Mission at Alpine Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 52 beds and averages 37.2 residents a day — about 72% occupied, or roughly 15 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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.77 hrs/resident/day on weekends vs 3.28 on weekdays — 16% thinner on weekends. RN hours go from 0.66 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above 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.

44 citations, most serious first. The 18 most serious are shown; the remaining 26 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-08-20 · 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 observation, interview and record review the facility did not ensure, 9 of 32 sampled residents, were free from abuse and neglect. Specifically, multiple residents with cognitive impairment were identified to have sexual contact and were not assessed for capacity to consent to a sexual relationship. In addition, 2 residents eloped from the facility and were returned to the facility without the staff's knowledge. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 21, 25, 27, 31, 33, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of…

  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 · K2025-08-20 · tag F0607 — failed to have anti-abuse policies — pattern
  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 observation, interview and record review it was determined, for 7 of 32 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse, neglect, and investigate and report allegations. Specifically, the facility did not have written policies and procedures that defined sexual abuse, how to evaluate a resident's capacity to consent to a sexual relationship and elopements. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 27, 33, 31, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to implement policies and procedures to prevent various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following…

  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 · K2025-08-20 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, for 10 of 32 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, the State Survey Agency was not notified of sexual relations between cognitively impaired residents, multiple resident elopements, injuries of unknown origin with some resulting in fractures, and a resident not secured in transportation vehicle. Resident identifiers: 2, 7, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to report various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief…

  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 · K2025-08-20 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 9 out of 32 sampled residents, allegations of sexual abuse, elopements, injuries of unknown origins and fractures were not investigated or the allegations were not investigated thoroughly. Resident identifiers: 2, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to investigate various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/8/25 at 4:46 PM, the Administrator provided the following abatement plan for the removal of the Abuse IJ effective on 8/8/25 at 11:59 PM. The community would add sexual abuse…

  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 · Kcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 6 out of 32 sampled residents, three residents with cognitive impairment eloped from the facility, this was at an immediate jeopardy level for two of these residents. A resident was not secured in a facility van and suffered a head injury, this was at a harm level. Two residents experienced falls with no interventions put into place and one resident had injuries of unknown origin. Resident identifiers: 7, 11, 12, 36, 42 and 47. NOTICE On 8/12/25 at 2:30 PM, IJ was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that each resident received adequate supervision to prevent accidents, specifically elopement. Notice of the IJ was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. On 8/13/25 at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2025-08-20 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 7,11, 12, 25, 27, 33, 31, 36, 42, 47, and 49.1. Based on interview and record review, it was determined for 7 out of 32 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level. In addition, two residents without capacity were able to elope from the facility. This was cited at an immediate jeopardy level. Resident identifiers: 11, 25, 27, 33, 31, 36, 42 and 49. (Cross refer to F600) 2. Based on observation, interview, and record review, it was determined for 6 of 32 sampled…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2025-08-20 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  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 it was determined that the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple residents were identified to be in Immediate Jeopardy (IJ) related to abuse and elopements and the facility did not develop and implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored. Resident identifiers: 11, 27, 31, 33, 36, 42, and 49.Findings included:1. A. Resident 11 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (TBI), cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression.B. Resident 49 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-30 · 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, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 16 sampled residents, a resident tripped over a cord placed on the ground by a Certified Nursing Assistant (CNA) and suffered a patella fracture and a subarachnoid hemorrhage. Resident identifier: 21. Findings included: Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, repeated falls, abnormalities of gait, presence of intraocular lens, fracture of right patella, subarachnoid hemorrhage, insomnia and mood disorder. Resident 21's medical record was reviewed on 11/27/23. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 99 and was unable to interviewed when attempted by this surveyor. A quarterly Minimum Data…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-20 · tag F0550 — failed to protect resident dignity and rights — widespread
  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

  Based on interview and observation, the facility did not care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, during the lunch meal, residents were served on Styrofoam plates and provided beverages in Styrofoam cups. Resident identifier: 18 and 41.Findings included: On 8/12/25 at 12:25 PM, an observation was made of the residents being served on small Styrofoam plates and cups in the dining room for the lunch time meal. On 8/12/25 at 12:26 PM, an observation was made of resident 41 served lunch in a Styrofoam bowl. On 8/12/25 at 12:30 PM, an observation was made of resident 18, who was legally blind, being served lunch in a Styrofoam bowl and juice in a Styrofoam cup. On 8/12/25 at 1:01 PM, an interview was conducted with CNA (Certified Nursing Assistant) 1. CNA 1 stated the sandwiches that were served today were cut up into pieces and served to the residents and they were not usually measured. CNA 1 stated they just used the tongs and gave them food…

  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 · Fcited before2025-08-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and dry food storage room were open to the air, some walls were in disrepair, several tiles were cracked throughout the kitchen and bugs were found in the freezer. Findings include: 1.On 8/4/25 at 6:59 AM, an initial walkthrough of the kitchen was conducted. In the walk-in freezer, a box of frozen green beans was open to air, a box of cubed carrots was open to air, a bag of breaded chicken was not dated and a bag of frozen fried rice was not dated. There were cracked tiles outside of the walk-in freezer and walk-in refrigerator. In the dry storage room, a large, plastic bag of white powder was found on the bottom shelf, and was open to air. The bag was also not labeled. There were several cracked tiles in the dish room and the wall under the dish machine was in disrepair. The paint was chipped on the wall next to the steam table. An interview was conducted with [NAME] 2,…

