Copperfield Healthcare and Rehabilitation

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.

57.5% 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 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 57.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 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 1.09 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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.

Staffing

How full it usually is: this home is certified for 124 beds and averages 111.0 residents a day — about 90% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.74 hrs/resident/day on weekends vs 3.44 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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.

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

• Immediate jeopardy · K2025-09-17 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate alternatives prior to installing a side or bed rail were used and if bed or side rails are used, the facility failed to ensure correct installation, use and maintenance of bed rails, including, but not limited to assessing the resident for risk of entrapment from bed rails prior to installation, reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation for 11 of 11 residents (Resident #8, #15, #22, #25, #44, # 60, #84, #90, #134, #145, and #149) reviewed for mobility bars/bedrails. 1. -The facility failed to assess Resident #84 for mobility bars, educate the resident RP on the risk and benefits of mobility bars, obtain a physician order and a consent for mobility bars. Resident #84 was observed in between the mobility and head of bed entrapped in her sheets and bedspread to her lower body torso (waist extending to lower legs). When…

  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
• Immediate jeopardy · Jdisputed · IDR2025-09-17 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 8 residents (CR #1) reviewed for notification of changes. The facility failed to notify CR #1's physician when the resident's family member reported slurred speech and altered mental status on 08/24/25. On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). After the stroke CR #1 suffered from a significant ADL decline that left him unable to walk An Immediate Jeopardy was identified on 09/10/25. The IJ template was provided to the facility 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jdisputed · IDR2025-09-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (CR #1) reviewed for quality of care. - The facility failed to act on 08/24/25 when CR #1's family member notified the nurse of slurred speech and altered mental status that indicated a stroke until 08/25/25. - On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). After the stroke CR #1 suffered from a significant ADL decline going from walking 150 feet with supervision to being unable to walk more than 3 steps with substantial/maximum assistance. An Immediate Jeopardy was identified on 09/10/25. The IJ template was provided to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-07 · 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 observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed resident rights. The facility failed to ensure CNA A treated Resident #1 with dignity and respect on [DATE] at 11:31 pm when discussing the need for incontinent care with the resident. This failure could place residents at risk for a diminished quality of life and a negative impact on the residents' psychosocial well-being. Findings included:Record review of Resident #1's face sheet revealed a 77- year- old man who was admitted to the facility on [DATE]. Admitting diagnoses were Parkinson's Disease (a progressive movement disorder of the nervous system), difficulty in walking, lack of coordination, muscle wasting and atrophy, and multiple myeloma without remission (type of blood…

  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 · E2025-09-17 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #12, Residents #80 and Resident #84) reviewed for comprehensive care plans. - The facility failed to care plan Resident #80's incontinence care due to a neurogenic bladder disorder.-The facility failed to care plan Resident #12 for an intravenous mid-line.-The facility failed to care plan Resident #84 for mobility bars on her bed.This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial…

