Pheasant Ridge Nursing and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

47.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 152 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 67.9% 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 84 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% 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 101 beds and averages 88.0 residents a day — about 87% occupied, or roughly 13 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.86 hrs/resident/day on weekends vs 3.43 on weekdays — 17% thinner on weekends. RN hours go from 0.73 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-11-21 · 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 interviews, clinical record review, and facility document review, the facility staff failed to appropriately respond to a decline/change in condition (lethargy, oriented to person only, clammy skin, Cheyne-Stokes labored irregular breathing) for one 1 of nine 9 sampled residents (Resident #9), resulting in death. The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The Administrator, Director of Nursing (DON), and Quality Assurance (QA) Nurse were notified on [DATE] at 1:45 p.m. that the survey team had identified Immediate Jeopardy in the area of Quality of Care. Upon verification of the removal plan, the Immediate Jeopardy was cleared on [DATE] at 2:45 p.m. The findings include: The facility staff failed to appropriately provide emergency care and timely transportation services, which aligned with the Resident #9's documented preferences, following a sudden decline 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
• Actual harm · G2026-05-07 · tag F0658 — failed to meet professional standards of care — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility policy review, the facility staff failed to provide care and services to meet professional standards of quality for 1 of 7 resident's in the survey sample, Resident #2. The findings included:The policy entitled Pain Management with a revised date of 09/24/2025 was reviewed and read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under the heading Recognition the document read, 1. In order to help a resident maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated b. Evaluate the resident for pain and the cause(s) of pain upon admission, during ongoing scheduled…

  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 plan of correction
• Actual harm · G2026-05-07 · 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

  Based on staff interview and clinical record review, the facility staff failed to maintain acceptable levels of nutritional status resulting in a significant 16-pound weight loss for 1 of 7 residents in the survey sample, Resident #2. The findings included: The admission Record for Resident #2 revealed the facility admitted the resident on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression and anxiety.The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/23/2025 assigned the resident a brief interview for mental status (BIMS) score of 08 indicating moderate cognitive impairment.The hospital discharge summary was reviewed. Resident #2's weight was documented as 115 lbs. during the discharge exam.The Documentation Survey Report where activities of daily living (ADL's) such as eating, toileting…

  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 plan of correction
• Actual harm · G2026-05-07 · 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

  Based on staff interview, clinical record review and facility policy review, the facility staff failed to provide pain management to residents who require such services that are consistent with professional standards of practice for 1 of 7 residents in the survey sample, Resident #2. The findings included:The policy entitled Pain Management with a revised date of 09/24/2025 was reviewed and read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under the heading Recognition the document read, 1. In order to help a resident maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated b. Evaluate the resident for pain and the cause(s) of pain upon admission, during ongoing scheduled assessments, and when…

  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 plan of correction
• Actual harm · G2026-05-07 · tag F0776 — isolated
  Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
  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 interview, clinical record review, facility document review and facility policy review, the facility staff failed to provide or obtain radiology services to meet the needs of its residents for 1 of 7 residents in the survey sample, Resident #5. This failure resulted in a delay in treatment for a left hip fracture sustained after a fall thus constituting harm.The findings included:A facility policy entitled, Radiology and other Diagnostic Services and Reporting, dated 11/07/2025, read in part, The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law. 1. The facility must provide or obtain radiology and other diagnostic service to meet the needs of its residents. Under item 4. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.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 plan of correction
• Potential for harm · Dcited before2026-05-07 · 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

  Based on staff interview and clinical record review, the facility staff failed to follow medical provider orders for one of seven residents in the survey sample, Resident #2.The findings included:For Resident #2 the facility staff failed to follow hold orders for the administration of Toprol XL (metoprolol). An admission Record revealed the facility admitted Resident #2 on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction and moderate protein-calorie malnutrition. The admission minimum data set (MDS) with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment.'The Medication Administration Record (MAR) for May 2025 revealed an order that read, Toprol XL oral tablet extended release 24-hour 25 mg (Metoprolol Succinate) give one tablet by mouth one time a day for htn…

  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 plan of correction
• Potential for harm · D2026-05-07 · tag F0773 — isolated
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and clinical record review the facility staff failed to obtain medical provider ordered laboratory tests for one of seven residents in the survey sample, resident #2.The findings included:For Resident #2 the facility failed to obtain a BNP (B-type natriuretic peptide test) and a TSH (thyroid stimulating hormone) level ordered by the medical provider.An admission Record revealed the facility admitted Resident #2 on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction and moderate protein-calorie malnutrition.The admission minimum data set (MDS) with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment.A History and Physical note dated 4/18/2025 and electronically signed by the facility Medical Director at the time, included an order that read,…

