Twin Lakes 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.

71.9% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 43.3% 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 60 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 140 beds and averages 97.8 residents a day — about 70% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.78 hrs/resident/day on weekends vs 3.23 on weekdays — 14% thinner on weekends. RN hours go from 0.39 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

This trend is not current. The most recent of these two inspections was over 3 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.

27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.

• Actual harm · Gcited before2019-05-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 interview, and clinical record review, the facility staff failed to ensure two of 28 residents did not develop pressure ulcers, and failed to ensure one of 28 residents had prevalon boots in place as ordered by the physician. 1. Resident #24 developed full thickness skin loss to her first (thumb) and fourth finger on her left hand. This was identified as harm by the survey team. 2. Resident #5 did not have weekly skin assessments completed by the nursing staff. On 02/01/2019 a Stage III pressure ulcer was discovered on her left heel. This was identified as harm by the survey team. 3. Resident #2 was not wearing physician ordered prevalon boots. Findings include: 1. Resident #24 was originally admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Hypertension, anxiety, diabetes mellitus, congestive heart failure, and chronic Atrial fibrillation. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24…

  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 · G2019-05-30 · 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 observation, staff interview, clinical record review, the facility staff failed to provide services to prevent an avoidable decline in range of motion for one of 28 residents, Resident #24. Resident #24 suffered an increase in the contractions of her left hand. Restorative nursing was being provided three times per week and was stopped on 03/21/201 pending an evaluation by occupational therapy for a hand orthotic. The evaluation was not done until 03/28/2019. At the time of the evaluation on 03/28/2019, Resident #24's hand had contracted into a fixed fist and the skin on her fingers had fused together. This was identified as harm by the survey team. Findings were: Resident #24 was originally admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Hypertension, anxiety, diabetes mellitus, congestive heart failure, and chronic Atrial fibrillation. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24 as having problems…

  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 · G2019-05-30 · 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 resident interview, staff interview, and clinical record review, the facility staff failed to ensure sufficient fluid intake to maintain proper hydration for one of 28 residents in the survey sample, Resident #45. Resident #45 was admitted to the hospital with a primary diagnoses of dehydration due to not receiving physician ordered fluids to keep hydrated. This was identified as harm. The Findings Include: Resident #45 was admitted to the facility on [DATE]. Diagnoses for Resident #45 included; Anemia, chronic kidney disease, crohn's disease, and dumping syndrome. The most current MDS (minimum data set) was a initial assessment with an ARD (assessment reference date) of 3/7/19. Resident #45 was assessed with a score of 15 indicating cognitively intact. On 5/29/19 at 8:45 AM Resident #45 was interviewed. During the interview Resident #45 was asked about being admitted to the hospital. Resident #45 stated that she had recently been admitted to the hospital twice, one time for infection the other time…

  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 · Ecited before2023-05-03 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident interview, staff interview, and clinical record review, the facility staff failed to obtain orders for the care and treatment of a colostomy for one of 20 residents, Resident #67. Findings were: Resident #67 was admitted to the facility with the following diagnoses including but not limited to: diabetes mellitus, hypertension, anxiety, depression, and gastro-esophageal reflux. An annual MDS (minimum data set) with an ARD (assessment reference date) of 04/06/2023 assessed Resident #67 as cognitively intact with a summary score of 14. On 05/02/2023 at approximately 2:15 p.m., Resident #67 was interviewed regarding life in the facility. During the conversation she stated that she had a colostomy. She stated the facility staff provided all the care for the colostomy. The clinical record was reviewed at approximately 4:00 p.m. There were no orders observed for the care of Resident #67's colostomy. The care plan was reviewed and included: Potential for infection/skin breakdown s/t (secondary to) incontinence and colostomy. Interventions included but were not limited 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-05-03 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of employee files, staff interview, and review of facility policy, the facility failed to implement their abuse prevention policy for the screening of new employees. The facility failed to obtain a Sworn Statement from seven of 24 new hired employees. The findings were: At approximately 1:30 p.m. on 5/3/2023, a review of 24 randomly selected personnel files of facility employees hired in the last two years was conducted. Two employees from the Human Resources Department assisted in the review. Documents included in the review were the Sworn Statement, Criminal Record Check, License (if applicable), and References. The review identified seven employees who did not have a Sworn Statement in their individual personnel file. The seven employees included the following: A CNA (Certified Nursing Assistant) hired on 4/13/2023 A CNA hired on 3/27/2023 A CNA hired on 3/17/2023 A CNA hired on 3/13/2023 A CNA hired on 3/6/2023 A CNA hired on 2/6/2023 A LPN (Licensed Practical Nurse) hired on 11/28/2022 The Human Resources (HR) Director explained that with the exception 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-05-03 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of twenty residents in the survey sample (Resident #47). The findings include: Resident #47's care plan was not revised to include interventions for injury prevention following bruising to the resident's hand/finger. Resident #47 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, atrial fibrillation, gout, hypertension, congestive heart failure, arthritis, and depression. The minimum data set (MDS) dated [DATE] assessed Resident #47 with moderately impaired cognitive skills and as requiring total assistance of one person for bed mobility. Resident #47's clinical record documented a nursing note dated 4/15/23 stating the resident's left hand was bruised during ADL (activities of daily living) care. A nursing note dated 5/1/23 documented the resident hit his right ring finger on the bed rail when turned in bed. Resident #47's plan of care (revised…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-05-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 interview, clinical record review, and facility document review the facility staff failed to follow infection control practices during the care and treatment of a pressure ulcer for one of 20 residents, Resident #58. Findings were: Resident #58 was admitted to the facility with the following diagnoses, including but not limited to: Anemia, protein-calorie malnutrition, dementia, Parkinson's disease, dementia, and sacral Osteomyelitis. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/21/2023, assessed Resident #58 as impaired with long and short term memory, as well as daily decision making skills. The clinical record was reviewed on 05/02/2023 at approximately 11:00 a.m. and included documentation regarding a pressure injury to her sacrum and an unstageable area to her left hip. The sacral area was measured on 05/01/2023 with the following measurements documented: 8 cm length, 9 cm width and 1.5 cm depth. Treatment orders were: After cleansing with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-05-03 · 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, staff interview and clinical record review, the facility staff failed to administer oxygen at the physician ordered rate for one of twenty residents in the survey sample (Resident #47). The findings include: Resident #47 was observed with oxygen administered at 2.5 lpm (liters per minute) when a physician's order required an administration rate of 4 lpm. Resident #47 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, atrial fibrillation, gout, hypertension, congestive heart failure, arthritis, and depression. The minimum data set (MDS) dated [DATE] assessed Resident #47 with moderately impaired cognitive skills. On 5/2/23 at 11:18 a.m., Resident #47 was observed in bed with oxygen administered at a rate of 2.5 lpm. Resident #47 was observed again on 5/2/23 at 3:16 p.m. and on 5/3/23 at 8:16 a.m. with oxygen administered at 2.5 lpm. Resident #47's clinical record documented a physician's order dated 11/21/22 for continuous oxygen administration via nasal…