  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 · E2025-09-17 · tag F0694 — pattern
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #12) residents reviewed for parenteral fluids.The facility failed to obtain a physician order to discontinue Resident #12's mid-line that had been inserted on 08/05/25. The resident completed her IV antibiotic therapy on 08/28/25. The facility did not obtain an order to discontinue resident mid-line until 09/10/25. This failure placed Resident #12 at risk for unwanted infections and further decrease in quality of life. Resident #12Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included chronic respiratory failure (difficulty breathing), type 2 diabetes mellitus (when the body has trouble controlling blood sugar 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-17 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents (Residents #2 and Resident #109) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2 safely by administering it more than 15 -minutes before meals on 25 occasions from 08/01/25 to 09/11/2025. - The facility failed to ensure nursing staff administered medication to Resident #109 as ordered when LVN K applied a Lidocaine patch to the resident's right knee without an order. These failures could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars), worsening of diabetes, medication errors and adverse reactions to medications. Findings include: Resident #2 Record review of the facility dining room meal teams revealed, Breakfast 07:45 AM to 08:15 AM, Lunch 11:45 AM to 12:15 PM, and Supper: 05:00…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-17 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 8 residents (Resident #25, Resident #38 and Resident #104) reviewed for environmental concerns. - The facility failed to ensure Resident #38's room door did not have a lock that required a key which resulted in the resident, who was bed bound with her ankle fixed with screws, being locked in the room and inaccessible for 15-20 minutes.- The facility failed to ensure Resident #25's dresser drawers did not swing open on their own, leaving the resident concerned that her head would be hit by the drawer.- The facility failed to ensure Resident #25 and Resident #104's bathroom door did not swing shut on its own.These failures could place residents at risk of falls, injuries, and decreased quality of life. Findings include: Resident #38 Record review of Resident #38's face sheet, dated 09/14/25, revealed a [AGE] year-old female who 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-17 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal privacy when providing personal care for 2 (Resident #12, Resident #150) of 7 residents observed for personal care. -CNA AR failed to provide privacy for Resident #150 during incontinent care. -LVN M failed to provide privacy for Resident #12 during tracheostomy care. This failure placed residents at risk for their loss of dignity, respect, and psychological distress. Findings included: Resident #150 Record review of Resident #150's face sheet, dated 09/16/25, revealed an [AGE] year-old female admitted on [DATE]. Resident #150's diagnoses included hypothyroidism, type 2 diabetes mellitus, protein-calorie malnutrition, hypertension (elevated blood pressure), pressure ulcer of left heel, chronic kidney disease, and gastrostomy (surgical procedure that creates an opening in the stomach to allow for feeding and medication administration into the stomach). Record review of Resident #150's MDS dated [DATE] coded 99 reflected 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 · Dcited before2025-09-17 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  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 MDS data was transmitted within 14 days of completion for 1 of 5 closed record reviews (CR #62), in that: -CR #62's MDS discharge assessment was not completed and submitted to CMS.This failure could place the resident at risk for receiving unnecessary services or inadequate care.Findings included:Record review of CR #62's face sheet, dated 09/17/2025, revealed a [AGE] year-old female admitted on [DATE] and discharged [DATE]. Her diagnoses included: pneumonia, ulcerative colitis (a chronic inflammatory bowel disease that affects the large intestine), moderate protein-calorie malnutrition, legal blindness, congestive heart failure, and muscle weakness.Record review of CR #62's most recent MDS, dated [DATE], was an admission MDS. Record review of CR #62's EMR on 09/17/2025 revealed the history and status of all of the residents' MDS assessments completed and submitted. A discharge MDS assessment was not completed or accepted for her 05/09/2025…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-17 · 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 observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #11) reviewed for accidents and supervision. The facility failed to ensure a disinfectant Sani-wipes container was not placed at the bedside of Resident #11. This failure could place residents at risk for unwanted injuries and a decreased quality of life. Findings include:Record review of Resident #11's face sheet, dated 09/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included the following: cerebral infarction (interruption of blood flow in the brain), aphasia (difficulty in communicating), type 2 diabetes mellitus (when the body is unable to utilize blood sugar for energy in the body), and malignant neoplasm (cancer). Record review of Resident #11 quarterly MDS, dated [DATE], reflected a BIMS score of 2, which indicated the resident cognition 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure 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 and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #72) reviewed for enteral feeding.The facility failed to ensure Resident #72's enteral feeding was turned off during bowel rest between 9AM and 11AM on 9/10/2025 . This failure could place residents at risk of health complications such as aspiration pneumonia or gastrointestinal injury. Record review of Resident #72's face sheet, captured 09/11/2025, reflected an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. Resident #72 had diagnoses which included paralysis following stroke affecting left non-dominant side, type 2 diabetes mellitus (high blood sugar),…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  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 and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 7 residents (Resident #12) reviewed for tracheostomy care. The facility failed to ensure -LVN M did not turn Resident #12's oxygen off for 2 minutes when providing resident tracheostomy (surgical opening that creates an opening in the trachea [(windpipe]) to allow air to enter and exit the lungs) care. This failure could place residents at risk for respiratory distress and hypoxia (deficiency of oxygen). Findings include: Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included : chronic 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.

  Quality of Life and Care 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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$23,029 in federal fines across 1 penalty.

• $23,029 — penalty dated 2025-09-17

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 THE ENSIGN GROUP — 342 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 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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.

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