The Legacy Living and Rehabilitation 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.

55.8% 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 189 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.8% 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 67 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% 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 160 beds and averages 71.5 residents a day — about 45% occupied, or roughly 88 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 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 3.92 hrs/resident/day on weekends vs 4.86 on weekdays — 19% thinner on weekends. RN hours go from 1.07 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

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.

38 citations, most serious first. The 18 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-01-17 · 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 observation, medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 sample residents (#6) reviewed for abuse and neglect. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to the lack of necessary services to ensure residents' safety. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #6 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses…

  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
• Immediate jeopardy · Jcited before2025-01-17 · 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 medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed ensure residents received adequate supervision to prevent accidents for 1 of 3 sample residents (#6) reviewed for accident hazards. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to a lack of implementation of interventions, including adequate resident supervision. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #6 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive…

  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 before2025-04-15 · 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 observation, staff interview, medical record review, facility incident investigation review, and performance improvement plan review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 3 of 4 sample residents (#1, #3, #5) involved in a resident-to-resident altercation. This failure resulted in actual harm to resident #1 who suffered a hematoma above his/her left eyebrow and an abrasion under his/her left eye. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 4/8/25. The findings were: 1. Review of the 1/10/25 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain injury, Alzheimer's disease, and non-Alzheimer's dementia. The resident had a BIMS score of 0 out of 15 which indicated severe cognitive impairment and signs and symptoms of delirium including inattention and disorganized thinking which…

  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 · G2025-01-17 · 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 and physician and staff interview, the facility failed to respond to a change of condition for 1 of 4 sample residents (#3) who experienced a change of condition. This failure resulted in actual harm to resident #3 who reported health concerns and passed away. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, hypertension, peripheral vascular disease, diabetes mellitus, cerebrovascular accident, anxiety disorder, depression, and asthma. Further review showed the resident required supervision or touching assistance with transfer and toileting hygiene. The following concerns were identified: a. Review of a progress note dated [DATE] and timed 7:30 AM showed .Nurse called to room per staff with resident c/o [complaints of] feeling like [s/he] has Pneumonia and wants an ambulance to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-19 · 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 investigation review, and policy and procedure review, the facility failed to ensure a resident's right to be free from physical abuse, verbal abuse, and neglect for 1 of 6 sample residents (#1). The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 6/18/24. 1. Review of a quarterly MDS assessment dated [DATE] showed resident #1 had brief interview for mental status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The resident had behaviors which included inattention, disorganized thinking, delusions and wandering and s/he was totally dependent on staff for toileting, showering, dressing and personal hygiene. Further review showed the resident had diagnoses which included dementia with other behavioral disturbance, anxiety, transient alteration of awareness, muscle weakness, and need for assistance with personal…

  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 before2024-05-23 · 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, staff interview, policy and procedure review, and review of the state licensing division incident report form, the facility failed to protect the resident's right to be free from abuse by another resident for 3 of 10 residents reviewed for abuse (#26, #63, #106). This failure resulted in harm to resident #106 who experienced sexual abuse. The findings were: 1. Review of the [DATE] admission MDS assessment for resident #106 showed s/he was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. The resident had a BIMS score of 3/15 (severe cognitive impairment), did not exhibit any behaviors, and require supervision or touching for walking up to 50 feet. The following concerns were identified: a. Review of a [DATE] alert note showed CNA notified writer that another resident was found with [his/her] hand up this residents shirt touching [resident's upper chest]. CNA immediately separated residents and notified writer. Writer assessed receiving resident 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-23 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (#98) reviewed for dementia care. This failure resulted in actual harm to resident #98. The findings were: 1. Review of the 2/9/24 significant change MDS assessment for resident #98 showed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, traumatic brain injury, and depression. The resident had a staff assessment which determined the resident to have severe cognitive impairment. Further review showed the resident had not been prescribed any high-risk medications. Review of the resident's care plan, initiated on 10/20/23, showed the resident was at risk for elopement and wandering related to dementia. The staff were to intervene as appropriate. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-27 · 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 resident and staff interview, medical record review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 2 sample residents (#5). This failure resulted in actual harm to resident #5 who had injuries to his/her hands/wrists. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 2/15/24. The findings were: 1. Review of resident #5's quarterly MDS assessment dated [DATE] showed the resident had a brief interview for mental status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. The resident had diagnoses which included non-Alzheimer's dementia. Review of the care plan provided by the facility on 2/27/24 showed Activity of Daily Living (ADL) self-care performance deficit related to dementia, poor safety awareness. Does not like showers. [Residents name] frequently has refusals of care, family states this is common behavior prior to admission.…

