Millcreek Rehabilitation and Nursing

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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 61 beds and averages 57.6 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.39 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 1.95 hrs/resident/day on weekends vs 2.36 on weekdays — 17% thinner on weekends. RN hours go from 0.77 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · J2025-03-31 · tag F0610 — failed to investigate and act on abuse reports — isolated
  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, for 1 of 43 sampled residents, the facility, in response to an allegations of abuse, neglect, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, a resident sustained a fall in a wheelchair while being transported in the facility van and the facility did not investigate the incident or report the incident to the SSA. This was determined to have occurred at an Immediate Jeopardy level. Resident identifier: 47 and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to thoroughly investigate alleged violations, prevent further potential abuse, neglect exploitation or mistreatment while the investigation was in progress, and report the results of all investigations to…

  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 · Jcited before2025-03-31 · 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, for 2 of 43 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident fell backwards while being transported in a facility van due to not being secured properly and the resident sustained an injury to the head/neck. This was determined to have occurred at an Immediate Jeopardy level. Also, a resident with multiple falls did not have interventions in place to prevent additional falls. Resident identifiers: 1, 47, and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility…

  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 · G2025-03-31 · 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 it was determined, for 3 out of 43 sampled residents, that the facility did not ensure resident's were free from abuse. Specifically, a resident reported that another resident groped his genitals and attempted to penetrate his anus without his consent to the sexual activity. This deficient practice was found to have occurred at a Harm level. Additionally, a resident's capacity to consent to sexual activity assessment was not completed prior to the resident engaging in sexual activity. Resident identifiers 23, 49, and 112. Findings included: HARM 1. Resident 23 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, type 2 diabetes mellitus, right below the knee amputation, phantom limb syndrome, congestive heart failure, hypertension, viral hepatitis C, schizoaffective disorder, insomnia, anxiety disorder, and post-traumatic stress disorder (PTSD). On 3/17/25 at 10:38 AM, an interview was…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-07 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that allegations of neglect were reported immediately to the State Survey Agency. Specifically, the facility did not report an incident where a resident was not secured while being transported in a facility van. Resident Identifier: 2 Findings include: The surveyor reviewed the facility's grievance binder. A resident grievance, dated 3/26/26, stated, Resident reported to SS/RA [social services/resident advocate] that during transportation to their appointment earlier this week, the [sic] observed that the other resident in the transport vehicle was not strapped in appropriately, resident specified that the residents w/c [wheelchair] was not anchored via straps to the van floor. It was documented that the grievance was confirmed. The corrective action to the grievance included: Driver 1 was written up and re-educated regarding the incident; all staff who drove the van were re-educated on the transport evaluation checklist; additional training on wheelchair securement,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that a resident's environment remained free of accident hazards. Specifically, a resident's wheelchair was not secured during transport. Resident Identifier: 1 and 2. It was determined the provider's non-compliance with the requirements of participation caused potential harm However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented on 3/27/26, educated and retrained all staff members who transport residents. Specifically, the facility provided Driver 1 with additional training, during which he demonstrated his step-by-step knowledge of proper wheelchair securement, and all drivers were given additional education to ensure ongoing compliance. In addition,, the Administrator performed random audits.…

  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
• Potential for harm · Ecited before2025-03-31 · 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 it was determined, for 5 of 43 sampled residents, that the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, the State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. Specifically, an allegation of sexual abuse was not reported to the SSA, APS, or local law enforcement within 2 hours after the facility became aware of the allegation, an allegation of sexual abuse was not reported to the APS within 2 hours after the facility became aware of the allegation, and an injury sustained in the transportation van was not reported to the SSA and APS within 2 hours of the incident. Resident identifiers 23, 50, 112, 113, and 114. Findings included: 1. a. Resident 23 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, type 2 diabetes mellitus,…

