YORK Post Acute

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.

44.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.4% 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 57 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 80 beds and averages 77.0 residents a day — about 96% occupied, or roughly 3 beds 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 2.76 hrs/resident/day on weekends vs 3.56 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.75 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 1 administrator has left in the past year.

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.

26 citations, most serious first. The 14 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · J2023-06-29 · 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 staff interview, record review, and policy review, the facility failed to ensure the physician was notified for a change of condition for one of 44 residents (Resident (R) 129). This failure to notify the physician when R129 was found to have low blood pressure, shallow breathing, and lethargy, resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. Findings include: Review of R129's printed Face Sheet from the electronic medical record (EMR) Reports tab showed a facility admission date of [DATE] with medical diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes, hypertension, pneumonia, abnormal electrocardiogram (EKG), heart failure, long term steroid use, interstitial pulmonary disease, heart disease, atrioventricular block, deep vein embolism and thrombosis, major depressive disorder, and urine retention. Review of R129's…

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

  Resident Rights Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2023-06-29 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 record review, the facility failed to ensure a resident's end of life wishes were clarified and consistent in the medical record for one of 44 residents (Resident (R) 129). The facility staff did not initiate CPR or call Emergency Medical Services (EMS) when R129 was found without a pulse or respirations. This resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. Findings include: Review of R129's printed Face Sheet from the electronic medical record (EMR) Reports tab showed a facility admission date of [DATE] with medical diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes, hypertension, pneumonia, abnormal electrocardiogram (EKG), heart failure, long term steroid use, interstitial pulmonary disease, heart disease, atrioventricular block, deep vein embolism and thrombosis. A review of R129's hospital…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe environment resulting in harm for one resident (Resident # 1) in a survey sample of 4 residents. This was cited at past non-compliance. Findings included: For Resident # 1, the facility staff failed to ensure the bed frame was free of jagged edges resulting in a large laceration on the right lower leg requiring stitches and hospitalization that was sustained during a transfer from Geri-chair to bed on 10/28/2023, resulting in harm for Resident #1. The facility staff failed to use a gait belt during transfer per the plan of care. Resident # 1 was admitted to the facility on [DATE] for skilled nursing care services with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with Chronic Hypoxic Respiratory Failure, Atrial Fibrillation on Eliquis, and history of Stroke. Review of the clinical record was conducted 11/20/2023-11/21/2023. Review of Nurses Notes…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-06-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of facility policy, the facility failed to protect the resident's right to be free from physical abuse by staff CNA C and CNA D for one (Resident (R) 42) of two residents reviewed for abuse. CNA C and CNA D caused bruising on R42's lower arms. This is harm. Findings include: Review of R42's Face Sheet printed from the electronic medical record (EMR) Resident Info tab showed medical diagnoses that included generalized muscle weakness, abnormalities of gait and mobility, and dementia. Review of a facility investigation showed that on 12/04/22 CNA C and CNA D were going to change R42 using a blue brief (incontinent product). R42 requested a pull up style product and relayed she was told No and that she would be changed whether she liked it or not. R42 stated that she tried to fight them by hitting and clawing but the aides held her arms. The bruising to the lower arms was photographed and included in the facility investigation. The facility investigation showed the two certified nurse aides had been suspended during the investigation;…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-11-21 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to implement the person-centered care plan for one resident (Resident # 1) in a survey sample of 4 residents. Findings included: For Resident # 1, the facility staff failed to implement the care plan intervention of use of a gait belt during a transfer from the Geri-chair to bed on 10/28/2023. Resident # 1 was admitted to the facility on [DATE] for skilled nursing care services with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with Chronic Hypoxic Respiratory Failure, Chronic Heart Failure, Atrial Fibrillation on Eliquis, history of Stroke. Review of the clinical record was conducted on 11/20/2023 and 11/21/2023. Review of Nurses Notes revealed documentation of an incident on 10/28/2023 when Resident # 1 received a deep laceration on the right lower leg from a jagged edge on the bed frame. The Nurses note written on 10/28/2023 at 7:38 p.m. by LPN (Licensed…

