Brookdale Lakeway SNF

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.

64.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 350 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 68.8% 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 64 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 98 beds and averages 43.8 residents a day — about 45% occupied, or roughly 54 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.62 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 2.82 hrs/resident/day on weekends vs 3.60 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.80 to 0.56 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2025-01-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a temperature range of 71' to 81' Fahrenheit for 38 (room numbers 2, 6, 8, 9, 11, 14, 16, 17, 23, 25, 28, 31, 32, 33, 46, 48, 49, 50, 51, 55, 64, 65, 66, 68, 72, 73, 74, 75, 78, 81, 84, 86, 87, 91, 94, 96, 97, 98) of 58 rooms on the 1st and 2nd floor reviewed for temperature of the environment, in that: The facility failed to ensure resident rooms had working heaters, working thermostats, and residents were warm. The facility failed to screen residents for signs and symptoms of hypothermia. For an unknown period of time: Rooms 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents did not have working heaters. room [ROOM NUMBER] occupied with a resident did not have a working thermostats. Rooms 2, 8, 9, 16, 23, 25, 31, 32, 49, 51, 55, 68, 74, 75, 84, 86, 87, 91, 94, 96, 97, 98 had…

  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 · J2024-09-01 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure each resident had the right to be free from abuse and neglect for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to ensure Resident #1 was free from abuse by his SO/AP when the facility neglected the interventions of Resident #1's care plan. The facility failed to follow the interventions in Resident #1's care plan, such as, keeping the Resident's door open during visits with SO/AP to keep the resident safe. This resulted in allegations that the SO/AP physically and verbally abused Resident #1. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/2024 at 1:30 PM. While the IJ was removed on 09/01/2024 at 01:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of 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
• Immediate jeopardy · J2024-09-01 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement their written policies and procedures to report, prohibit, and prevent abuse for one (Resident #1) of five residents reviewed for developing and implementing abuse and neglect policies, in that: The facility failed to implement abuse policies and procedures when they failed to protect Resident #1 from being abused by his SO/AP. The facility failed to report and investigate all suspected abuse and/or aggressive behaviors when staff reported observing SO/AP slap, hit, punch, grab, kick, yell, and shake Resident #1 and reported suspicious bruises, skin tears, and a burn on Resident #1's body and abdomen. By failing to implement these policies, the facility failed to identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/2024 at 1:30 PM. While the IJ…

  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 · F2025-08-21 · tag F0813 — widespread
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for CR 8 (CR #1, CR #2, CR #3, CR #4, CR #5, CR #6, CR #7, CR #8) of 8 CR reviewed for food and nutrition services. 1. The facility failed to have a system in place for reheating resident food items brought in from outside sources to ensure safe food handling and were not allowing residents to bring in food from outside sources.2. The facility failed to accurately document temperature recordings of nourishment station refrigerators. These failures could place residents at risk for foodborne illnesses.Findings included: Observation on 8/19/25 at 11:30 AM of 2nd floor nourishment station revealed no refrigerator present at station. Observation on 8/19/25 at 12:30 PM of 1st floor nourishment station on hall 3 revealed no refrigerator present at station. Observation on 8/19/25 at 1:00 PM of 1st floor nourishment station on hall 2 revealed 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-21 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 4 pureed diets of 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure [NAME] G refrained from adding an unmeasured amount of liquid to southwestern style chicken pureed during meal service on August 20, 2025.This failure could place all 4 residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.Findings included: Observation on August 20, 2025, at 4:27 PM, revealed [NAME] G took an unmeasured amount of liquid from a pitcher and added to the southwestern style chicken in the food processor and blended.Interview conducted with [NAME] G on August 20, 2025, at 4:31 PM, revealed she used broth to puree the southwestern style chicken. [NAME] G was asked how many servings of chicken she prepared. She stated four. When asked what amount of bread she used, she replied she was not sure, but stated she used enough so the product would stand on its own like…

  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 before2025-08-21 · 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

  Based on observations, interviews, and record reviews the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in the walk-in refrigerator, freezer and in the dry food pantry area on 8/19/2025, 8/20/2025, and 8/21/2025. 2. The facility failed to discard expired food items located in the walk-in refrigerator and in the dry food pantry area.3. The facility failed to ensure that dietary staff [NAME] G on 8/20/2025 at 3;35 PM, practiced appropriate hand hygiene and glove use when necessary, during food preparation activities, such as between handling raw fish and other foods, to prevent cross-contamination.These failures could place all residents who received meals from the kitchen at risk of foodborne illnesses. The findings included: Observation during the initial tour of the kitchen on 8/19/2025 beginning at 9:30 AM, the following was observed:Walk-in refrigerator:3 Packages of hamburger buns, not labeled or dated.20 1-pound…

