Shepherd of the Valley Rehabilitation and Wellness

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.

36.6% 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 219 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 51.6% 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 182 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 192 beds and averages 161.9 residents a day — about 84% occupied, or roughly 30 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 3.26 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 2.27 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 2.65 hrs/resident/day on weekends vs 3.50 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.69 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%.

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 fewer than at the previous inspection — improving. 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.

39 citations, most serious first. The 17 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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

  Based on observation, staff interview, incident report review, medical record review, manufacturer's recommendation review, and mechanical lift reference guide review, the facility failed to ensure safe staff practices and safe working condition of assistive devices for 1 of 4 sample residents (#1) reviewed for accident hazards. This failure resulted in a cervical fracture to resident #1 who fell during a mechanical lift transfer which resulted in the determination of immediate jeopardy due to a failure to follow manufacturer's instructions for safe mechanical lift transfers. Corrective measures were implemented prior to the survey and compliance was determined to be met on 2/16/26. The findings were: 1. Review of the 11/13/25 quarterly MDS assessment showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact and had diagnoses which included morbid obesity, heart failure and renal insufficiency. Further record review showed the resident was dependent with transfers and required the use of a full body mechanical lift. The following…

  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 · Gcited before2025-05-22 · 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 medical record review, resident representative and staff interview, facility incident review, and performance improvement plan review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 of 8 sample residents (#12). This failure resulted in actual harm to resident #12. Corrective measures were implemented prior to the survey and compliance was determined to be met on 5/16/25. The findings were: 1. Review of the discharge MDS assessment dated [DATE] for resident #12 showed the resident admitted to the facility on [DATE] and a brief interview for mental status score of 2 out of 15, which indicated severe cognitive impairment. Further review showed the resident had wandering behaviors which occurred daily and diagnoses which included encephalopathy and restlessness and agitation. The following concerns were identified: a. Review of a facility incident report dated 4/28/25 and timed 3:50 PM showed resident #12 wandered into the room of resident #11,…

  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 · Past Non-Compliance
• Actual harm · G2025-03-20 · 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 resident representative and staff interview, medical record review, and policy review, the facility failed to notify residents' physicians with changes of condition or treatment for 2 of 10 sample residents reviewed (#9, #10). This failure resulted in actual harm to resident #9 who required additional surgical intervention. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included wound infection, displaced simple supracondylar fracture without intercondylar fracture of the right humerus, unspecified open wound of the right elbow, and methicillin resistant staphylococcus aureus. Further review showed the resident had a surgical wound. Review of the care plan, initiated on 10/22/24 showed .I admitted with a right elbow surgical wound that has an infection and interventions included dressing changes as ordered. The following concerns were identified: a.…

  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
• Actual harm · Gcited before2025-03-20 · 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 observation, resident representative and staff interview, medical record review, and policy review, the facility failed to provide quality of care for 3 of 10 sample residents (#2, #4, #10). This failure resulted in actual harm to resident #4 who was hospitalized for sepsis infection. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included diabetes mellitus, neuropathy, and renal insufficiency, renal failure, or end-stage renal disease. Further review showed the resident was at-risk for developing pressure ulcers/ injuries, had no venous or arterial ulcers, and no other ulcers, wounds, or skin problems present. Review of the care plan initiated on 1/27/25 showed I have potential for pressure ulcer development and skin breakdown . and interventions which included an air mattress for skin integrity. The following concerns were identified: a. Review of…

  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 · G2025-03-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident representative and staff interview, and medical record review, the facility failed to ensure residents received necessary treatment and services to promote healing, prevent infection, and prevent new ulcer development for 1 of 5 sample residents (#9) review for pressure ulcers. This failure resulted in actual harm to resident #9 who required additional surgical intervention. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included wound infection, displaced simple supracondylar fracture without intercondylar fracture of the right humerus, unspecified open wound of the right elbow, and methicillin resistant staphylococcus aureus. Further review showed the resident had a surgical wound. Review of the care plan, initiated on 10/22/24 showed .I admitted with a right elbow surgical wound that has an infection and interventions included…