  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 · Fcited before2023-06-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview and facility documentation review, the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food service safety in the main kitchen, which had the potential to affect Residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to wear proper hair restraints when in food preparation areas. On 6/13/23 at 11:30 AM, during an inspection of the kitchen, Surveyor C observed the Assistant Administrator/Employee F enter the kitchen and walk halfway into the kitchen which was around the steam table area. The Dietary Manager/Employee D noticed that the Assistant Administrator did not have any type of hair restraint (hair net or hat) on and immediately asked him to exit the kitchen. Employee F did leave the kitchen and did not re-enter. On 6/13/23 at approximately 11:45 AM, while conducting an inspection of the kitchen Employee E, who was a dietary aide, was observed working the tray line, assisting with meal trays for the lunch meal. Employee E did not have a beard guard on…

  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 · E2023-06-29 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure that four of four residents (Resident (R) 19, R35, R54, and R65) reviewed for bed rail use, had documented alternatives to the use of bed rails before the rails were used. Findings include: 1. Review of R19's quarterly Minimum Data Set (MDS) assessment reference date (ARD) of 05/18/23 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, or indicative of being cognitively intact. During an interview on 06/13/23 at 1:51 PM, it was noted that R19 had bilateral upper side rails on her bed. Review of Bed Rail Entrapment Risk Evaluation forms, dated 02/15/23 and 05/23/23, found no documentation regarding what alternatives were attempted prior to the use of bed rails. A review of the facility admission packet showed the Bed Rail Consent was included as a blank form to be completed with the other admission forms. In an interview on 06/15/23 at 12:50 PM the Admission/Resident Navigator, Employee J, stated, The form is in the admission packet and is signed and then nursing staff is to go 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 · D2023-06-29 · 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 observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide care and services in accordance with professional standards for 2 residents, Residents #229 and #6, in a survey sample of 44 residents. The findings included: 1. For Resident #229, facility staff failed to administer medications as ordered by the physician on 4/1/22 and 4/5/22. On 6/14/23, Resident #229's clinical record was reviewed and revealed physician orders, schedule times, and actual administration times as follows: *Carbidopa 25mg-levodopa 100mg tablet (1/2 tab) TABLET Oral, Two times daily for Five Days--scheduled for 4/1/22 at 6:00 PM--documented as given at 8:07 PM *Carbidopa 25mg-levodopa 100mg tablet (1/2 tab) TABLET Oral, Three times daily for Five Days--scheduled for 4/5/22 at 6:00 PM--documented as given at 8:47 PM On 6/15/23, an interview was conducted with the Director of Nursing (DON) who confirmed the findings and…

  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 · D2023-06-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide the care and assistance for personal grooming for one of 44 residents (Resident (R) 35). Findings include: Observation of R35 on 06/14/23 at 9:06 AM showed the female resident had minimum half inch long facial hair on the lower right cheek and chin. In an interview on 06/14/23 at 12:54 PM, R35's family member stated, As of March 1 she was put on hospice and a CNA [certified nurse aide] was assigned she did things like that [shaving]. The CNA had shoulder surgery and the facility has not done it [shaved R35]. In an interview and observation on 06/14/23 at 4:45 PM, CNA B confirmed R35 had facial hair and stated She can switch on you and may or may not let you shave her. She's hospice also and they also help out. At 4:50 PM on 06/14/23, the Director of Nursing [DON] entered R35's room, observed R35 and asked her if she wanted the facial hair shaved off. R35 responded Yes. The DON exited the room and confirmed that R35 needed to be shaved. Review of the facility policies titled, Bath (Bed), Bath…

