Tudor Oaks Health Center

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.

60.4% 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 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.6% 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 33 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 50 beds and averages 44.8 residents a day — about 90% occupied, or roughly 5 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.93 hrs/resident/day on weekends vs 4.50 on weekdays — 13% thinner on weekends. RN hours go from 0.75 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 56% 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.

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.

37 citations, most serious first. The 13 most serious are shown; the remaining 24 are one tap away and print in full.

• Actual harm · Gcited before2025-06-16 · 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 interview and record review, the facility did not ensure 6 of 10 residents (R34, R11, R23, R2, R9, and R13) reviewed received adequate supervision and assistance devices to prevent accidents. * R34's fall on 10/29/24 was not thoroughly investigated and a root cause was not determined to help prevent additional falls. On 5/16/25, R34 fell, was transferred to the hospital, and diagnosed with a hip fracture. R34 had been observed prior to this fall coming out the bathroom by herself. The facility did not implement interventions after observing R34 coming out of the bathroom prior to R34's fall. R34 was not assessed by a Registered Nurse (RN) prior to being placed in a wheelchair after the fall even though there was an RN available. The facility's investigation did not include a root cause analysis of R34's fall to help prevent additional falls. * R11 fell from the wheelchair on 5/28/24. The facility did not conduct a thorough investigation as the facility did not investigate how R11 was seated in her…

  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 · Gcited before2025-04-23 · 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 2.) R3 was admitted to the facility on [DATE] with a primary diagnosis of parkinsonism. R3's admission Minimum Data Set (MDS) assessment completed 1/2025 documents that R3 has no cognitive impairment, upper extremity impairment on one side, wheelchair for mobility, does not walk and requires staff assistance with ADLs. R3's Care Area Assessment (CAA) for Falls documents under the Analysis of Findings section: The Fall CAA triggered related to recent fall at home with hospitalization. R3 requires maximum to moderate assist with most ADLs. There were falls reported at home prior to hospitalization and no falls in look back period. On 4/23/25 at 9:30 AM, Surveyor interviewed, and observed, R3 in R3's room. R3 was sitting in their wheelchair with their feet firmly on the ground. R3 had sneakers on their feet. R3 stated they had 2 falls in the facility. The first fall was from the wheelchair. R3 stated the staff told them a driver was here to transport them to an appointment. R3 thought the appointment was a video…

  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 · Gcited before2023-01-05 · 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 interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R2) of 3 Residents reviewed for pressure injuries. R2 developed a coccyx pressure injury which was identified on 12/03/22. The treatment was not implemented until 12/05/22. On 12/06/22, Facility staff assessed R2's pressure injury and incorrectly staged the pressure injury as Stage 2 when there was 70% slough. R2's pressure injury continued to be incorrectly staged, the care plan was not revised after R2 developed the pressure injury, and R2's heels were observed not being offloaded according to the plan of care. Findings include: R2's diagnoses include unspecified protein calorie malnutrition, dementia, anxiety, depressive disorder, and peripheral vascular disease. R2 started receiving hospice services on 11/28/22. The risk for pressure ulcers care plan initiated 5/11/17,…

  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 before2025-12-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents (R4).R4 made an allegation of abuse by a staff member on 9/5/25 and the facility did not put measures into place to correct the abuse and ensure R4 and other residents were kept safe and free from any additional abuse by staff.The facility's abuse policy states, in part:* The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and or misappropriation of resident property is more likely to occur.* An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1.) Identifying staff responsible for the investigation 2.) Exercising caution in handling…

  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 before2025-08-06 · 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 record review and staff interviews, the facility did not always ensure that 3 out of 5 residents reviewed (R11, R297, R298) were free from physical and verbal abuse. R11 was provided cares by an agency CNA (Certified Nursing Assistant) on 6/15/25. During this time, a facility CNA was present in the room and did not intervene when she witnessed the agency CNA being rough with R11. R297 and R298 were allegedly both physically and verbally abused by a facility Registered Nurse on 6/18/25. The facility staff did not ensure that R297 and R298 were kept safe and free from any additional abuse by immediately reporting the allegations of abuse. Findings include: The facility's policy dated as implemented on 4/24/25 and titled, Abuse, neglect and Exploitation documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VI. Protection of ResidentThe 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-06 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interviews, the facility did not ensure that allegations of potential verbal and physical abuse involving 3 out of 5 residents (R11,R297, R298) reviewed were reported to the Nursing Home Administrator (NHA) or Designee and Law Enforcement. The facility did not contact the local law enforcement after they became aware that an agency CNA was witnessed to be rough with R11 when providing cares on 6/15/25. R297 was allegedly physically and verbally abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA . This allegation was not reported to Law Enforcement as a possible crime of abuse. R298 was allegedly physically abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA. This allegation was not reported to Law Enforcement as a possible crime of abuse. Findings include: The facility's policy dated as implemented on 4/24/25 and titled Abuse, Neglect and Exploitation documents: Policy: It is the policy of this facility to provide protections for…

