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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D40 | E27 | F18 |
| Minimal | A· | B· | C2 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Apr 17, 2026 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Apr 17, 2026 | Health | Health Complaint, Health Standard | 23 | Actual harm | — | Open → |
| Sep 17, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Aug 5, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 12, 2025 | Fire safety | Fire Safety Standard | 9 | Potential harm | — | Open → |
| Mar 12, 2025 | Health | Health Complaint, Health Standard | 12 | Potential harm | — | Open → |
| Dec 27, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 23, 2024 | Fire safety | Fire Safety Standard | 9 | Potential harm | — | Open → |
| May 23, 2024 | Health | Health Complaint, Health Standard | 11 | Potential harm | — | Open → |
| Apr 17, 2024 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Nov 20, 2023 | Health | Health Complaint | 6 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 12, 2025 | Denial of payment for new admissions | — | Apr 24, 2025 · 7 days | 235050|Payment Denial|2025-04-24 |
| Apr 17, 2024 | Civil money penalty (fine) | $15,593 | — | 235050|Fine|58976 |
| Nov 20, 2023 | Civil money penalty (fine) | $15,593 | — | 235050|Fine|58832 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D40 | E27 | F18 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 17, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jun 16, 2026 | |
| Apr 17, 2026 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 | |
| Apr 17, 2026 | E-0030 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Heritage Community of Kalamazoo | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 1966 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Heritage Community of Kalamazoo | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 1966 |
| Jordan Houston | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Mar 19, 2026 |
| Amy Barnes | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 9, 2018 |
| Gerald Easlick Shirely | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 24, 2025 |
| Benjamin Smith | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2024 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Villa at Borgess Place 3057 Gull Road, Kalamazoo, MI 49048 CCN 235289 | 5.8 km | 101 | Apr 21, 2026 | 855 harm | $46k | |
| Medilodge of Portage 7855 Currier Dr, Portage, MI 49002 CCN 235399 | 7.2 km | 117 | May 14, 2026 | 454 harm | $35k | |
| Medilodge of Kalamazoo 1701 S 11th Street, Kalamazoo, MI 49009 CCN 235282 | 7.3 km | 39 | Jun 11, 2026 | 333 harm | — | |
| Friendship Village 1400 N Drake Rd, Kalamazoo, MI 49006 CCN 235248 | 7.7 km | 57 | Apr 2, 2026 | 44 | — | |
| Medilodge of Westwood 2575 N Drake Road, Kalamazoo, MI 49006 CCN 235542 | 8.5 km | 97 | Jul 16, 2026 | 805 harm | $66k | |
| Bronson Commons 23332 Red Arrow Highway, Mattawan, MI 49071 CCN 235434 | 17.6 km | 100 | Jul 23, 2026 | 281 IJ1 harm | — | |
| Alamo Cove Rehab and Nursing Center 8290 W C Ave, Kalamazoo, MI 49009 CCN 235311SFF Candidate | 18 km | 100 | Apr 30, 2026 | 1037 harm | $18k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 235050 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 235050 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness |
| F · Potential harm Widespread |
| Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Apr 17, 2026 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 15, 2026 |
| Apr 17, 2026 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 15, 2026 |
| Apr 17, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 16, 2026 |
| Apr 17, 2026 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2026 | Complaint |
| Apr 17, 2026 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 16, 2026 | Complaint |
| Apr 17, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 15, 2026 | Complaint |
| Apr 17, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 16, 2026 |
| Apr 17, 2026 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 16, 2026 |
| Apr 17, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 15, 2026 | Complaint |
| Apr 17, 2026 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 15, 2026 |
| Apr 17, 2026 | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Jun 16, 2026 |
| Apr 17, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Jun 16, 2026 |
| Sep 17, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 24, 2025 | Complaint |
| Sep 17, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 24, 2025 | Complaint |
| Sep 17, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 24, 2025 | Complaint |
| Aug 5, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 29, 2025 | Complaint |
| Aug 5, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 29, 2025 | Complaint |
| Mar 12, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 1, 2025 |
| Mar 12, 2025 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 21, 2025 | Complaint |
| Mar 12, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Mar 12, 2025 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 21, 2025 |
| Dec 27, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 31, 2025 | Complaint |
| May 23, 2024 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0522 | Have an externally vented heating system. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 28, 2024 |
| May 23, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2024 | Complaint |
| May 23, 2024 | F-0625 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2024 | Complaint |
| May 23, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| May 23, 2024 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Apr 17, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Past non-compliance Mar 1, 2024 | Complaint |
| Apr 17, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 10, 2024 | Complaint |
| Apr 17, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 10, 2024 | Complaint |
| Nov 20, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Dec 19, 2023 | Complaint |
| Nov 20, 2023 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2023 | Complaint |
| Nov 20, 2023 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2023 | Complaint |
| Nov 20, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2023 | Complaint |
| Nov 20, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2023 | Complaint |
| Nov 20, 2023 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 19, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.49 (case-mix index 1.22).
| Amy Barnes | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 9, 2018 |
| Jordan Houston | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 29, 2025 |
| Jordan Houston | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 29, 2025 |
| Amy Barnes | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Nov 9, 2018 |
| Gerald Easlick Shirely | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 24, 2025 |
| Benjamin Smith | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2024 |