  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 plan of correction
• Potential for harm · Dcited before2026-05-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain medical records in accordance with accepted professional standards and practices for 1 of 8 residents in the survey sample, Resident #8 (R#8). The findings included:On 5/5/26 at 1:59 pm, during a record review for Resident #4 (R#4), a wound progress note titled, patient visit record dated 3/17/2026 and a hospice consent dated 3/16/26 for Resident #8 (R#8) were observed uploaded in the chart of R#4. On 5/5/2026 at 3:10 pm an interview was conducted with the Medical Records Coordinator. She stated her procedure is to upload the records as soon as she receives them if possible, limiting who all uploads' records as to keep mistakes at a minimum. If a wrong record is uploaded into the wrong chart by staff the records are deleted immediately. She reports taking pride in her work and was upset when she was advised on the records for R#8 being uploaded into R#4's electronic record. It was noted that R#8 has a similar last name to R#4. On 5/6/2027, 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2024-11-21 · tag F0711 — pattern
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were signed by the provider when the orders were entered into the residents' clinical records by non-prescribing facility staff members. The findings include: Review of residents' clinical records revealed multiple orders that had not been signed by the prescribing medical provider. The following information was found in a facility document titled Physician Orders (with a revision date of 3/3/21): - The center will ensure that Physician orders are appropriately and timely documented in the medical record. - admission ORDERS: Information received from the referring facility or agency [sic] to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. - ROUTINE ORDERS: A Nurse may accept…

  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 · D2024-11-21 · tag F0573 — isolated
  Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility document review, the facility staff failed to respond to a request for a copy of clinical documentation in the required time frame for one (1) of nine (9) sampled residents (Resident #9). The findings include: It took the facility greater than two (2) working days to respond to a request for copies of Resident #9's clinical record by the Resident Representative (RR). Resident #9 had expired while a resident at the facility. This request for the clinical records was declined due to the need for supporting documentation indicating authority to access records on the resident's behalf. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], was signed as completed on [DATE]. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition.…

  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 before2024-11-21 · 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 interviews, clinical record review, and facility document review, the facility staff failed to ensure a medical provider and/or a resident representative were promptly notified of a change in condition for two (2) of nine (9) sampled residents (Resident #8 and Resident #9). 1. The facility staff failed to promptly notify Resident #9's resident representative when the resident experienced a decline/change in condition. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/24, was signed as completed on 10/22/24. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. The following information was found in a facility document titled Notification of Change in Condition (with a revision date of 12/16/20): - The Center [sic] to promptly notify the Patient/Resident, the attending…

  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 · D2024-11-21 · tag F0635 — isolated
  Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure one (1) of the medications ordered to be continued after hospital discharge was promptly ordered when admitted to the facility for one (1) of nine (9) sampled residents (Resident #9). The findings include: One (1) of Resident #9's medications ordered to be continued when the resident was discharged from the hospital was not ordered until Resident #9's second day at the facility. This medication was Prednisone. This resulted in the resident missing a day's dose of the medication. No documentation was found by or provided to the surveyor to address why this medication had not been ordered with Resident #9's admission medication orders. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/24, was signed as completed on 10/22/24. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this…

  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 · D2024-11-21 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  3. For Resident #9 the facility staff failed to develop and implement a baseline care plan. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/24, was signed as completed on 10/22/24. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. This surveyor was unable to locate a baseline care plan in Resident #9's clinical record. On 11/21/24 at 12:40 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Quality Assurance Nurse (QAN). During this meeting, this surveyor asked for Resident #9's baseline care plan. On 11/21/24 at 3:55 p.m., the DON reported a baseline care plan for Resident #9 was unable to be found. Based on staff interview, record review and facility document review, the facility staff failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide…

  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 · D2024-11-21 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, clinical record review and facility document review, the facility staff failed to develop and implement a comprehensive person centered care plan for one of nine residents in the survey sample, resident #2. The findings included: For resident #2 (R2) the facility staff failed to develop and implement a comprehensive person centered care plan. R2's diagnoses included but were not limited to right hip fracture with surgical repair, unspecified protein calorie malnutrition, diabetes, chronic kidney disease, anemia, breast cancer and hypertension. The minimum data set (MDS) assessment with an assessment reference date of 10/3/24 assigned the resident a brief interview for mental status score of 13 out of 15 indicating mild cognitive impairment. The review of the MDS revealed that R2 was frequently incontinent of bowel and bladder, had occasional pain rated at 10/10 on the pain scale that interfered with sleep, therapy and day to day activities, received insulin injections, was at risk for pressure ulcers, had a surgical wound and was getting speech,…

  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 · D2024-11-21 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide necessary respiratory services for 1 of 7 residents, Resident #101. The findings included: The facility staff failed to provide oxygen per the physician's order and failed to transcribe an order for a flutter valve breathing device. Resident #101's face sheet included diagnoses which included but not limited to acute respiratory failure with hypoxia. Resident #101's admission minimum data set had not yet been completed, but an interview revealed that resident was alert and oriented. Resident #101's baseline care plan was reviewed and read in part, Other Services/Orders: O2 2L (liters) @ bedtime. Resident #101's clinical record was reviewed and contained a physician's order summary which read in part, Oxygen at 2 L NC (nasal canula) at bedtime for SOB (shortness of breath). Resident #101's hospital Discharge summary dated [DATE] read in part, . (Resident #101)…

  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 AVARDIS HEALTH — 38 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 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

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 $583K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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