  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 · F2025-08-20 · tag F0843 — widespread
  Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview and record review, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility did not have a hospital transfer agreement. Findings included: On 8/7/24 at 2:03 PM, a hospital transfer agreement was provided from the Administrator. The transfer agreement was observed to be void of any facility information, hospital information or signatures. On 8/7/25 at 3:00 PM, an interview was conducted with the Administrator (Admin). The Admin stated that the facility just had a verbal agreement with the local hospitals that if the facility would send a face sheet, medication list and allergy list with the resident then it would be fine for the resident to go to that hospital. On 8/20/25 at 10:00 AM, a follow up interview was conducted with the Admin. The Admin stated the facility did not have a signed transfer agreement with the local hospitals.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-20 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined that the facility did not develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program. Specifically, the facility did not identify and prioritize problems related to resident abuse and elopements and corrective actions were not identified, monitored, or evaluated for effectiveness. The facility was found to be in non-compliance with F600, F607, F609, F610, and F689 at an Immediate Jeopardy level, indicating substandard quality of care. Resident identifiers: 7, 11, 12, 27, 31, 33, 36, 42, 47, and 49.Findings included:On 8/19/25 at 11:54 AM, an interview was conducted with the Administrator (Admin). The Admin stated that the QAPI team met once a month and included all department heads and the Medical Director. The Admin stated that examples of topics for QAPI review included dry wall repairs, concrete hazards in the courtyard, and dementia care. The Admin stated that he completed a performance improvement plan for dementia training. The Admin stated that 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0605 — failed to not use drugs as a restraint — pattern
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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, it was determined for 4 out of 32 sampled residents, that the facility did not ensure that residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, a resident was being given risperidone for over affectionate behaviors when the resident was not exhibiting those behaviors, residents were not being monitored while on psychotropic medications, there was no follow-up when medications were ineffective, and a resident was provided anti-anxiety medication on an as needed basis for longer than 14 days without justification. Resident identifiers: 24, 25, 27, 40, and 41.Findings included: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia and psychosis. On 8/04/25 at 7:51 AM, resident 25 opened the door to his room [ROOM NUMBER]B and said he…

  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 · Ecited before2025-08-20 · 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, it was determined that for 3 of 32 sampled residents, 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. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 12, 42, and 47.Findings included:1. Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0728 — failed to protect against nurse-aide misconduct — pattern
  Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, seven Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified.Findings included: On 8/12/25, the list of Nursing Assistants (NAs), Certified Nursing Assistants (CNAs) and Environmental Aides provided by the facility was reviewed and revealed the following:NA 1 was listed as an environmental aide and had a hire date listed as 12/6/24. NA 2 was listed as an environmental aide and had a hire date listed as 12/3/24.NA 3 was listed as an environmental aide and had a hire date listed as 12/17/24. NA 4 was listed as an environmental aide and had a hire date listed as 3/10/25.NA 5 was listed as an environmental aide and had a hire date listed as 1/3/25. NA 6 was listed as an environmental aide and had a hire date listed as 11/7/23.NA 7 was listed as an environmental aide and had a hire date listed as 1/30/24.The facility staff schedule for the week of…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation and interview, the facility did not have menus that met the nutritional needs of residents in accordance with established nutritional guidelines, did not follow the menu, and although the menus were reviewed by the facility's dietitian, did not demonstrate nutritional adequacy given the resident population. Specifically, the menus were altered from their original form to include the removal of the continental breakfast, a snack during the lunch time, and a larger dinner meal. A snack was then offered in the evening, although it could not be determined to be substantial to meet nutritional needs. Resident identifiers: 5, 18 and 25. Findings included: On 8/4/25 the breakfast meal was observed. Residents were served 2 pieces of French toast, a bowl of hot cereal, a bowl of cold cereal if they wanted one, one sausage link, 4 oz (ounces) of orange juice and 8 oz of milk. On 8/5/25 at 12:52 PM, an observation was made of the lunch meal. Residents were being served 1 slice of cheese pizza and their…

  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 · E2025-08-20 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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, it was determined for 2 of 32 sampled residents, that the facility went over 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, a resident was provided late breakfasts and another resident experienced weight loss with no nourishing evening snack documented. Resident identifiers: 12 and 25.Findings included:1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with Korsakoff Syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures. The posted dining schedule was Breakfast from 8:30 - 11:00 AM; Snack from 12:15 - 1:30 PM; Dinner from 4:00…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0943 — pattern
  Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not provide training to their staff that at a minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and resident abuse and neglect prevention. Findings included: On 8/6/25 at 11:58 AM, an interview was conducted with Nursing Assistant (NA) 6. NA 6 stated they did education at the facility. NA 6 stated they just went over things that needed to be fixed. Usually the teaching was done during the in-service or the daily huddle that they had with everyone. NA 6 was not sure what the Quality Assurance and Performance Improvement (QAPI) meetings were about or if there was education that went over that stuff. On 8/19/25 at 1:33 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they did get education at work but he was unsure what QAPI was. RN 2 stated they did education when there was something that needed to be corrected.During…

  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

“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

$125,737 in federal fines across 2 penalties.

• $118,294 — penalty dated 2025-08-20
• $7,443 — penalty dated 2023-11-30

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 MISSION HEALTH SERVICES — 7 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 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in UT