Hearthstone Nursing 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.

48.4% 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 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 120 beds and averages 93.8 residents a day — about 78% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.53 hrs/resident/day on weekends vs 3.08 on weekdays — 18% thinner on weekends. RN hours go from 0.46 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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.

24 citations, most serious first. The 14 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2023-12-02 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of three residents reviewed for notification of changes, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who…

  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 · Past Non-Compliance
• Immediate jeopardy · Kcited before2023-12-02 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect. The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2023-12-02 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization.…

  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 before2024-12-19 · 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 interview and record review, the facility failed to protect one resident (Resident #1) out of seven residents reviewed for abuse and neglect in that: CNA A slapped Resident #1 on his head in the front lobby in the presence of the facility's Receptionist and the Van Driver from another facility. This noncompliance was identified as PNC. The deficient practice occurred on 11/30/2024 and in-service was completed on 12/03/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old male that was admitted to the facility on [DATE] with re-admission date of 10/27/2024 with diagnoses including Cerebral infarction, Hemiplegia and hemiparesis following cerebral infraction, acute respiratory failure with hypercapnia, bipolar disorder, Review of Resident #1's quarterly care plan assessment, dated 11/29/24, reflected a BIMS score…

  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 · E2026-04-03 · tag F0641 — pattern
  Ensure each resident receives an accurate 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, observation and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #22, Resident #34, and Resident #61) reviewed for accuracy of assessments. The facility failed to ensure Resident #22's annual MDS, dated [DATE], accurately reflected her smoking status.The facility failed to ensure Resident #34's admission MDS, dated [DATE], accurately reflected her smoking status.The facility failed to ensure Resident #61's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.Findings included: 1. Record review of Resident #22's face sheet, dated 04/02/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), dementia (memory,…

  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 · E2026-04-03 · 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 observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure the food Processor used for puree' was sanitized prior to use on 04/01/2026.2. The facility failed to ensure CK H used proper hand hygiene when preparing puree' foods on 04/01/2026.3. The facility failed to ensure CK H hair restraint was on properly and covered her hair completely to prevent hair from contacting food. These deficient practices could place residents at risk for food borne illness. Observation of CK H preparing puree food on 04/01/26 at 10:45 a.m., revealed CK H did not wash her hands before starting the puree process for the chicken. CK H did not wash or sanitize the preparation counter, and she did not wash or sanitize the puree machine prior to putting the chicken in the machine. Observation of CK H distributing food to trays on 04/01/26 at 12:45 p.m., revealed CK H's hair restraint was not…

  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 before2026-04-03 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 19 of 103 residents reviewed for infection control: The facility failed to ensure staff used proper hand sanitation while serving meals to the residents. These deficient practices could place residents at risk for food borne illness. The Findings included:Observation of DM distributing drinks on 04/01/26 at 12:16 p.m., revealed DM did not use proper hand hygiene between serving drinks to residents.Observation on 04/01/26 at 12:25 p.m., revealed MDSN, CNA B and CNA C did not use hand sanitizer between serving trays to residents.During an interview on 04/01/26 at 12:26 p.m., it was revealed that CNA B said she had been trained on hand hygiene. She stated she did not know why she had not used hand sanitizer after serving each resident.During an interview on 04/01/26 at 12:28 p.m., it was revealed that CNA C had been…

  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 · D2026-04-03 · tag F0925 — failed to control pests — isolated
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 2residents (Resident #23 and ) reviewed for environmental concerns. The facility failed to ensure Resident #23's room was roach-free. This failure could place residents at risk of pests in their rooms that spread bacteria. Findings Include: A review of Resident #23's records reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Annual MDS Assessment, dated 12/19/25, her BIM was 15, and she was cognitively intact. The resident has a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #23 was dependent on staff for Activities of daily living. Review of Resident #23's Care Plans reflected:Revised 12/31/25 - Resident had an activity of daily living deficit.Facility interventions: maximal assistance of one staff…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-14 · 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 review and revise the person-centered care plan to reflect the current condition for 1 of 6 residents (Resident #1) reviewed for care plan revisions.The facility failed to update Resident #1's care plan to reflect ongoing aggressive behaviors toward staff and interventions to meet her physical, psychosocial, and functional needs.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings included:Record review of Resident #1's face sheet dated 1/14/2026, revealed 75-years-old female was admitted on [DATE] with diagnoses of unspecified dementia, severe, without behavioral disturbance (describes a late-stage cognitive decline where memory, thinking, and daily function are significantly impaired, but without associated agitation, aggression, or psychosis), type 2 Diabetes Mellitus (a chronic condition where the body either doesn't use insulin effectively (insulin resistance) or can't produce…

  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 · D2025-11-19 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6(Resident #1) residents reviewed for PASARR. The facility failed to ensure that Resident #1 was referred for a level II PASARR after an evident diagnosis of Major Depressive Disorder diagnosed on [DATE]. These failures could place residents at risk for decline and the inability to receive services. Findings Included:RR of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet revealed that Resident #1 had a diagnosis of Major Depressive Disorder as of 10/06/2025. RR of Resident #1's MDS record dated 10/02/2025 revealed that Resident #1 had a psychological diagnosis of depression. RR of Resident #1's undated care plan revealed that Resident #1's…

  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 · D2025-11-19 · tag F0646 — isolated
  Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
  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 notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 6 (Resident #2) residents reviewed for PASARR. The facility failed to ensure that Resident #2 was referred to PASARR services after a positive level II PASARR screening. These failures could place residents at risk for not receiving services intended for the residents mental, intellectual or developmental disabilityFindings Included: RR of Resident #2's undated face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE]. The face sheet revealed that Resident #2 had a diagnosis of Major Depressive Disorder as of 03/14/2013. RR of Resident #2's MDS record dated 09/01/2025 revealed that Resident #2 had a psychological diagnosis of depression. Resident #2 had a BIMS…

  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 · D2025-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
  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, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #10) reviewed for care plans. The facility failed to include Resident #10 was receiving hospice services in the comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #10's face sheet dated 01/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: diabetes (a group of diseases that result in too much sugar in the blood), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), dementia (a general name for a decline in cognitive abilities that…

  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 · Dcited before2025-01-30 · tag F0880 — failed to prevent and control infections — isolated
  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 observations, interviews, 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 transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records. The facility failed to ensure LVN C documented any follow-up observations or assessments of Resident #2 after she initiated treatments for his uncontrolled coughing. This failure could result in errors in care and treatment. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), disturbances of salivary secretion, and unspecified dementia. Review of Resident #2's quarterly MDS assessment, dated 11/25/24, reflected a BIMS score of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not receive tracheostomy care. Review of Resident #2's quarterly care plan, dated 09/27/24, reflected he had a…

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

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

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

Fines & penalties

$25,626 in federal fines across 2 penalties.

• $10,033 — penalty dated 2024-12-19
• $15,593 — penalty dated 2023-12-02

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 CARADAY HEALTHCARE — 8 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 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

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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