Lindengrove New Berlin

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.

49.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 165 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 51.0% 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 51 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 110 beds and averages 82.5 residents a day — about 75% occupied, or roughly 28 beds typically open. It usually has some room. 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.80 on weekdays — 14% thinner on weekends. RN hours go from 0.79 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 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.

32 citations, most serious first. The 14 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · Gcited before2025-09-08 · 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 observation, interview, and record review, the facility did not ensure 2 (R1 & R3) of 3 residents received adequate supervision and assistance devices to prevent accidents.*R1 was admitted to the facility on [DATE] with a history of falls. R1 fell on 8/11/25 while attempting to self transfer. The facility did not thoroughly investigate this fall and was aware of R1's multiple attempts to self transfer but did not address R1's self transferring behaviors. On 8/19/25 R1 fell, was transferred to the hospital and diagnosed with a pelvic fracture. R1 returned to the facility on 8/28/25. On 8/31/25 R1 fell. The facility did not thoroughly investigate this fall.*R3's falls on 6/26/25, 7/7/25, 7/13/25, 7/29/25, 8/2/25, 8/20/25, & 8/26/25 were not thoroughly investigated. On 9/4/25 R3 received the incorrect diet for lunch., putting R3 at risk for choking. On 9/8/25 during morning cares, R3 bed was not lowered according to R3's falls plan of care when CNA-L went into the bathroom and/or left R3's room.Findings…

  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 before2025-06-26 · 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 interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 2 (R1 and R2) residents reviewed for accidents. R1 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. CNA's transferred the resident with 2-person pivot. R1 sustained a leg fracture.R2 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. The CNA transferred the resident alone. R2 sustained a fall from the sit to stand resulting in a head laceration requiring staples.Findings include:R1 admitted to the facility on [DATE] and entered onto Hospice [DATE]. Diagnoses included Atrial Fibrillation, Heart Failure, Peripheral Vascular Disease, Dementia, anxiety, Osteoporosis and Pulmonary Hypertension. R1 passed away at the facility on [DATE].R1's Care Plan documented: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) activity…

  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 before2025-01-21 · 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 interview and record review, the facility did not ensure that residents remain free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (R12) reviewed for accidents. R12 sustained a significant injury to her leg which required surgical intervention. The facility did not complete a thorough investigation as to how the injury occurred. Findings include: R12 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease, Anemia, Atherosclerotic Heart Disease, PVD (Peripheral Vascular Disease), Hypothyroidism, Vascular Dementia with anxiety, Osteoarthritis and Neuromuscular Dysfunction of bladder. R12's BIMS (Brief Interview For Mental Status) Evaluation dated [DATE] documents a score of 4, indicating severe cognitive impairment. R12's admission MDS (Minimum Data Set) dated [DATE] documents: Self-Care Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding…

  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 · G2022-08-10 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 residents were free of a significant medication error for 1 (R86) of 1 resident reviewed for medication errors. R86 did not receive omeprazole as ordered for four weeks resulting in a hospitalization for a gastrointestinal bleed. Findings include: The facility policy and procedure entitled Transcribing Physician's Orders dated 3/2021 states: I. Basic Entry of Physician Orders: A. At the implementation stage, three conditions must be met before a nurse may legally follow through on any medication or treatment order: 1. The medication or treatment order must be valid. 2. The physician and nurse obtaining the order must be licensed. 3. The nurse must know the purpose, actions, effects, major side effects and appropriate dose for all medication orders. B. A valid order is one that leaves no room for doubt as to the directive, treatment or medication prescribed. Medications ordered must have a dose and route, and dosing intervals. All orders must…

  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 · Dcited before2025-09-08 · 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 interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 2 allegations reviewed for neglect/mistreatment to the State Survey Agency during the required timeframe.R2's daughter sent an email to the Nursing Home Administrator regarding a concern of mistreatment and neglect towards R1. This was delayed in being reported to the state agency.Findings include:The Facility Policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed 11/8/23, documents (in part): G. Reporting and ResponseAbuse Policy Requirements:It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R2) of 4 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. * R2 developed a rash and R2's physician was not notified in order for R2 to obtain treatment. Findings include: The facility policy and procedure titled, Standard Skin Protocol, with no date, documents, in part: Goal: Breaks in skin integrity will be minimized with current plan of care.RN: Complete skin assessment on admission, weekly with bath and PRN (as needed).Consult wound certified Nurse PRN.Individual/POA (power of attorney) education regarding minimizing skin breakdown.Notify MD (medical doctor) of changes in skin integrity as nurse observations deem appropriate.R2 was admitted to the facility on [DATE] with pertinent diagnoses that include hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side (a serious neurological condition characterized by paralysis…

  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 before2025-06-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not thoroughly investigate an allegation of abuse or neglect affecting 1 (R3) of 3 Facility Reported Incidents reviewed. R3 was found to have a large bruise to the back of the base of the neck. Staff members that cared for R3 were not interviewed to determine the cause of the bruise. Administration interviewed other residents to determine if they had safety concerns; no residents from R3's unit or floor were interviewed. The report that was filed with the State Agency documented conflicting dates of when the injury of unknown origin was discovered. Findings include: The facility policy and procedure titled Comprehensive 'Abuse', Neglect, Mistreatment and Misappropriation of Resident Property Program dated 11/8/2023 documents: E. INVESTIGATION: ABUSE POLICY REQUIREMENTS: It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI (Quality Assurance and Performance Improvement) Incident…

