Bethany Home - Brandon

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.

39.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 68.1% 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 94 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% 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 60 beds and averages 55.1 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.53 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 4.02 hrs/resident/day on weekends vs 4.92 on weekdays — 18% thinner on weekends. RN hours go from 0.83 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-11-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to: *Ensure that staff were able to verify the chemical sanitation level required to clean the main kitchen surfaces used for the preparation of residents' food. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the main kitchen. *Maintain the dishwasher sanitation rinse cycle temperature at a minimum of 180 degrees Fahrenheit per the manufacturer's manual for two of four kitchenette dishwashers. Failure to ensure that increased the potential risk of foodborne illnesses for 27 of 27 residents (1, 3, 14, 17, 18, 21, 23, 24, 25, 26, 27, 31, 34, 35, 36, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, and 52) who received meals on dishware cleaned in those two kitchenettes. Findings include: 1. Observation and interview on 11/5/24 at 11:41 a.m. during the initial tour of the main kitchen revealed: *There was a metal cart with visibly soiled…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-05-28 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure residents were free of significant medication errors for one of one sampled resident (3) who received 2.5 milliliters (mL) of Morphine Sulfate (narcotic) by mouth instead of the ordered dose of 0.25 mL from a certified nursing assistant (CNA)/medication aide (MA) E and experienced decreased oxygen levels, lethargy (abnormal drowsiness or sluggishness that involves low energy, decreased alertness, reduced mental and physical activity), respiratory distress (trouble breathing), and required the use of Narcan (a medication that reverses the effects of opioids).Findings include:1. Review of the provider's 5/15/26 SD DOH FRI revealed that resident 3 had a physician's order for 0.25 mL of Morphine Sulfate, 100 milligrams (mg)/5 (mL), to be administered orally as needed for pain or shortness of breath (SOB).On 5/14/26 at 8:45 p.m., resident 3 was administered 2.5 mL of morphine from CNA/MA E, which was the incorrect dose. This…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-10-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure certified nursing assistant (CNA) L had used the whirlpool bath chair safety belt according to the provider's policy during resident 6's bath, CNA K had used the whirlpool bath chair safety belt according to the provider's policy during resident 7's bath, and CNA M had followed resident 4's care plan regarding safe transfers with the mechanical lift equipment. Resident 6 fell out of the bath chair and sustained a pelvic fracture. Resident 7 fell out of the bath chair and sustained multiple fractures to her lower spine, pelvis, and tibia. Resident 4 was transferred using the wrong mechanical lift equipment according to her care plan, and sustained leg bruising and a tibia fracture. Residents 4, 6, and 7 were hospitalized related to their injuries. This citation is considered past noncompliance based on review of the corrective…

  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 · Gcited before2025-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (3) who fell out of her wheelchair and received a laceration to the left side of her forehead that required sutures. The fall was related to assistive devices (wheelchair pedals) not being in place to prevent an accident. Findings include: 1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 3 revealed: *On 3/15/25 at 8:30 a.m. certified nursing assistant (CNA) Q yelled out while in resident 3's room. *CNA D responded and went to assist resident 3 in her room and alerted licensed practical nurse (LPN) R that resident 3 was on the floor. *LPN R entered the room and found resident 3 lying on the floor on her left side and bleeding from the left side of her forehead from an approximately ½ inch laceration with immediate swelling/bruising to forehead with bleeding unable to be controlled with pressure at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-28 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure resident privacy and dignity during the administration of personal care treatments for two of two sampled residents (1 and 4) who were administered vaginal cream in the dining room by registered nurse (RN) L where other residents and staff were present. Findings include1. Review of the provider's 2/4/26 SD DOH FRI revealed that residents (1 and 4) had an order for medicated vaginal cream. Certified nursing aide/medication aide (CNA/MA) J reported that she witnessed RN L prepare and instill cream in the dining room for residents (1 and 4). 2. Review of resident 1's EMR revealed a physician's order for 1 gram (gm) Conjugated Estrogen Cream 0.625 mg/gm, to be inserted vaginally at bedtime every Monday, Wednesday, and Friday for urinary incontinence (unintentional passing of urine). Resident 1's 5/7/26 Brief Interview for Mental Status (BIMS) assessment…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-28 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report incidents to law enforcement and the ombudsman for two of two sampled residents (1 and 4) when they were administered vaginal medication in the dining room by one of one registered nurse (RN) (L). The facility failed to report to the resident's representative, primary care provider (PCP), law enforcement, and the ombudsman for one of one sampled resident (2) who was verbally abused by one of one certified nursing assistant (CNA) (M) when she provided resident 2 personal care. The facility also failed to report resident 2's incident within a timely manner to the SD DOH. 1. Review of the provider's 2/4/26 SD DOH FRI revealed that residents 1 and 4 had a physician's order for medicated vaginal cream. On 2/4/26 around 7:00 p.m. CNA/medication aide (MA) J reported that she witnessed RN L prepare and administer the vaginal cream to residents 1 and 4 in 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-28 · 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