  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 before2025-08-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility did not ensure 1 (R298) of 3 allegations of abuse were investigated.* The facility did not conduct an investigation for R298's allegation of physical abuse.Findings include:The facility's policy titled, Abuse, Neglect and Exploitation and dated 4/24/25, documents under the policy section: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section V. Investigation of Alleged, Abuse, Neglect and Exploitation it documents: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3.…

  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 · Fcited before2025-06-16 · 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, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 resident unit refrigerators in the facility. The facility did not ensure food was stored in a safe manner and, kitchen staff member had beard hair exposed and uncovered while preparing food, which had the potential to affect all 41 Residents currently living in the facility. *Temperature logs were not maintained for unit refrigerator/freezers. *Multiple food items were observed undated on the metal racks located in the facility's freezer. *Hand scoops were observed left in the ready to use sugar, flour, and rice flour bins. *Cook-Q was observed not wearing a beard hair guard on 6/11/25 while preparing food in the kitchen. Findings include: Temperatures Not Documented for Unit Refrigerators and Freezers The facility's undated policy General HACCP Guidelines for Food Safety documents: a.Take the internal temperatures of each unit b. Periodically, take internal temperatures of foods in the unit .…

  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 · Fcited before2025-06-16 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. * The facility was not computing baseline rates of infections for prevalent infections. * The eye wash station was not flushed weekly. * R12 has Stage 2 coccyx pressure injury. R12 was not placed on EBP (enhanced barrier precautions) staff was observed not wearing the appropriate PPE (personal protective equipment) during personal care & treatment observations and hand hygiene concerns were identified during R12's treatment observation. * Hand hygiene concerns were identified during R23's medication administration. * R24 was not placed on EBP. R24 has a heel pressure injury. * R38 was not placed on EBP. R38 has a Stage 2 coccyx pressure injury. * R3's catheter collection bag and tubing was observed during multiple observations to be laying directly on the floor. This has the potential to affect the 41 residents currently…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-16 · tag F0628 — pattern
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 4 (R12, R34, R39, & R41 ) of 4 residents were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed was not documented in the Transfer, Bed hold Notice and readmission Rights form. Findings include: The facility's undated policy titled, Bed Hold Notice documents: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Under Policy Explanation and Compliance Guidelines documents 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifics: a. The duration of the State bed-hold policy, if any, during which the resident…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-16 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R12) of 1 resident was clinically appropriate to self administer medications. * R12 was observed with 7 medication pills in a medication cup on the over bed table next to R12. R12's self administration assessment dated [DATE] documents that R12 not approved for the self-administration of medications. Findings include: The facility's undated policy titled, Resident Self-Administration of Medication documents under the Policy section: It is the policy of this facility to support each resident's right to self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Under Policy Explanation and Compliance Guidelines: document 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident'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 · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not protect 1 (R16) of 1 Resident by not implementing their written policies and procedures to prohibit and prevent the right to be free from verbal abuse from Registered Nurse (RN)-E. * Staff did not report allegations of verbal abuse made by R16 regarding RN-E to the Nursing Home Administrator (NHA)-A immediately. This allowed for additional potential allegations of verbal abuse to occur to other residents whom RN-E provided nursing care to for the remainder of the shift. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. Include training for new and existing staff on activities that constitute abuse, neglect,…

  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 before2025-06-16 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator and/or Grievance Officer. This was observed with 1 (R16) of 1 Resident reviewed for alleged verbal abuse. * An allegation of verbal abuse by Registered Nurse (RN)-E towards R16 was reported by Certified Nursing Assistant (CNA)-G at approximately 4:30 AM to Licensed Practical Nurse (LPN)-F on 4/29/25. LPN-F informed Director of Nursing (DON)-B at approximately 7:00 AM, after RN-E's shift had ended at the facility. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: .Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. Include training for new and existing staff on activities that…

  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

$180,810 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $180,810 — penalty dated 2025-06-16
• Medicare payment denial — starting 2025-07-17 for 62 days

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 AMERICAN BAPTIST HOMES OF THE MIDWEST — 6 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 20 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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 $734K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 WI