  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 · E2025-03-31 · 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 observation, interview, and record review it was determined, for 3 of 43 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident that received dialysis did not have a care plan, a resident that vaped THC (Tetrahydrocannabinol) did not have a care plan, and a resident with frequent falls did not have care plan interventions implemented. Resident identifiers: 1, 33, and 58. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, mild intellectual disabilities, traumatic brain injury, subdural hemorrhage, dementia with agitation, presbyopia, and sensorineural hearing loss. On 3/19/25 at 1:14 PM, an…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-31 · tag F0775 — pattern
  Keep complete, dated laboratory records in the resident's record.
  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 3 of 43 sampled residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, 3 residents did not have laboratory reports filed in their medical record. Resident identifiers: 33, 37, and 49. Findings included: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, congestive heart failure, thrombocytopenia, disorder of bilirubin metabolism, chronic kidney disease, hypertension, bipolar disorder, and generalized anxiety disorder. Resident 37's medical record was reviewed 3/17/25 through 3/31/25. A physician's order, dated 10/4/24 at 12:32 PM, indicated, Collect one time BMP [Basic Metabolic Panel] on 10/29/24 one time only . There were no laboratory results in resident 37's medical record. On 3/31/25 at 11:50 AM, an interview was conducted with the Director of Nursing (DON). 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-31 · tag F0842 — failed to keep accurate, complete medical records — pattern
  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 observation, interview, and record review it was determined that, for 4 of 43 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, and readily accessible and failed to protect resident-identifiable information from being released to the public. Specifically, one resident did not have a physician's rationale for an on-going use of a PRN (as needed) psychotropic medication located in the medical record and 3 residents had another resident's name or documents located in their medical records. Resident identifiers: 49, 59, 164, and 214. Findings included: 1. Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included post-traumatic stress disorder (PTSD), schizoaffective disorder bipolar type, generalized anxiety disorder (GAD), cognitive communication deficit, and frontal lobe and executive function deficit. Resident 59's medical record was reviewed 3/17/25 through 3/31/25. A physician'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 · Ecited before2025-03-31 · 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 it was determined, for 2 of 43 sampled residents, that the facility failed to 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. Specifically, there was direct food contact with bare hands and 2 residents who had indwelling medical devices or wounds and did not have Enhanced Barrier Precautions (EBP) in place. Resident identifiers: 22 and 58. Findings included: 1. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure with hypoxia, hypertension, pneumonia, paroxysmal atrial fibrillation, chronic viral hepatitis C, chronic kidney disease, bladder-neck obstruction, and retention of urine. On 3/17/25 at 9:45 AM, resident 22 was observed in his room in bed with a foley catheter drainage bag hanging from his bed. Resident 22 stated he 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-31 · tag F0924 — pattern
  Put firmly secured handrails on each side of hallways.
  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 failed to ensure that all corridors were equipped with firmly secured handrails. Specifically, 3 handrails throughout the facility were found to be loose which created a resident safety hazard. Findings included: On 3/17/25 at 2:09 PM, an observation was made in the resident corridor of a handrail outside of room [ROOM NUMBER]. The handrail was not secured to the wall. On 3/20/25 at 4:09 PM, an observation was made in the resident corridor of the handrail between rooms [ROOM NUMBERS]. The handrail was not secured to the wall. On 3/20/25 at 4:10 PM, an observation was made in the resident corridor of the handrail between rooms [ROOM NUMBERS]. The handrail was not secured to the wall. On 3/31/25 at 10:13 AM, an interview was conducted with the Maintenance and Housekeeping Supervisor (MHS) who stated audits were conducted with housekeeping staff everyday. The MHS stated audits included inspecting handrails at least everyday. The handrail between rooms [ROOM NUMBERS]…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-31 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  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 1 of 43 sampled residents that the facility did not promote and facilitate the resident right to self-determination through support of the resident choice. Specifically, a resident who was assessed as not requiring supervision with smoking was not allowed access to the secured outside smoking patio after 9:00 PM unless it was at the supervised smoking times of 11:00 PM or 3:00 AM. Resident identifier 33. Findings included: Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type II diabetes mellitus, end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, hidradenitis suppurativa, borderline personality disorder, major depressive disorder, anxiety disorder, and ascities. On 3/18/25 at 10:43 AM, an interview was conducted with resident 33. Resident 33 stated that he would like to sit outside on the smoking patio at night but he was told by staff that he had to be inside 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that, for 1 of 43 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, a resident had a brown substance on the wall next to the toilet for the entire length of the survey. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10:07 AM, resident 50 stated there was fecal matter on the wall next to the toilet that had been there since he was admitted . The State Surveyor (SS) observed the area in the resident's bathroom and found there was a brown substance on the wall near the toilet next to the toilet paper dispenser and below the dispenser. On 3/27/25 at 11:15 AM, an observation was made in resident 50's bathroom. The brown substance that was observed on the wall…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$25,441 in federal fines across 1 penalty.

• $25,441 — penalty dated 2025-03-31

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 BEAVER VALLEY HOSPITAL — 5 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 13 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.

2 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 $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 38% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in UT