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety for one of one sampled resident (3) who fell onto the floor and hit his face while being pushed in his wheelchair by certified nursing assistant (CNA) (C), who did not attach and use the wheelchair foot pedals as required when transferring resident 3 to the dining room.Findings include: 1. Review of the provider's 3/3/26 SD DOH FRI revealed that on 3/3/26, resident 3 was being pushed in his wheelchair by CNA C to the dining room with no wheelchair foot pedals attached. Resident 3 put his feet down and fell forward onto the floor, hitting his face. Resident 3 was upset after the incident. He had a raised egg-shaped lump to the center of his forehead and open skin abrasions to the bridge of his nose. There was a small skin tear noted on his right hand between his thumb and pointer finger. The area was cleansed; skin was put back over, and a steri-strip bandage was applied. Neurological evaluations…

  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 · E2025-12-18 · 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 — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to involve five of thirty (4, 9, 19, 44, and 59) sampled residents' primary care provider (PCP) in the development of the resident's advanced directives according to facility policy, failed to update one of five (44) sampled resident's electronic medical record (EMR) after the resident's code status had changed, failed to include one of five (59) sampled resident's code status on their care plan according to facility policy, and failed to make the resident's updated code status form available to direct care staff in the resident's EMR, which created potential confusion for staff when the most updated form was not available.Findings include:1. Review of resident 4's EMR revealed his code status was Do Not Resuscitate (DNR) on the top dashboard. His current care plan indicated his code status was DNR. There was no scanned document of his signed code status form in the Miscellaneous section, where scanned documents were stored. There was no…

  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 before2025-12-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to protect three of three sampled residents (16, 37, and 50) and one of one closed sampled resident (101) from alleged verbal abuse and neglect. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include: 1. Review of the provider's 9/12/25 submitted to SD DOH FRI final report revealed:*On 9/11/25 at 9:28 a.m., director of nursing (DON) B received a text message from certified nurse aide/certified medication aide (CNA/CMA) Y about CNA/CMA N's interactions with residents in the Maple Valley neighborhood (residential living unit). That neighborhood was a memory care unit (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, which is secured to minimize unsafe wandering). In her text message, CNA/CMA Y indicated…

  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 · Past Non-Compliance
• Potential for harm · E2025-12-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide 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 policy review, the provider failed to follow their policy and provide the necessary respiratory care and services for four of four sampled residents (4, 8, 10, and 49), resulting in inadequate storage, humidification, and replacement of those devices.Findings include:1. Observation and interview on 12/16/25 at 10:45 a.m. with resident 49 in her room revealed:*She was sitting in her recliner chair.*She had an oxygen concentrator machine (a machine that filters room air into pure oxygen and then delivers it through a tube with prongs that fit in the nostrils or a mask) next to the foot of her bed.*She had oxygen nasal cannula tubing (tubing that delivers oxygen through the nose) stored on top of the concentrator.-The tubing was not dated, and there was no storage bag or other container to hold the tubing when it was not in use.*A nebulizer machine (a medical device that turns liquid medicine into a mist that is then inhaled into the lungs through a mask or…