  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 before2023-05-03 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to follow their infection control policy for hand washing during the care and treatment of a pressure ulcer for one of 20 residents, Resident #58, and failed to follow infection control practices during a medication pass on Unit 1. Findings were: 1. Resident #58 was admitted to the facility with the following diagnoses, including but not limited to: Anemia, protein-calorie malnutrition, dementia, Parkinson's disease, dementia, and sacral Osteomyelitis. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/21/2023, assessed Resident #58 as impaired with long and short term memory, as well as daily decision making skills. The clinical record was reviewed on 05/02/2023 at approximately 11:00 a.m. and included documentation regarding a pressure injury to her sacrum and an unstageable area to her left hip. On 05/03/2023 at approximately 10:00 a.m., RN (registered nurse) #4 and LPN (licensed practical nurse) #2 were observed providing wound 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2021-06-10 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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, and clinical record review, the facility staff failed to ensure sufficient staffing to provide resident care for 3 of 23 residents in the survey sample, Resident #74, Resident #11, and Resident #33. Resident #74, Resident #11, and Resident #33 did not receive their showers as scheduled. The findings include: 1. Resident #74 was admitted to the facility on [DATE] with diagnoses that included hypertension, peripheral vascular disease, hyperlipidemia, type 2 diabetes, anxiety disorder, depression, chronic kidney disease, and hypothyroidism. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #74 as cognitively intact for daily decision making with a score of 14 out of 15. Under section G - Functional Status, the MDS assessed Resident #74 total dependent with the assistance of one person for bathing. On 06/09/2021 at 10:30 a.m., Resident #74 was interviewed regarding her quality of life and quality of care at…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2021-06-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner. Frozen meat patties were stored uncovered and unlabeled in the freezer. Sliced cheese was stored in the refrigerator without a date opened or use by date. The manual can opener in the main kitchen was dirty. The findings include: On 6/8/21 at 11:48 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. Observed in the walk-in freezer was a large bag of frozen turkey sausage patties. The bag was open with the meat patties exposed to air. The turkey sausage patties had no manufacturer's label and no date opened or use by date posted on the bag. Observed in the walk-in refrigerator were 16 slices of cheese in an aluminum pan. The individual slices were in separate Ziploc bags with no date opened, no use by date and no commercial packaging indicating an expiration date. The dietary manager stated the cheese was served last…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2021-06-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to develop a baseline care plan regarding a PICC (peripherally inserted central catheter) line, for one of 23 residents, Resident #29. Findings include: Resident #29 was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. Diagnoses for Resident #29 included, but were not limited to: anemia, morbid obesity, heart disease, high blood pressure, diabetes mellitus with hyperglycemia and diabetic neuropathy, diabetic foot ulcer with an open lesion and osteomyelitis (left foot). The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. During an interview with Resident #29 on 06/08/21, the resident was observed with a PICC line in the right antecubital area. Resident #29 stated that it was inserted while she was in the hospital and it 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2021-06-10 · tag F0814 — failed to dispose of garbage properly — isolated
  Dispose of garbage and refuse properly.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and staff interview, the facility staff failed to dispose of garbage/waste in a sanitary manner. Bags of garbage and a broken blind were on the ground and not contained within the dumpster/compactor. The findings include: On 6/8/21 at 12:15 p.m., accompanied by the dietary manager (other staff #2), the facility's waste/dumpster area was inspected. Three bags of garbage and a broken window blind were on the ground to the right of the dumpster/compactor. The dietary manager was interviewed at the time of the observation about the garbage on the ground. The dietary manager stated the garbage was from the quarantine units and not the kitchen. The dietary manager stated all garbage was supposed to be placed in the dumpster/compactor and not on the ground. The dietary manager stated if the dumpster was not available for some reason, a gray barrel was available for garbage storage until the dumpster/compactor was back in service. This finding was reviewed with the administrator and director of nursing during a meeting on 6/9/21 at 4:45 p.m.

  Nutrition and Dietary 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 EASTERN HEALTHCARE GROUP — 18 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 24 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

What families pay in VA