Park Forest Care Center LLC

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.

Staffing

How full it usually is: this home is certified for 103 beds and averages 84.4 residents a day — about 82% occupied, or roughly 19 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the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026.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 2.61 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.38 hrs/resident/day on weekends vs 2.70 on weekdays — 12% thinner on weekends. RN hours go from 0.32 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

• Immediate jeopardy · Lcited before2024-12-31 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  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 record review, observation, and interviews, the facility failed to create an environment that protected the right of eight (#1, #2 #3, #4, #5, #6, #7, #8) of eight residents reviewed for abuse out of eight sample residents to be free from abuse. The facility's failure contributed to repeated incidents of abuse and actual harm. Record review and interview revealed Resident #1, under age [AGE], was blind, nonverbal, non-interviewable, severely cognitively impaired, and dependent on care. On 10/14/24 at 9:39 a.m., a housekeeper observed Resident #2 sexually abusing Resident #1 in her bed. Resident #1 had blood in her incontinence brief and was actively bleeding. A review of the facility's investigation of the 10/14/24 incident revealed Resident #2 had previously engaged in inappropriate sexual behavior toward other male and female residents in the facility. Resident #2 grabbed male Resident #4's breast/chest and torso about a year ago and grabbed male Resident #3's buttocks around a month ago. In addition,…

  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 before2026-02-09 · 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 record review and interviews, the facility failed to ensure one (#11) of three residents reviewed for feeding tube out of 22 sample residents received necessary care and services to remain free from neglect. Resident #11 was nonverbal and dependent on staff for nutrition and hydration through a gastrostomy tube (G-tube). The resident was unable to communicate needs, discomfort, or hunger and relied entirely on staff to provide ordered tube feeding. The physician's orders revealed the resident required continuous enteral feeding with scheduled water flushes to meet the resident's nutritional and hydration needs.On 1/28/26, the resident's tube feeding was not administered beginning at 4:00 p.m. until 6:00 a.m. on 1/29/26. Record review revealed no documentation that the ordered tube feeding was provided during this time period. Nursing documentation reflected that the failure to administer the tube feeding was identified after the fact, and the physician was notified on 1/29/26. The facility failed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-02-09 · 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 observations, record review and interviews, the facility failed to ensure two (#5 and #2) of seven residents reviewed for accidents out of 22 sample residents received adequate supervision to prevent accidents. Resident #5 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness.Resident #5 was identified as a high fall risk. On 12/25/25, Resident #5 sustained an unwitnessed fall. On 12/29/25, the resident sustained an additional unwitnessed fall. The facility recommended implementing a communication board due to the resident's difficult communication. However, observations during the survey revealed the staff did not utilize the communication board. Resident #5 sustained an additional fall on 1/1/26, where she hit the back of her head. The resident was transferred to the hospital…

  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 · G2023-11-30 · 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, record review, and interviews the facility failed to provide the necessary treatment and services to prevent a pressure injury from occurring for one (#32) of two residents out of 36 residents. Specifically, the facility failed to implement interventions to reduce pressure injury risk factors for Resident #32 who was identified by the facility as high risk for developing pressure injuries. The resident required extensive assistance for activities of daily living (ADL) and was dependent upon facility staff for bed mobility and transfers. The facility failed to ensure preventative interventions were implemented which resulted in the development of a facility acquired stage 3 pressure injury to the sacrum (base of lower back). Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third…

  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 before2026-02-09 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#1 and #10) of four residents reviewed, out of a total sample of 22 residents, remained free of significant medication errors. Specifically, the facility failed to:-Ensure staff timely and accurately updated Resident #1's Methadone dose and indicated use in his electronic medical record (EMR) per external provider orders; -Ensure staff accurately administered and documented the dose of Methadone Resident #1 received in his medication administration record (MAR); -Ensure staff implemented and documented care interventions to identify, assess, monitor, or treat Resident #1's specific triggering/craving behaviors related to his documented history of substance use disorder (SUD); -Ensure staff obtained a standing order to administer Narcan to Resident #1, who had a history of SUD and was currently prescribed opioid medications; and,-Ensure Resident #10's antibiotic was administered per the provider's order.Cross-reference F842: the facility…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain accurate and complete medical records for one resident (#1), of four residents reviewed out of a sample of 22 residents. Specifically, the facility failed to ensure Resident #1's addiction provider notes were obtained and uploaded into the resident's electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Documentation In Medical Record policy and procedure, dated 12/1/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 3:07 p.m. It read in pertinent part: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.II. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), the diagnoses included displaced fracture of fifth…