  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
• Potential for harm · E2026-03-13 · 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 medical record review and staff interview, the facility failed to ensure transfer and/or discharge notices included the reason for transfer or discharge for 4 of 5 sample residents (#1, #3, #77, #79) reviewed for transfer and discharge. The findings were: 1. Review of a progress note for resident #79 dated [DATE] and timed 2:19 PM showed .This nurse was notified of resident unwitnessed fall. Upon assessment, resident was found to be A&Ox1 [alert and oriented times 1] and slightly decreased LOC [level of consciousness], noted by increased response times. Resident was found to have an abnormal pulse on left wrist and clammy skin. Resident was incontinent at the time of fall, per staff report. Provider on call aware of clinical findings and transfer to ER [emergency room] obtained . The following concerns were identified: a. Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-13 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (#37, #63) reviewed for dementia care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] for resident #63 showed the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia and anxiety. Review of the resident's care plan, initiated on 1/26/26 revealed the resident had behavioral symptoms which included wandering into other resident's rooms, taking others food and scavenging for food throughout the environment. Interventions were to reorient resident to her/his own food during mealtimes, redirect resident and intervene as appropriate. The following concerns were identified: a. Observation on 3/10/26 at 5:39…

  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 · D2026-03-13 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 a resident, whose hospitalization or therapeutic leave exceeded the bed-hold period under the State plan, was allowed to return to the facility for 1 of 4 sample residents (#79) reviewed for transfer and discharge. The findings were: 1. Review of a progress note for resident #79 dated [DATE] and timed 2:19 PM showed .This nurse was notified of resident unwitnessed fall. Upon assessment, resident was found to be A&Ox1 [alert and oriented times 1] and slightly decreased LOC [level of consciousness], noted by increased response times. Resident was found to have an abnormal pulse on left wrist and clammy skin. Resident was incontinent at the time of fall, per staff report. Provider on call aware of clinical findings and transfer to ER [emergency room] obtained . Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs…