  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 before2024-09-10 · 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 medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 4 allegations reviewed, which resulted in actual harm to resident #1. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/6/24. 1. Review of the 8/18/24 quarterly MDS assessment showed resident #1 (victim) had severely impaired cognitive skills, had a diagnosis of non-Alzheimer's dementia, wandered daily, and exhibited physical behaviors 1-3 days a week. 2. Review of the 7/17/24 quarterly MDS assessment showed resident #2 (perpetrator) had a BIMS score of 10, indicating moderate impairment. In addition, the resident had diagnoses including traumatic brain injury and non-Alzheimer's dementia, and did not exhibit behaviors. Review of the the care plan, initiated 11/13/23, showed the resident had a behavior problem of making comments about being violent to women in the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-03-22 · 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 medical record review, family and staff interview, and the resident's family's written timeline, the facility failed to ensure timely assessment and treatment for 1 of 5 sample residents (#1) with a change of condition. This failure resulted in actual harm for resident #1 who was transferred to the hospital and passed away while in the emergency room waiting area. The findings were: 1. Review of the admission MDS assessment dated [DATE], showed resident #1 had a brief interview for mental status score of 9 out of 15, which indicated moderate cognitive impairment, and required moderate assistance with toileting, dressing, and personal hygiene. Further review showed the resident received antiplatelet therapy (to prevent blood clots). 2. Review of the physician orders for February 2024 showed resident #1 received Reglan (anti-emetic) 10 mg by mouth 4 times a day for 7 days for treatment of enteritis and ondansetron (anti-emetic) 4 mg by mouth every 6 hours as needed for nausea/vomiting. Further review…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-13 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and staff interview, the facility failed to ensure infection prevention practices were implemented for 3 of 3 sampled residents (#7, #8, #9) reviewed for infection control. The findings were:1.Review of the 2/20/26 quarterly MDS assessment for resident #7 showed a BIMS score of 2 out of 15, which indicated severe cognitive impairment and had diagnoses which included cancer, depression, and non alzheimer's dementia. In addition the resident had lower extremity impairment, was wheelchair bound, and required substantial to maximal assistance with toileting hygiene. a. Observation on 3/10/26 at 11:58 AM showed approximately 100 milliliters of amber colored urine in a urinal hanging from a trash can next to resident #7's recliner. Further observation showed a dark blue and black discoloration inside the urinal and a dried yellow substance around the opening of the urinal. The urinal was not labeled with a date.b. Interview with CNA # 3 on 3/10/26 at 1:18 PM revealed residents' urinals were emptied every 2 hours and replaced with a new one monthly. c. Interview with…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, medical record review and review of the bathing schedule, the facility failed to ensure activities of daily living were maintained based on the needs and choices of 1 of 3 sample residents (#11) reviewed for bathing. The findings were: 1.Review of the 1/23/26 quarterly MDS assessment for resident #11 showed a BIMS of 3 out of 15, which indicated severe cognitive impairment and diagnoses which included a history of hip fracture, stroke, anxiety and depression. Review of the care plan dated 10/24/25 showed the resident preferred bathing twice a week. Further review showed s/he required maximum assist with bathing and showering.a. Review of the resident's bathing record from 12/10/25 through 1/6/25 showed showers were completed twice weekly until 1/14/26, at which time they were decreased to once a week.b. Interview with the administrator on 3/12/26 at 10:50 AM revealed the resident had moved from another unit on 12/30/25 and his/her shower preferences should have been reassessed and had changed; however, no evidence of reassessment was provided. c. Interview…

  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 before2026-01-29 · 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, resident and staff interview, and medical record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 3 sample residents (#1). The following concerns were identified: Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15 which indicated s/he had moderately impaired cognition, and diagnoses which included non-Alzheimer's dementia, depression, and cancer. Review of the care plan last revised on 11/19/25 showed the resident was a moderate risk for falls related to confusion, gait and balance problems, and psychoactive drug use. Further review showed a care plan intervention initiated on 11/25/24 was to be sure the resident's call light was within reach. Review of the Braden Scale for Predicting Pressure Sore Risk dated 1/2/26 showed the resident scored 16 out of 23, which indicated the resident was at risk for skin breakdown. The following concerns were identified:a. Observation 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-31 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview and medical record review, the facility failed to ensure activities meet the interest/needs of each resident for 4 of 6 sample residents (#22, #30, #41, #61) reviewed for activities. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #30 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included amputation. Further review showed the resident indicated it was very important to go outside and get fresh air when the weather was good and somewhat important to listen to music s/he liked and to do his/her favorite activities. Review of the care plan last revised on 10/22/24 showed the resident would like staff to continue to invite him/her to activities that may be of interest, and encourage him/her to participate in activities of interest. The following concerns were identified a. Interview with the resident on 10/28/24 at 2:45 PM revealed s/he was unaware of any group activities…