  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 before2025-08-21 · 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 record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #42, Resident #20, and Resident #57) reviewed for infection control. 1. The facility failed to ensure CNA A was following prescribed Enhanced Barrier Precautions by not putting on a gown before providing peri-care to Resident #42. 2. The facility failed to ensure CNA B was cleansing male residents properly and conducting hand hygiene and glove change during peri-care for Resident #20. 3. The facility failed to ensure CNA D was conducting proper Foley catheter care for Resident #57. These failures could place the residents at risk of transmission of disease and infection.Findings included: Resident #42 Observation on 08/19/25 at 1:49 PM revealed Resident #42 had Enhanced Barrier Precaution…

  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 · D2024-10-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment and no more than 21 days after admission for two (Resident #1 and #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's and #2's comprehensive care plans were completed within seven days after completion of their comprehensive assessments. This deficient practice could place residents at risk of not receiving assistance with activities of daily living and sustaining a serious injury, impairment or death. Findings included: Resident #1 Review of Resident #1's face sheet, dated 10/07/24, reflected he was a [AGE] year-old male who was initially admitted to the facility on [DATE], readmitted on [DATE], and his own RP. Review of Resident #1's medical diagnoses, dated 10/07/24, reflected he had unspecified angina pectoris (A type of chest pain caused by reduced blood flow to the heart), unspecified hyperlipidemia (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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-31 · 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 interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2(Residents #14, and # 58) of 16 residents reviewed for care plans. The facility failed to ensure Resident #14's comprehensive care plan was updated when wound care was ordered to his left knee. The facility failed to ensure Resident # 58's comprehensive care plan was updated when the external feeding was discontinued. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The Findings included: Record review of Resident # 14's Quarterly MDS dated [DATE] revealed an [AGE] year old male admitted to the facility on [DATE] and 08/13/2020 with diagnoses that included Acquired Absence of Kidney (surgical removal of Kidney), Epilepsy ( a brain condition that causes recurring seizures due to abnormal electrical signals) Dementia…

  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 before2024-07-31 · 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

  Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: The facility failed to ensure foods were safely stored, labeled, and dated in the refrigerator. This failure could place residents at risk of foodborne illness. The findings include: Observation on 7/29/2024 at 9:13 am in the kitchen of the refrigerator revealed an unsealed Ziploc bag containing food items that resembled croutons. This item was labeled and dated but unsealed. Observation on 7/29/2024 at 9:15 am in the kitchen of the refrigerator revealed an unsealed Ziploc bag containing food items that resembled romaine lettuce. This item was labeled and dated but unsealed. Observation on 7/29/2024 at 9:16 am in the kitchen of the refrigerator revealed a large, unsealed, clear, plastic bag containing food that resembled uncooked bacon This food item was not labeled or dated. Interview on 7/31/2024 at 2:20pm with DC-F revealed they…

  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 · D2024-07-31 · 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 interview and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates the catheterization is necessary for 1 of 5 residents (Resident #22) reviewed for incontinent and catheter care. The facility failed to obtain physician orders for Resident #22's indwelling catheter, catheter care, and maintenance. This failure could place residents at risk of infection or accidental dislodgement. Findings included: Review of Resident #22's 5-day MDS assessment, dated 07/13/24, Section A (Identification Information) reflected an [AGE] year-old male originally admitted to the facility 04/18/24 and readmitted on [DATE]. Section I (Active Diagnoses) reflected his current diagnoses included cancer, iron deficiency anemia due to blood loss - chronic (lack of red blood cells in the blood), coronary artery disease (the blood vessels…

  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 · D2024-07-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #56 had a preexisting mental illness for which an antipsychotic medication (Seroquel) would be warranted. This failure could place residents at risk for unnecessary psychotropic drug use. Findings included: Review of Resident #56's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), urinary tract infection, hyperlipidemia (abnormally high level of fats in the blood), thyroid disorder, non-Alzheimer's dementia, anxiety disorder (intense 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-06-09 · tag F0755 — failed to provide safe pharmacy services — widespread
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 3 of 6 Residents (Resident #28, Resident #142 and #146) reviewed for medication administration in that: 1. Resident #142 was observed with 4 pills in a medication cup, an open box of over-the-counter allergy pills, a container of nasal spray and an open package with a lidocaine patch at the bedside. 2. Resident #146 was observed with a prescription box of Ondansetron (prescribed to prevent nausea/vomiting) and a prescription bottle of Trazadone (prescribed for treatment of depression and used as a sedative) at the bedside. 3. Resident #28's breathing treatments were documented as administered at 9:21 a.m. The order was to administer them at 7:00 a.m. These deficient practices could affect residents who received medication and place them 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.

  Pharmacy Service 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

$91,420 in federal fines across 2 penalties.

• $74,848 — penalty dated 2025-01-14
• $16,572 — penalty dated 2024-09-01

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 BROOKDALE SENIOR LIVING — 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 30 rows in the source record cover these 24 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 $616K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

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