  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 · D2026-03-13 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure pre-admission screening was performed after a new diagnosis of mental illness for 1 of 3 sample residents (#6) with qualifying diagnoses. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #6 had diagnoses which included depression and psychotic disorder (other than schizophrenia). The following concerns were identified:a. Review of the PASARR Level I assessment completed on 3/8/21 showed the resident did not have a psychiatric diagnosis and did not present evidence of mental illness which included a possible disturbance in orientation, affect or mood that was not attributable to dementia or other medical diagnosis.b. Review of the medical record showed the new diagnosis of psychotic disorders with hallucinations due to known physiological condition was created on 9/5/25.c. Interview with the NHA on 3/12/26 at 4:19 PM revealed the resident had a new diagnosis of psychosis that was related to 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-13 · tag F0679 — failed to provide activities — isolated
  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 observation, resident and staff interview, medical record review, and activity calendar review, the facility failed to ensure individual activities of preference were provided to 1 of 2 sample residents (#68) reviewed for activities. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #68 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and Review of an Activities-Initial Review dated 6/26/24 showed activities/interests/hobbies the resident participated in included team roping and cribbage. The assessment showed the resident wished to participate in activities while in the home, participate in group activities, participate in outings, participate in 1 to 1 activities with staff, and participate in independent activities. Further review showed activities should be modified to accommodate cognitive deficit and hearing deficit, and assistance should be provided to get the resident to activities. Review of the Activities care plan last…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and policy review, the facility failed to ensure adequate supervision was provided to prevent resident injuries for 1 of 8 sample residents (#21) reviewed for accident hazards. The findings were: 1. Review of the MDS assessment dated [DATE] showed resident #21 had a BIMS score of 0 which indicated severe cognitive impairment and had diagnoses of Alzheimer's Disease and Non-Alzheimer's Dementia. Review of resident #21's care plan dated 8/2025 and last revised on 4/28/25 identified that the resident was at risk for falls related to dementia, and poor safety awareness. The following concerns were identified:a. Interview with CNA #1 on 3/13/26 at 10 AM revealed the resident had been sitting at the end of long table in the dining room where his/her chair was pushed up to the table. The resident tried to push the chair out, was unable to get back far enough, the resident climbed over the arm of chair and fell on the floor. The CNA reported she was not close enough to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · 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 observation, resident and staff interview, medical record review, facility incident investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from mental abuse by another resident for 2 of 6 sample residents (#28, #41) reviewed. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included non-traumatic brain dysfunction, cerebral palsy, anxiety disorder, depression, and bipolar disorder. The following concerns were identified:a. Review of an incident report dated 5/30/25 showed resident #36 reported resident #9 had touched his/her genitalia, in front of resident #36, before lunch. Resident #36 reported s/he told resident #9 You're nasty, go away and resident #9 left. Further review showed resident #36 reported s/he did not feel safe to the unit manager.b. Interview with resident #36 on 9/11/25 at…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · 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 medical record review, staff interview, State Survey agency incident database review, facility incident review, and policy and procedure review, the facility failed to ensure allegations of abuse and investigation findings were reported for 3 of 6 sample residents (#9, #36, #41) reviewed for abuse allegations. The findings were:1. Review of a progress note for resident #9 dated 4/12/25 and timed 5:05 PM showed Note Text: 4/11/2025 09:12 CNA documentation: I was informed by another resident that [resident #9] was being inappropriate at breakfast. Resident told her that [s/he] wanted [him/her] to touch [his/her] [genitals] during breakfast. Informed other resident to alert staff if it occurs again. Receiver calm and required no interventions. 2. Review of a progress note for resident #41 dated 6/4/25 and timed 2:13 PM showed LATE ENTRY Note Text: Nursing staff communicated to leadership and social services resident stated a [male/female] resident exposed [his/her] genitals to [him/her]. SW [social worker]…

  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 before2025-09-11 · 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 medical record review, staff interview, state survey agency incident database review, facility incident review, and policy and procedure review, the facility failed to ensure allegations of abuse were thoroughly investigated for 2 of 6 sample residents (#9, #41) reviewed for abuse. The findings were: 1. Review of a progress note for resident #9 dated 4/12/25 and timed 5:05 PM showed Note Text: 4/11/2025 09:12 CNA documentation: I was informed by another resident that [resident #9] was being inappropriate at breakfast. Resident told her that [s/he] wanted [him/her] to touch [his/her] [genitals] during breakfast. Informed other resident to alert staff if it occurs again. Receiver calm and required no interventions.2. Review of a progress note for resident #41 dated 6/4/25 and timed 2:13 PM showed LATE ENTRY Note Text: Nursing staff communicated to leadership and social services resident stated a [male/female] resident exposed [his/her] genitals to [him/her]. SW [social worker] [name] and SW [name] met…

  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 before2025-09-11 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 and resident interview, incident investigation review, and policy and procedure review, the facility failed to ensure residents with dementia received treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 sample residents (#9) reviewed for dementia care. The findings were:1. Review of the annual MDS assessment dated [DATE] showed resident #9 had a brief interview for mental status score of 5 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and unspecified dementia with psychotic disturbance. Further review showed the resident had no behavior symptoms present and had a foley catheter in place. Review of the care plan last revised on 9/10/25 showed the resident had a risk behavior challenge r/t [related to] Specify Behavior: history of making sexually suggestive comments to other residents, often comments are associated with catheter. Interventions…

  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

$115,597 in federal fines across 4 penalties.

• $14,505 — penalty dated 2025-04-15
• $14,508 — penalty dated 2025-01-17
• $78,566 — penalty dated 2024-05-23
• $8,018 — penalty dated 2024-02-27

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 15 rows in the source record cover these 11 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.

What families pay in WY