  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 · D2023-06-29 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store controlled medications appropriately in 1 of 3 medication carts within the facility. The findings included: The facility staff failed to secure controlled medications in a separately locked, permanently affixed compartment. On 6/13/23 at 2PM, the pharmacy delivery arrived. LPN C was observed to receive and sign for controlled medications from the delivery person. While Surveyor C was conducting medication administration observations with LPN B, LPN C approached with several packets of controlled medications and said she would secure them in her (LPN C's medication cart) until LPN B was able to receive them and log them. On 6/13/23 at 2:40 PM, LPN C was asked about the controlled medications. LPN C said she still had them secured in her medication cart. Surveyor C asked to see them. LPN C opened one of her drawers on the medication cart and received 4 cards of controlled medications. When asked why they were not secured under double lock, she said she was just holding them…

  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 · D2023-06-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  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 documentation review, the facility staff failed to provide an influenza vaccine for 1 resident, Resident #69, out of 5 residents reviewed for influenza immunization. The findings included: The facility staff failed to provide influenza immunization for Resident #69. On 6/14/23 at approximately 10:30 AM, a clinical record review was performed and revealed Resident #69, who was admitted to the facility on [DATE], had no documentation with regard to influenza immunization, to include the resident's current influenza vaccination status, offer to provide immunization against influenza infection, or documentation of resident refusal or medical contraindication. On 6/14/23 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical record for Resident #69 and verified the findings. The DON confirmed there was no additional information. A facility policy was requested and received. On 6/15/23 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-29 · tag F0887 — isolated
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 1 resident, Resident #69, in a survey sample of 5 residents reviewed for COVID-19 vaccination. The findings include: The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Residents #69. On 6/14/23 at approximately 10:30 AM, a clinical record review was performed and revealed Resident #69 completed a primary COVID-19 vaccine series on 9/27/21, however there was no evidence that Resident #69 had been offered or received a COVID-19 bivalent booster dose. On 6/14/23 at approximately 4:15 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the facility policies and procedures follow CDC (Centers for Disease Control and Prevention) guidance and recommendations for resident COVID-19 immunization. The DON stated there were no concerns with the facility's ability to provide COVID-19 immunizations to residents. The DON stated that it is expected for all residents…

  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 · D2023-06-29 · tag F0942 — isolated
  Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and facility documentation review, the facility staff failed to ensure employees received Resident Rights training and education for 1 employee, (Employee #28), in a sample of 5 employees reviewed for training. The findings included: For Employee #28, the facility staff failed to provide any evidence of Resident Rights training. On 6/14/23, the facility Administrator was asked to provide in-service training for 5 employees. On the afternoon of 6/14/23, the facility administrator submitted training records for 4 of the 5 employees being sampled. The Administrator stated they were still looking for Employee #28's records. On the morning of 6/15/23, the facility Administrator acknowledged they were still trying to pull together Employee #28's training records. On 6/15/23 at 12:15 PM, the facility administrator was asked to provide the facility policy with regards to annual training needs of staff. The Administrator let the survey team know they do not have a policy with regards to annual in-service/training of facility staff. The facility administration…

  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 · D2023-06-29 · tag F0943 — isolated
  Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and facility documentation review, the facility staff failed to ensure employees received training on abuse, neglect and exploitation for 1 employee, (Employee #28), in a sample of 5 employees reviewed for training. The findings included: For Employee #28 who had been an employee for greater than 2 years, the facility staff failed to provide any evidence of training on abuse, neglect and exploitation. On 6/14/23, the facility Administrator was asked to provide in-service training for 5 employees. On the afternoon of 6/14/23, the facility administrator submitted training records for 4 of the 5 employees being sampled. The Administrator stated they were still looking for Employee #28's records. On the morning of 6/15/23, the facility Administrator acknowledged they were still trying to pull together Employee #28's training records. On 6/15/23 at 12:15 PM, the facility administrator was asked to provide the facility policy with regards to annual training needs of staff. The Administrator let the survey team know they do not have a policy with regards to annual…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$9,311 in federal fines across 1 penalty.

• $9,311 — penalty dated 2023-11-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MARQUIS HEALTH SERVICES — 87 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 36 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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