  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 · E2024-10-31 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interviews and medical record review, the facility failed to ensure sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on 2 of 5 resident care units (south, east). The census was 155. The findings were: 1. Interview with 10 residents during the resident council meeting on 10/29/24 at 9:28 AM revealed turnover in CNAs and the facility being short-staffed has resulted in care not being provided timely, call lights were not answered for 30 to 40 minutes, beds were not made, and rooms did not look nice. The group felt the facility needed more staff. 2. Interview with resident #41 on 10/29/24 at 10:21 AM revealed there was never enough staff. 3. Interview with resident #67 on 10/29/24 at 2:42 PM revealed sometimes the facility did not have enough staff. 4. Interview with resident #24 on 10/29/24 at 10:03 AM revealed s/he felt the facility could use more staff and call lights were not always answered timely. 5. Interview with resident #22 on 10/29/24 at 2:12 PM revealed s/he did 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-31 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  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 medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified for 5 of 5 sample residents (#45, #96, #72, #114, #120) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #45 had a BIMS score of 7 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia, seizure disorder, anxiety disorder, depression, psychophysiological insomnia, and severe intellectual disabilities or severe mental retardation. Further review showed the resident received antipsychotic medication, antianxiety medication, and antidepressant medication during the look back period. Review of the physician orders showed the resident received Ativan (antianxiety) 1 milligram (mg) by mouth three times per day for anxiety, bupropion (antidepressant) 300 mg by mouth daily for depression, buspirone (antianxiety) 10 mg by mouth three…

  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 · Ecited before2024-10-31 · 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

  Based on observation, staff interview, and policy review, the facility failed to label and provide the date medications were opened in 2 of 6 medication storage areas (south hall medication cart #1, south hall medication cart #2). The findings were: 1. Observation of the South Hall medication cart #1 on 10/29/24 at 2:50 PM showed the following three Lantus Solostar Insulin pens, two Novolog Insulin Aspart pens, and a Humalog Insulin pen which were opened and not dated. 2. Observation of the South Hall medication cart #2 on 10/29/24 at 2:35 PM showed the following one Novolog Insulin Aspart pen which was opened and not dated. 3. Interview with the RN #1 on 10/29/24 at 2:35 PM revealed insulin pens should be labeled with the date they were opened. 4. Interview with the DON on 10/31/24 at 10:41 AM revealed the nursing staff were responsible for labeling multidose medications with the resident's name and the date the medication was opened. 5. Review of the policy titled Medication Storage and Handling dated 6/23 showed .multi-dose vials which have been opened or accessed should be dated…

  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 · E2024-10-31 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interview, medical record review, bath schedule log review, and policy and procedure review, the facility failed to ensure medical records were accurately documented for 3 of 5 sample residents (#22, #27, #130) reviewed for bathing. The findings were: 1. Interview with resident #22 on 10/29/24 at 2:12 PM revealed s/he did not always receive showers. The resident revealed during the beginning of October, s/he went without showers for a while at the end of September and beginning of October and then only provided 1 shower per week due to staffing issues. Review of the 30-day bathing record on 10/30/24 showed the resident received no showers prior to 10/21/24 and the resident was marked not applicable on 10/10/24 and 10/16/24. Review of the updated 30-day bathing record on 10/31/24 showed the resident received showers on 10/3/24, 10/8/24, and 10/14/24, which were not previously documented. Further review showed the showers were documented by the DON. Review of East Station Bath Schedule logs for 10/3/24, 10/8/24, and 10/14/24 showed the resident was listed…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-31 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure restorative nursing care was provided to maintain residents' ability to carry out activities of daily living for 2 of 3 sample residents (#22, #100) reviewed for restorative nursing. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #22 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included an unspecified fracture of right lower leg, morbid obesity, and other muscle spasms. Further review showed the resident had functional limitation in range of motion for bilateral upper and lower extremities and no restorative programming was performed during the 7-day lookback period. The following concerns were identified: a. Interview with the resident on 10/29/24 at 2:12 PM revealed s/he recently declined with transfers and now had to use a full body mechanical lift instead of a sit-to-stand mechanical…

  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 before2024-10-31 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and policy review, the facility ensure infection control procedures were implemented for 1 of 2 sample residents (#77) reviewed for enhanced barrier precautions. The findings were: 1. Observation of resident #77's room door on 10/29/24 at 9:56 AM revealed an Enhanced Barrier Precaution (EBP) stop sign posted on the outside of the room door. Observation of personal care for the resident at that time showed RN #2, wore gloves and no gown and was crawling on the residents' mattresses, which were on the floor. The RN removed the resident's gastric tube dressing then assisted CNA #1 to reposition the resident to the edge of the mattress. RN #1 bear hugged the resident and lifted him/her up and onto the shower chair while CNA #1 held and positioned the shower chair. Further observation showed there were no gowns in the room; however, the RN stated there was a whole box at one time. Further interview with the RN at that time revealed the EBP sign on the door indicated that staff were supposed to wear a gown along with gloves for high contact 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.

  Infection Control 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

$97,031 in federal fines across 5 penalties.

• $26,685 — penalty dated 2026-03-13
• $12,438 — penalty dated 2025-05-22
• $15,857 — penalty dated 2025-03-20
• $7,718 — penalty dated 2024-08-15
• $34,333 — penalty dated 2024-03-22

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 EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 13 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.

5 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 $353K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WY