Oak Grove Health & Rehab Center, LLC

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.

62.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 398 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 204 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 120 beds and averages 118.8 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.01 hrs/resident/day on weekends vs 3.73 on weekdays — 19% thinner on weekends. RN hours go from 0.60 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 47% 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 fewer than at the previous inspection — improving. 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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

• Actual harm · G2023-08-09 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a family interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to notify the Physician and/or Practitioner of an abnormally elevated blood pressure reading, the inability to procure a newly ordered blood pressure medication and of identified changes in mentation which progressed to a serious and life-threatening hypertensive emergency and a large left-brain bleed for 1 of 5 residents (Resident #1), in the survey sample, which constituted harm. Past Non-Compliance was given to this citation. The Findings Included: Resident #1 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #1 was originally admitted to the facility on [DATE] and she was last discharged from the facility to a local hospital on 6/21/23 after a change in condition. Resident #1's diagnoses included a stroke, high blood pressure, and heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date…

  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
• Actual harm · G2019-07-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing, prevent infection and to prevent development of new foot ulcer for 1 of 39 residents (Resident #75) in the survey sample. The findings included: The facility staff failed to prevent, identify, and treat Resident #75's foot ulcer to the back of left heel prior to being found at an advance stage (unstageable) resulting in harm. The ulcer was first identified as a black crusty scabbed measuring 2 cm x 2 cm. Resident #75 was admitted to the facility on [DATE]. Diagnoses for Resident #75 included, but were not limited to *Dementia with behavioral disturbance, *Diabetes Mellitus and involuntary movements (not done by choice; done unwillingly). Resident #75's quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/24/19 coded a 05 out of a possible score of 15 on the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2019-07-19 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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 staff interviews, resident interview, and clinical record review, and in the course of a complaint investigation, the facility staff failed to provide pain management consistent with professional standards of practice for one (Resident #84) of 39 residents in the survey sample, resulting in harm. The resident was not assessed for pain from the time of admission until the following day during occupational therapy. There was no evidence that once pain was identified that it was treated timely. The findings include: Resident #84 was admitted to the facility 08/16/2018. Resident #84 left the facility, AMA (Against Medical Advice) on 08/27/2018. Diagnoses included but were not limited to, Left Distal Femur Fracture, Left Distal Radius Fracture and End Stage Renal Disease. Resident #84's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 08/23/2018 coded the resident with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 review of facility policy, record review, observations, and interviews, the facility failed to ensure a splint was applied routinely for one out of one resident (Resident (R) 11) reviewed for position and mobility. The facility's failure to ensure R11's splint was routinely applied created the potential for this and other residents to experience avoidable decline in range of motion (ROM). A total of 31 residents were reviewed in the sample. Review of R11's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke and reduced mobility. Review of R11's Occupational Therapy Discharge summary, dated [DATE] and found in the EMR under the Documents tab, revealed facility staff had been trained to ensure the application of the resident's right upper extremity splint/brace for three hours daily. Review of R11's quarterly Minimum Data Set (MDS),…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 record review, interviews, and review of facility policy, the facility failed to ensure consistent and comprehensive management of nutritional services for one out of 11 residents (Resident (R) 67) reviewed for nutrition. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits. A total of 31 residents were reviewed in the sample. Review of the Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R67 was admitted to the facility on [DATE]. The resident's diagnoses included rheumatoid arthritis, history of stroke, and malnutrition. Review of R67's Physician's Order Report, dated 02/19/26 and found in the EMR under the Orders tab, revealed orders, with an initial order date of 12/12/25 for the resident to receive a regular mechanical soft diet with nectar thick liquids and an order…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 record review, observations, interviews, and review of facility policy, the facility failed to ensure a medication error rate of less than five percent. Two errors occurred during the administration of one Resident's (Resident (R) 134) medications out of 30 observed opportunities, resulting in an error rate was 6.67 percent. The facility's failure created the potential for R134 and other residents to experience negative physical and/or psychosocial effects related to improper medication administration. A total of 31 residents were reviewed in the sampleReview of R134's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included congestive heart failure and malnutrition. Review of R134's Physician's Order Report, dated 02/19/26 and found in the EMR under the Orders tab, revealed an order, with an original order date of 02/13/26, for the resident to receive…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-01-28 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on compliant investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 1 of 34 residents (Resident #47) in a survey sample. The findings included: The facility staff failed to ensure blood pressures were taken prior to the administration of medication (Zanaflex) as ordered by the physician Resident #47 was admitted to the nursing facility on 06/03/21. Diagnosis for Resident #47 included but not limited to Myasthenia Gravis. Resident #47's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/10/21 coded the resident's Brief Interview for Mental Status (BIMS) score 08 of a possible 15 with moderate impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #47 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene and set-up help only with eating for Activities of Daily Living (ADL) care.…

