,323 — penalty dated 2025-09-11
• $16,149 — penalty dated 2025-05-09

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 SKYBLUE HEALTHCARE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 22 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 81% 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. 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 OK