  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 before2025-01-21 · 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, interviews, and policy review the facility did not utilize a sanitary process for the dishwashing machine. This had the potential to effect all 87 residents in the facility. - The dietary staff was observed handling dirty items and placing them into the dishwashing machine. Then handling the clean items from the dishwashing machine with performing hand hygiene and using the same contaminated hands. Findings include: The facility's policy titled: Manual Dishwashing, undated, was reviewed. The policy documents: . All flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitization. The procedures document under #9 to allow the dishes to air dry; #10 remove the dishes, inspect for cleanliness and dryness, and put them away if clean, Be sure your hands are clean. On 1/15/25, at 1:41 PM, Surveyor observed the dishwashing machine in the main kitchen. The facility has a single dish rack machine. Surveyor…

  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 before2025-01-21 · 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 implement an effective infection prevention and control program. This had the potential to affect all 87 residents, staff, and visitors in the facility. - The facility did not have documentation they investigated infection outbreaks in the facility. - The facility did not have a system to track all facility staff illnesses. - The facility did not implement enhanced barrier precautions for R1 and R50 identified as having wounds. Findings include: The facility's policy titled: Infection Prevention and Control Program dated 12/5/24, was reviewed. The policy documents: To prevent the development and transmission of disease and infection. The Procedure includes: Perform surveillance and investigation to prevent, to the extent possible, the onset and spread of infection. The facility's Outbreak and Isolation Procedures dated 12/5/24 were reviewed. The Procedures include: Initiate timeline documentation of outbreak management. The IP (Infection…

  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 · E2025-01-21 · tag F0761 — failed to label and store drugs safely — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 3 of 4 medication carts and 2 of 2 medication rooms reviewed. Insulin vials and pens were not dated when opened. Findings include: The Facility Policy titled: Vials and Ampules of Injectable Medications dated May 2018, documents (in part) . Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. A. Vials and ampules dispensed by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed. B. Expiration dates: Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this shortened expiration date are both important to be recorded on multidose vials…

  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 · D2025-01-21 · 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 observations, interviews and record review the facility did not ensure it was safe and clinically appropriate for residents to self administer medications for 3 of 3 (R63, R75, and R56) residents observed for self administration of medications. R63 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications. R75 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications. R56 was observed to have medications at bedside. There was no assessment, physicians order or care plan for self administration of medications Findings include: The facility policy titled Self-Administration of Medications dated May 2018, documents (in part) . In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be…

  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 before2025-01-21 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  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 3 (R62, R283, R67) of 7 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the ombudsman. R62 was transferred to the hospital on [DATE] for a change in condition. R62 or their representative did not receive written notification of the reason for the transfer to the hospital and appeal rights and the State Ombudsman was not sent a copy of this notice. R283 was transferred to the hospital on [DATE] for a change in condition. R283 or their representative did not receive written notification of the reason for the transfer to the hospital and appeal rights and the State Ombudsman was not sent a copy of this notice. R67 was transferred to the hospital on 6/13/24 for a change in condition. R67 or their representative did not receive written notification of the reason for the transfer to the hospital and appeal rights and the State Ombudsman was not…

  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 before2025-01-21 · tag F0625 — isolated
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  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 3 (R62, R283, R67) of 7 residents received a written notice of the bed hold policy when they were transferred to the hospital. R62 was transferred to the hospital on [DATE] and did not receive written notice of the bed hold policy. R283 was transferred to the hospital on [DATE] and did not receive written notice of the bed hold policy. R67 was transferred to the hospital on 6/13/24 and did not receive written notice of the bed hold policy. Findings include: 1. The medical record indicates R62 was transferred to the hospital on [DATE] due to a change in condition. Surveyor requested a copy of R62's written notice of the bed hold policy. On 1/14/25, at 3:21 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B who indicate floor nursing is responsible for providing the written notice of bed hold policy if a resident is sent out to the hospital. DON- B states the facility Social Worker (SW) will provide 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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, interviews and record review the facility did not ensure that residents who enter the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 2 (R12) residents reviewed for catheters. R12 admitted to the facility without a catheter. R12 was hospitalized and returned to the facility with a Foley catheter. R12 did not have a diagnosis or clinical condition indicating the necessity of the catheter. Findings include: The facility policy titled: Standard Indwelling Catheter Protocol, undated, documents (in part) . Problem: Individual has Indwelling Catheter. RN (Registered Nurse)/LPN (Licensed Practical Nurse): Obtain order for indwelling catheter. Document type, size, balloon inflation size and indication for use (Neurogenic Bladder, Obstructive Uropathy, for promotion of healing pressure injuries related to incontinence 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.

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

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

Fines & penalties

$100,006 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $55,200 — penalty dated 2025-09-08
• $44,806 — penalty dated 2025-01-21
• Medicare payment denial — starting 2025-02-21 for 12 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.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

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.

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