  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 · E2022-01-28 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 information gleamed during a complaint investigation, staff interviews, and review of facility documents, the facility staff failed to have a procedure in place to ensure that a presumed Graduate Nurse (GN) had a license or authorization to practice in the state prior to hiring, starting orientation and rendering care to residents in the facility. The findings included: An interview was conducted with the Director of Nursing and Administrator on 1/28/21 at approximately 5:45 p.m. regarding the complaint that they had nurses right out of school without proper credentials working in the facility. The Director of Nursing stated they didn't have anyone working as a nurse who didn't meet the requirements to work as a graduate Nurse. Review of one presumed Graduate Nurse (GN) Personnel record revealed the staff was originally hired 10/18/21 and rehired 12/20/21. Further review of the personnel records didn't reveal a license to practice as a practical Nurse neither a letter from the Department of Health…

  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 · E2022-01-28 · tag F0742 — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  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, resident interview, family interview, staff interviews, and clinical record review, the facility staff failed to to ensure a resident exhibiting resistive behaviors secondary to a history of pain related trauma received person-centered services to support and promote mental and physical well-being which resulted escalated behaviors and a significant decline in mental and physical functioning for 1 of 34 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 10/11/21, and readmitted [DATE], after an acute care hospital stay. The current diagnoses included; Cerebral palsy/paraplegia, status post Right hip fracture, Chronic pain, an Adjustment disorder with anxiety and Generalized Weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/9/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident…

  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 · E2022-01-28 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  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, clinical record review, staff interview the facility, the failed to ensure 1 of 34 Residents (#92) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis. The findings included: The facility staff failed to review Resident #92's medication regimen for the month of August 2021. Resident #92 was admitted to the facility on [DATE]. Diagnosis for Resident #92 included but not limited to Major Depressive disorder and Anxiety disorder. Resident #92's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 01/09/22 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS coded Resident #92 requiring extensive assistance of one with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing for Activities of Daily Living (ADL) care. Resident #92's comprehensive care plan documented Resident #92 is on 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-01-28 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  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, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #35), in the survey sample of 34 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #35 was originally admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to other abnormalities of gait and mobility and Chronic Kidney Disease. The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 12/04/21 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 9 which indicated moderate cognitive impairment for daily decision-making. Resident #35 was coded to require limited assistance of one staff with personal hygiene. The Care Plan revealed the following: I have an ADL Self Care Performance Deficit r/t my cognition. Goal: I will maintain current level of function in my adls (Activities of Daily Living)…

  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 · D2022-01-28 · 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 observations, record review and staff interviews, the facility staff failed to ensure one Resident (Resident #45) in the survey sample of 28 residents did not smoke inside the facility. The findings included: Resident #45 had a re-admit date of 12/09/21. Resident #45 was re-admitted with diagnoses which included muscle weakness, paraplegia, neuromuscular dysfunction of bladder, schizoaffective disorder, and adjustment disorder. Resident #45 was assessed as requiring maximum assist with Activities of Daily living. Resident was noted to have a colostomy. Resident #45 had a care plan dated 11/05/21 which indicated: Focus- Smoking paraphernalia no-complaint with smoke free facility; Goal- The resident will have an understanding of the effects of being non complaint with smoke free facility. Interventions- Educate and encourage of the risk verses benefits of not following non-smoking facility policy. Resident #45 was observed on 1/25/22 at 2:35 p.m. in bed. Resident #45 was able to speak and carry on a conversation. Resident #45 was observed in bed on 1/26/22 at 9:15 a.m. in…

  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 · D2022-01-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, resident and staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to follow the physician order for the oxygen flow rate, monitor the flow rate and failed to label and date the oxygen tubing for 1 of 34 residents (Resident #23) in the survey sample. The findings included: Resident #23 was originally admitted to the nursing facility on 03/11/21. Diagnosis for Resident #23 included but not limited Diabetes Mellitus and Respiratory Failure. Resident #23's Minimum Data Set (MDS-an assessment protocol) a quarterly revision assessment with an Assessment Reference Date (ARD) of 11/17/21 coded Resident #23 an 8 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive skills for daily decision-making. In addition, under respiratory treatments was coded for the use of oxygen therapy. Resident #23's person centered care plan had a focus which read; Resident #23 is on oxygen therapy. The goal read; will be free from signs and symptoms of hypoxia. One of the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 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 23 rows in the source record cover these 15 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.

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

Follow the money — this home’s finances

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

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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 VA