  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 · E2025-06-03 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances brought up by the resident council. Findings include: I. Facility policy and procedure The Grievance policy, reviewed 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part, All grievances are forwarded to the grievance official and a written acknowledgment is provided to the complainant within three calendar days of receipt. The grievance official conducts a prompt investigation. Written resolution is provided within 14 calendar days. If more time is needed, interim updates are provided, with justification for delay. II. Resident group interview Five alert and oriented residents (#65, #33, #18, #76 and #39) who regularly attended the resident council meetings were interviewed on 6/2/25 at 1:00 p.m. The residents were identified as alert and oriented through facility and assessment. The group of residents…

  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 before2025-06-03 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' bathrooms; -Ensure housekeeping staff applied alcohol-based hand sanitizer per guidelines when cleaning residents' rooms; -Ensure staff donned appropriate personal protective equipment (PPE) when providing direct care for Resident #45, who was on enhanced barrier precautions (EBP); and, -Ensure staff donned appropriate PPE when providing wound care for Resident #16, who was on EBP. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/5/25 from https://www.cdc.gov/healthcare-associated-…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-03 · tag F0923 — pattern
  Have enough outside ventilation via a window or mechanical ventilation, or both.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for one of two shower rooms and nine of 16 resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in the north shower room and nine resident rooms were working properly. Findings include: I. Facility policy and procedure The Ventilation and Environmental Condition policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, This facility shall maintain ventilation, lighting, and indoor environmental conditions that are safe, functional, and comfortable for residents, staff, and visitors. This policy applies to all maintenance and environmental services personnel responsible for managing heating, ventilation and air conditioning (HVAC), lighting and general facility comfort. Ventilation system requirements include operating HVAC systems in accordance with manufacturer…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-03 · 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 interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) Level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#38) of two residents reviewed for PASRR out of 35 sample residents. Specifically, the facility failed to notify the State Mental Health Agency when a resident received a new diagnosis (bipolar disorder) of a serious mental disorder for a PASRR Level II evaluation. Findings include: I. Facility policy and procedure The PASRR Evaluation and Screening policy, reviewed 1/29/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part, Re-screening is required for; a new or changed psychiatric diagnoses, addition or change in psychotropic medication, or worsening behavioral or cognitive symptoms. II. Resident status Resident #38, age [AGE], was admitted on [DATE].…

  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 before2025-06-03 · 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 IV. Resident #133 A. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances and attention-deficit hyperactivity disorder. The 5/22/25 minimum data set (MDS) assessment revealed that Resident #133 was severely cognitively impaired and unable to participate in the brief interview for mental status (BIMS) assessment. According to the staff assessment for mental status, Resident #133 had short term and long term memory deficits, severely impaired decision making skills and continuous disorganized thinking. Resident #133 was not cognitively orientated to staff names and faces, where his room was or what type of facility he was in. He was independent in his activities of daily living (ADL) and ambulated independently. The MDS assessment indicated Resident #133 had not displayed any wandering behaviors within the seven day assessment look back period. -However, Resident #133 eloped from 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
• Potential for harm · D2025-06-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when 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 observations, record review and interviews, the facility failed to ensure one (#184) of two residents who required respiratory care received care consistent with professional standards of practice out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #184. Findings include: I. Facility policy and procedure The Respiratory Care and Oxygen Administration policy and procedure, revised 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, The facility provides respiratory care, including the administration of oxygen, in accordance with medical orders and based on residents' clinical needs. Care shall be safe and evidence-based. Procedures, including respiratory care, must be ordered by a physician, nurse practitioner, or physician's assistant. Nursing staff will assess residents for signs of respiratory distress upon admission and routinely thereafter. Respiratory…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-03 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#55) of six residents reviewed for medications errors out of 35 sample residents. Specifically the facility failed to ensure Resident #55 was administered Percocet (pain medication) per physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:…

  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 · F2024-12-31 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis Specifically, the facility utilized the DON as a floor nurse several times a week when the facility's average daily census was over 60 residents. Findings include: I. Facility policy and procedures The Staffing policy, dated 8/1/24, was provided by the NHA on 12/31/24 at 4:28 p.m. It read in pertinent part, The facility will maintain sufficient, competent nursing staff to provide care and services 24 hours per day, seven days per week, in alignment with the resident care needs, acuity levels, and applicable state and federal requirements. II. Record review The facility assessment, reviewed 8/8/24, was provided by the NHA on 12/31/24 at 10:57 a.m. and documented the DON was planned to work as a full-time employee as the DON. The DON position description, undated, was provided by the nursing home administrator (NHA) on 12/31/24 at 4:28 p.m. It read in pertinent part, The DON is responsible for overseeing and managing all aspects…

  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

“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

$16,146 in federal fines across 1 penalty.

• $16,146 — penalty dated 2026-02-09

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

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in CO