  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 before2025-12-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to:*Maintain food safety requirements related to one of one Maple Valley neighborhood pantry room, and one of one Maple Valley kitchenette. *Maintain clean and sanitary conditions for three of three foodservice handwashing sinks in the [NAME] Creek neighborhood.*Implement interventions to supervise and monitor resident refrigerator temperatures to identify any hazards of foodborne illness for two of two observed residents (17 and 24).Findings include:1. Observation on 12/16/25 at 9:47 a.m. of the Maple Valley neighborhood food service pantry revealed:*A wheeled cart was inside that room. Clean drinking cups, coffee mugs, silverware wrapped in napkins, a water pitcher, and a plate guard sat on a towel on top of that cart. One end of the cart had openings for pushing the cart. There were multiple, dried white-colored runs down the inside lip of that end of the cart near the edge of the towel and by the clean kitchenware. The clean kitchenware…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-18 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to:*Ensure staff members followed proper storage and cleaning procedures for both clean and dirty utility rooms in two of the four facility neighborhoods ([NAME] Creek and [NAME] Wood) to prevent the spread of infection.*Discard products found in one of four resident neighborhoods, such as hand sanitizer and germicidal (germ-killing) wipes, on or before the expiration date which had the potential to affect all people in the facility.Findings include:1. Observation on [DATE] at 2:03 p.m. in the common area outside the beauty/barber shop revealed an automatic hand sanitizer dispenser on the wall. The hand sanitizer had expired on [DATE]. 2. Observation on [DATE] between 2:16 p.m. and 2:24 p.m. in the soiled utility room of the [NAME] Creek neighborhood revealed: *A four-product disinfectant dispensing system that was mounted inside the door on the left wall with black and white discharge tubes and hoses connected to dispense the chemicals. *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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-18 · tag F0554 — isolated
  Allow 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 policy review, the provider failed to ensure one of one sampled resident (19), who had a medication pill at his bedside, was assessed for the ability to safely self-administer medications and had a physician's order to self-administer medications according to the provider's policy.Findings include:1. Observation and interview on 12/16/25 at 4:12 p.m. with resident 19 in his room revealed there was a small white oval pill in a plastic medication cup sitting on his bedside table. The pill had 0164 stamped on one side, and the letter R stamped above the number 5 on the other side. Resident 19 said that if he is sleeping, staff would leave his pills on his bedside table so he could take them later. He swallowed the medication at that time with a drink of water.2. Review of resident 19's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. He did not have a physician's order to self-administer any medications. There was no 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and policy review, the provider failed to maintain resident rooms in a clean and well-kept manner, free from damage to walls, for two of two sampled residents (10 and 17) in one of four facility neighborhoods (Cottonwood Court).Findings include:1. Observation on 12/16/25 at 10:16 a.m. in resident 10's room and interview on 12/17/25 at 11:50 a.m. with resident 10 in a resident common area between the neighborhoods revealed:*There were at least three gouges with chipped paint, which were approximately quarter-size, and a gouge with exposed drywall about half-dollar size, in the left wall, between two to three feet above the floor, just inside the resident's door. Additionally, there were vertical scratch marks with chipped paint along the entire length of the left wall. *There were at least three gouges with chipped paint that ranged from one to four inches in size, and vertical scratch marks with chipped paint on the wall to the right, just outside of his bathroom. Additionally, there were vertical scratch marks with chipped paint on the bathroom door…

  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

“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

$51,350 in federal fines across 3 penalties.

• $17,345 — penalty dated 2025-10-21
• $9,620 — penalty dated 2025-05-29
• $24,385 — penalty dated 2024-11-08

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.

Who owns this facility

CMS files one row per role, so the 28 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD