Pearl Of Orchard Valley
2330 West Galena Boulevard, Aurora, IL 60506 · For profit - Limited Liability company · 203 certified beds · (630) 896-4686 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (65) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $542,423 in federal fines (most recent 2026-03-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.7% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.2% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 96.6% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 80.9% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.5% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 29.5% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.0% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.20 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.61 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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.
44.4% 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 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 57 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 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.4%CMS range 34.4–56.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.5–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 66.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.0–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 203 beds and averages 131.3 residents a day — about 65% occupied, or roughly 72 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.79 hrs/resident/day on weekends vs 3.41 on weekdays — 18% thinner on weekends. RN hours go from 0.90 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
65 citations, most serious first. The 20 most serious are shown; the remaining 45 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review, the facility failed to keep residents free from sexual abuse when R3 sucked on R2's breast. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on February 9, 2026, at 11:30 AM, when R2, a female dementia resident with known inappropriate sexual behaviors was left unsupervised in the dining room with R3, a male dementia resident, and R2 waved R3 over, lifted her shirt, and R3 sucked on R2's breast. This applies to 2 of 4 residents (R2 and R3) reviewed for sexual abuse in the sample of 6. V3 (Assistant Administrator), V17 (Senior Administrator), and V18 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on March 10, 2026, at 11:47 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2026, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: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.
- Immediate jeopardy · Jcited before2025-09-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observations, interviews, and record reviews, the facility failed to ensure the safety and protection of R1, a female resident with severe cognitive impairment, from R2, a male resident with a documented history of wandering and entering other residents' rooms within the secured dementia care unit.This failure resulted in an incident on August 29, 2025, in which R2 entered R1's room without staff awareness. R2 had remained in the room with the door closed for approximately eight minutes. Staff later discovered R2 near R1, with his genitals exposed and near R1's face. This incident was a significant breakdown in supervision necessary to protect vulnerable residents from harm including sexual abuse.This applies to 1 of 2 residents (R1) reviewed for abuse, from a total sample of 11 residents.The facility's failure to supervise and protect R1 from sexual abuse constituted an Immediate Jeopardy to resident health and safety. The Immediate Jeopardy began on August 29, 2025, when staff member V4 (Restorative…
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.
- Actual harm · Gcited beforedisputed · IDR2026-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that individualized interventions were implemented to address identified causative and triggering factors associated with a pattern of falls. The facility also failed to identify and address recurrent urinary tract infections (UTIs) and catheter management issues that contributed to repeated falls. This failure resulted in R1 sustaining a right 5th rib fracture following a fall on May 18, 2026. This applies to 1 of 3 residents (R1) reviewed for falls.The Findings Include: Review of the Electronic Medical Record (EMR) showed that R1, an [AGE] year-old female, was admitted to the facility on [DATE]. Diagnoses included a recent right 5th rib fracture and a current urinary tract infection (UTI). Chronic diagnoses included Type 2 diabetes mellitus, hypertension, dementia, abnormalities of gait and mobility, muscle disorder, lack of coordination, muscle weakness, anxiety disorder, senile degeneration of the brain, obstructive and reflux…
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.
- Actual harm · Gcited before2025-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to assess a resident after an unwitnessed fall. This failure resulted in a delay of treatment for R1 who sustained subdural hematoma after a fall incident. This applies to 1 of 3 residents (R1) reviewed for assessments in the sample of 3. The findings include:R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, delirium due to known physiological condition, unsteadiness on feet, unspecified lack of coordination, unspecified abnormal gait and mobility, muscle weakness, cognitive communicative deficit, and vascular dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's MDS (Minimum Data Set) dated September 11, 2025, shows R1 had severely impaired cognition and required partial/moderate staff assistance to go from sitting to standing, from chair to bed, and getting on and off toilet. R1's care plan shows R1 had…
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.
- Actual harm · Gcited before2025-03-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to monitor a resident's skin for breakdown. This failure resulted in a pressure injury not being identified until it was a stage 3, which delayed treatment, and the wound became infected. The facility also failed to implement pressure ulcer care plan interventions. This applies to 1 of 3 residents (R108) reviewed for pressure injury in a sample of 32. The findings include: On 03/18/2025, observations made at 10:18 AM, 11:01 AM, 12:17 PM, 1:04 PM, and 2:35 PM, showed R108 was visible from his doorway and was lying in bed on his back on a regular mattress. R108 appeared frail and lethargic. The sign on R108's door showed he was on contact and droplet isolation precautions. R108's 3/17/2025 antibiotic care plan showed he was on the antibiotic because of a MRSA (multi-drug resistant organism)/Strep A infection in his wound. On 03/19/2025, observations made at 10:02 AM, 10:58 AM, 12:53 PM, and 2:06 PM again showed R108 lying on his back on a regular mattress. R108's 3/12/2025 Weekly Skin Assessment Tool (effective…
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.
- Actual harm · Gcited before2025-02-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, interview, and record review, the facility failed to implement interventions to prevent a resident from acquiring a pressure ulcer. This failure resulted in R2 developing a stage 2 pressure ulcer on the left ischium. This applies to 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 6. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure. R2's MDS (Minimum Data Set) dated December 27, 2024, showed R2 has moderate cognitive impairment. The MDS continued to show R2 required maximal assistance from facility staff for rolling left to right in bed and was dependent on facility staff for toileting hygiene. R2's skin care plan dated December 24, 2024, showed [R2] has potential impairment to skin integrity related to fragile skin, limited mobility, morbid obesity. The care plan continued 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.
- Actual harm · Gcited before2024-06-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to successfully notify the physician of a significant change in condition in a timely manner and failed to notify administration when the physician's answering service did not respond. As a result of this failure, there was a delay in obtaining treatment and pain relief for R1 for 2 days after swelling and pain was noted. R1's radiology revealed a supracondylar fracture with anterior angulation of the fracture site and a supracondylar fracture of the distal femur with anterior angulation at the fracture site. This applies to 1 of 3 residents (R1) reviewed for pain and injuries of unknown origin. The findings include: The EMR (Electronic Medical Record) shows R1, was a [AGE] year-old, admitted to the facility on [DATE]. The EMR also shows R1's diagnosis that included heart failure, other disorders of psychological development, cardiomyopathy, restlessness and agitation, encounter for palliative care, underweight, personal history of Covid-19,…
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.
- Actual harm · G2024-02-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and provide pain medication for a resident who is in pain. In addition, the facility failed to reassess if the pain medication that was provided was effective. This failure resulted to R97 and R98 to experience severe pain and resulted in R97's inability to complete activities during her physical therapy session. This applies to 2 of 3 (R97 and R98) reviewed for pain management in a sample of 29. The findings include: 1. Face sheet showed that R97 has multiple medical diagnoses which include radiculopathy in the lumbar region, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Minimum Data Set (MDS) dated [DATE] shows that R97 is alert and oriented. R97's active Physician Order Summary shows that she was prescribed Gabapentin Capsule 600 mg (milligrams) twice daily and at bedtime for neuropathy, Hydromorphone HCL (Dilaudid) 4 mg tablet every 6 hours as needed for pain, and Voltaren Arthritis…
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.
- Actual harm · Gcited before2023-09-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services regarding a resident's excoriated sacral areas and follow their plan of care to protect and maintain skin integrity, promote wound healing, and prevent wound infection. This failure resulted in the development of a newly opened wound on R3's right upper thigh, and R2's excoriated sacral areas with active bleeding and was contaminated with urine-soaked incontinence brief. This applies to two of three residents (R2 and R3) reviewed for skin alteration. The findings include: 1. The EMR (Electronic Medical Record) shows that R3, a [AGE] year-old, with diagnoses that included metabolic encephalopathy, morbid obesity, diabetes mellitus type 2, neuropathy, congestive heart failure, vascular dementia, without behavioral disturbance, psychotic and mood disturbance, anxiety, Alzheimer's disease, hypertension, repeated falls, depression, COPD (chronic obstructive pulmonary disease), lack of coordination, reduce…
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.
- Actual harm · Gcited before2023-09-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, interview and record review the facility failed to monitor, identify, and provide specific care interventions for pressure ulcer prevention and treatment for two (R1 and R2) of three residents reviewed for pressure ulcers from a sample of 11. This failure resulted in R1's developing a new pressure ulcer categorized at an advance stage 3 pressure ulcer. The findings include: 1. R1 is a [AGE] year-old resident with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, affecting left dominant side, perforation of intestine, encounter for surgical aftercare following surgery on the digestive system; cutaneous abscess of abdominal wall, generalized muscle weakness, lack of coordination, Crohn's disease, Candida sepsis, depression, bipolar disorder, and positive for Covid-19. R1 was admitted to the facility on [DATE]. The admission Nursing assessment dated [DATE] showed that R1 was admitted with no pressure ulcers. The most recent comprehensive MDS (Minimum Data Set)…
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.
- Potential for harm · Dcited beforedisputed · IDR2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the physician-ordered plan of care and follow interventions intended to prevent and manage constipation for a resident with declining renal function and Stage IV chronic kidney disease. The facility failed to ensure the resident received appropriate assessments, dietary interventions, and as-needed constipation treatments despite documented evidence of ongoing bowel elimination concerns. This applies to 1 of 4 residents (R4) reviewed for bowel elimination.The Findings include:Review of the electronic medical record (EMR) showed that R4, a [AGE] year-old resident, was admitted to the facility on [DATE]. Diagnoses included hypertension, type 2 diabetes mellitus, cerebral infarction with right-sided hemiplegia and hemiparesis, peripheral vascular disease, iron deficiency anemia, Stage IV chronic kidney disease (CKD), acute kidney injury, malignant neoplasm of the bladder, and obesity.The Minimum Data Set (MDS) assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide catheter care in accordance with accepted standards of practice by failing to cleanse the urethral meatus during indwelling urinary catheter care. The facility also failed to follow a physician's order to change an indwelling urinary catheter when a urinary tract infection (UTI) occurred. This applies to 2 of 3 residents (R1 and R3) reviewed for indwelling urinary catheter care.Findings include:The Electronic Medical Record (EMR) showed that R1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her current diagnoses included a right fifth rib fracture and urinary tract infection (UTI). Chronic diagnoses included type 2 diabetes mellitus, hypertension, dementia, abnormalities of gait and mobility, muscle disorder, lack of coordination, muscle weakness, anxiety disorder, senile degeneration of the brain, obstructive and reflux uropathy, chronic kidney disease stage III, history of recurrent UTIs, left femur fracture,…
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.
- Potential for harm · Dcited before2026-03-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy for notification of resident's change in condition. This applies to 1of 3 residents (R1) reviewed for falls in the sample of 6.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to facility on May 21, 2025, with the diagnoses of chronic obstructive pulmonary disease, hypertension, anxiety, metabolic encephalopathy, wedge compression fracture of fifth lumbar vertebra, disorders of bone density and structure, falling, fracture of lower end of left femur, atrial fibrillation, hypothyroidism, lack of coordination, urinary tract infection, and cirrhosis of liver.R1's MDS (Minimum Data Set) dated February 17, 2026, showed R1 was cognitively intact. The MDS continued to show R1 required maximal assistance from facility staff with toileting hygiene and moderate assistance from facility staff for transfer. On March 9, 2026, at 11:50 AM, R1 stated she had a fall during the night on February 24, 2026, when she put…
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.
- Potential for harm · Dcited before2026-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow fall prevention interventions for a resident who was a known fall risk.This applies to 1of 3 residents (R1) reviewed for falls in the sample of 6.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to facility on May 21, 2025, with the diagnoses of chronic obstructive pulmonary disease, hypertension, anxiety, metabolic encephalopathy, wedge compression fracture of fifth lumbar vertebra, disorders of bone density and structure, falling, fracture of lower end of left femur, atrial fibrillation, hypothyroidism, lack of coordination, urinary tract infection, and cirrhosis of liver.R1's MDS (Minimum Data Set) dated February 17, 2026, showed R1 was cognitively intact. The MDS continued to show R1 required maximal assistance from facility staff with toileting hygiene and moderate assistance from facility staff for transfer. R1's fall risk care plan dated May 21, 2025, showed [R1] is at risk for fall related to weakness, fatigue, activity intolerance, pain, history of falls. 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.
- Potential for harm · Dcited before2025-09-18 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interview and record review, the facility failed to timely report allegations of sexual and verbal abuse to the residents' Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and the local police department in accordance with the facility's abuse policy. This applies to 2 of 4 residents (R1, R3) reviewed for abuse in the sample of 11. The findings Include: 1. The EMR (Electronic Medical Record) shows that R1 is a [AGE] year-old female, admitted [DATE], with diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, anxiety disorder, and is under hospice care. The Minimum Data Set (MDS) dated [DATE], indicates R1 has severe cognitive impairment and requires total assistance for Activities of Daily Living (ADLs). The EMR shows that R2 is a [AGE] year-old male admitted [DATE], with diagnoses including dementia, bipolar disorder, alcoholic cirrhosis, and adjustment disorder. The MDS dated [DATE], indicates cognitive intactness (BIMS 14/15), and a history…
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.
- Potential for harm · Dcited before2025-09-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a comprehensive investigation into an allegation of sexual abuse. As a result, the facility prematurely concluded the allegation to be unsubstantiated without completing all required investigative steps.This applies to 1 of 2 residents (R1 and R2) reviewed for sexual abuse allegations in a sample of 11 residents.The findings include: The facility's incident report dated September 4, 2025 showed an event investigation of sexual abuse dated August 29, 2025 at 11:30 A.M. The incident report showed that staff had expressed concern of R2 standing at the head of R1's bed with R2's pants lowered. During the discovery of this situation, R1 was asleep. V4 (Restorative Aide) was the one who discovered this incident. The report showed that V4 asked R2 what he was doing, and that R2 immediately pulled his pants up, turned around and replied nothing. On September 9, 2025 at 12:12 P.M., V4 was asked about the incident. V4 also demonstrated in R1's room how…
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.
- Potential for harm · D2025-06-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 7 residents (R1) reviewed for dignity in the sample of 7. The findings include: On 6/4/25 at 11:48 AM, R1 was in a hospital gown in bed. R1 said she was really upset about how the night shift doesn't help her. R1 said she puts on her call light to have her incontinence brief changed and it will be on for 5-6 hours before anyone will respond. R1 said one night a girl came in and she was all ticked off that she had to change her and said she would come back and then never did. R1 said she was sitting in a stool and urine filled incontinence brief for hours. R1 said she knows she is a big lady, but she is able to help move herself to be changed. R1 stated it makes me feel like crap, like I'm a bother! R1 said that same girl came the next day and R1 said she reminded her she never came back to change her, and the girl said yes I did leave you in that with an attitude. R1 said she is…
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.
- Potential for harm · Dcited before2025-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who had complaints of redness and burning to her buttock area for 1 of 7 residents (R1) reviewed for quality of care in the sample of 7. The findings include: On 6/4/25 at 11:06 AM, V5 Certified Nursing Assistant (CNA) was providing incontinence care for R1. V5 lowered R1's incontinence brief (with R1 rolled on her left side) and R1's right and left buttocks area was red in color. R1 had a dressing to her right inner buttocks. R1 said her bottom is red since she sits in urine because the CNAs at night don't change her. R1 said she could feel something was burning and hurting her, so she told the nurse who had the wound nurse come look at her bottom. R1 said this was a few days ago and the wound nurse came in and took pictures and put the dressing on her bottom. V5 lifted the corner of the dressing to reveal 3 round open areas about the size of a pencil eraser…
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.
- Potential for harm · Fcited before2025-03-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 132 residents in the facility receiving dietary services. Findings include: On 03/18/25 at 11:29 AM, V3 Regional Nurse Consultant confirmed 132 residents were being served from dietary services on 03/18/25. 1. On 03/18/25 at 10:28 AM, V16 Dietary Manager stated the dishwasher disinfects by temperature. The dishwasher needs to reach 180 degrees to disinfect the dishes. V16 ran the dishwasher twice. The wash cycle gauge max temperature was 142 degrees Fahrenheit. The rinse cycle gauge max temperature was 154 degrees Fahrenheit. The final rinse cycle gauge max temperature was 150 degrees. The test strip used for the test cycle reached 160 degrees Fahrenheit. On 03/18/25 at 10:49 AM, V18 Dietary Aide stated when she has logged the temperature for the dishwasher, she used the black and white strips circles. V18 stated the dishwasher needs to reach 185 degrees to disinfect the dishes. The dishwasher temperatures are logged. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-21 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents who require assistance with their ADLs (Activities of Daily Living). This applies to 5 out of 5 (R71, R90, R117, R109, and R19) residents reviewed for ADLs in a sample of 32. The findings include: 1. On 3/19/2025 at 3:50 PM, R109 was walking in and out of his room aimlessly, trying to hold his pants up from the waist. R109 was confused and unable to express his needs. R109's incontinence brief could be visibly observed that it had partially fallen off and was bunched on his left mid-thigh area. R109's pants were visibly soiled and had a foul urine odor. R109's floor next to his bed was visibly soiled. V10 (RN) was asked to assess and assist R109 with incontinence care. V10 said she was unsure when he was last provided with incontinence care but would try to find a CNA. R109 stayed sitting on his bed confused and repeatedly said he was sorry. At 4:20 PM, V10 was again asked to assist R109 with his soiled clothing 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.
Show the remaining 45 citations
- Potential for harm · Ecited before2025-03-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for smokers, and failed to properly assess residents for safe smoking. This applies to 5 out of 5 (R28, R50, R75, R95, R116) residents reviewed for safe smoking in the sample of 32. The findings include: 1. R50 is a [AGE] year-old resident admitted on [DATE]. On 3/18/25 at 9:57 AM, a cigarette burn was noted on resident's wheelchair cushion. R50 said she smokes regularly. On 3/20/25 at 8:40 AM, R50 was observed smoking in the patio. There was no staff supervising the smokers. On 3/20/25 at 12:04 PM, V14 (SSD-Social Services Director) said she was not aware of R50 having a cigarette burn on her wheelchair cushion. She said if she knew that, she would have re-assessed R50 for safe smoking. R50's Smoking Risk Assessment was done on 1/31/24 and 7/16/24 only. Assessment done on 7/16/24 documents that there are no concerns with R50 being careless with smoking materials. 2. R75 is a [AGE] year-old resident 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.
- Potential for harm · E2025-03-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to obtain physician orders for medications brought from home and failed to secure resident medications in a locked compartment. This applies to 4 of 4 residents (R54, R78, R86, R195) reviewed for medications in a sample of 32. The findings include: 1. On 3/18/25 at 10:32 AM, R195 was not in her room. On her windowsill, she had a bottle of regular strength Tylenol 325 MG (Milligrams). On her shelf, she had a tube of Icy-Hot pain relief balm and bottle of Sooth (Bismuth subsalicylate) 525 MG. On 3/19/25 at 10:36 AM, surveyor went back to R195's room. The medications were still in her room. Surveyor asked R195 about the medications, but she was unable to speak English because her primary language was Spanish. R195's face sheet shows diagnoses of depression, lack of coordination, other specified disorders of muscle, and bilateral primary osteoarthritis of knee. Review of R195's March POS (Physician Order Sheet) shows no orders for the medications. R195's MDS (Minimum Data Set) dated 1/4/25 shows a BIMS (Brief…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review the facility failed to protect a resident's right to be free from physical abuse. This applies to 2 of 3 residents (R67 and R124) reviewed for abuse in a sample of 32. Findings include: R124's MDS (Minimum Data Set) dated 01/24/25 shows she is cognitively intact. On 03/19/25 at 10:21 AM, R124 stated R67 stepped on her toe, then she pushed him. R124 stated R67 then pushed her back. R124 stated she spoke to V1 Administrator the following day about the physical altercation. R124 stated V1 Administrator informed her he sent a report to [NAME] regarding the incident. R67's MDS (Minimum Data Set) dated 12/4/24 shows he is cognitively intact. On 03/20/25 09:52 AM, R67 stated he was assisting R124's roommate back to her room when R124 hit him with a grabber twice. R67 stated R124 told him to stay out of their room. R67 stated he never pushed R124. R67 stated he had stepped on R124's foot by accident on another occasion for which he apologized. R67 stated R124 had accepted his…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
Based on interview and record review the facility failed to submit reports of abuse to the Illinois Department of Public Health within the mandated timeframes. This applies to 1 of 3 residents(R36) reviewed for abuse in a sample of 32. Findings include: R36's MDS (Minimum Data Set) dated 02/10/25 shows she is cognitively intact. On 03/18/25 at 11:55 AM, R36 stated she had money, a debit card, an ID (identification card), and her birth certificate stolen from her purse. V36 stated she thought V21 CNA (Certified Nursing Assistant) might have taken them. R36 stated she had already reported the theft to V1 Administrator / Abuse Coordinator, but he did not do anything, On 03/18/25 01:11 PM, V1 Administrator stated R36 had previously informed him she had missing money and an ID. V1 stated residents are encouraged to give cash to the business office to be secured. V1 stated Social Services was working on getting R36 a replacement ID. V1 stated he had no knowledge of the other missing items. V1 stated he had no way to verify what was missing. On 03/20/25 at 11:35 AM, V14 Social Services…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately initiate an investigation into allegations of abuse to assure the wellbeing of a resident. This applies to 1 of 3 residents(R124) reviewed for abuse in a sample of 32. Findings include: R124's MDS (Minimum Data Set) dated 01/24/25 shows she is cognitively intact. On 03/19/25 at 10:21 AM, R124 stated she had an altercation with R67. R124 stated she told R67 she did not want him in the room because she had belongings come up missing after his visits with her roommate. R124 stated R67 purposely stepped on her already injured toe. R124 stated she then pushed R67, and he pushed her back. R124 stated she had informed V1 Administrator / Abuse Coordinator the day after the occurrence. R124 stated V1 informed her he sent a report regarding the occurrence to [NAME]. On 03/19/25 at 10:35 AM, the surveyor notified V1 Administrator of R124's accusation against R67. On 03/20/25 at 11:35 AM, V14 Social Services Director stated V1 Administrator informed her…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative services to residents with contractures. This applies to 2 out of 3 (R71 and R90) residents reviewed for contractures in a sample of 32. The findings include: 1. On 3/20/2025 at 10:10 AM, R90 said he was unable to extend his fingers on both of his hands. R90's hands were severely contracted, and his hands were in a fixed fist position. R90 said he could not recall the last time he received exercises for his hands. V12 (Restorative Aide) said R90 was to be receiving PROM exercises daily. V12 was asked to open R90's hands. When V12 attempted to perform PROM to R90's hands, she was unable to due to his contractures. When V12 checked his hands, R90's fingernails were so long that they caused indentations to the palm of his hand. R90's palms also had brown substances with a foul odor. R90's Mobility assessment dated [DATE] said R90 had full flexion and extension of his fingers to both hands. R90's 10/21/2024 care plan had 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.
- Potential for harm · Dcited before2025-03-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide catheter care to residents. This applies to 2 out of 2 (R90, R54) residents reviewed for urinary care in a sample of 32. The findings include: 1. On 3/19/2025 at 9:50 AM, V7 (Certified Nurse Assistant/CNA) said she was going to provide incontinence care to R54. R54 had an indwelling urinary catheter. R54's incontinence brief was soiled with a large liquid bowel movement. V7 cleaned R54's perineal and buttock area from front to back. V7 then applied a clean incontinence brief. V7 did not provide R54 with catheter care after having an incontinence episode of bowel. R54's indwelling urinary catheter care plan said R54 was to be provided with catheter care during routine peri care. 2. On 3/20/2025 at 10:30 AM, V11 (Registered Nurse/RN) said she was going to provide catheter care to R90. R90 had an indwelling urinary catheter. V11 said R90 recently was treated for a urinary tract infection. V11 proceeded to clean R90's catheter, wiping the tubing in repeated downward and upward strokes using the same wipe.…
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.
- Potential for harm · D2025-03-21 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to clean and empty a resident's ostomy bag. This applies to 1 of 1 resident (R19) reviewed for ostomies in a sample of 32. The findings include: On 3/18/25 at 10:39 AM, during initial tour, R19 was in her lying in bed. Her ostomy bag was almost full. She stated, It's always full and it needs to be changed it takes a long time for them (staff) to change it. On 3/19/25 at 10:33 AM, R19 was in bed. R19's ostomy bag was still all the way full. R19 stated, They still haven't changed it. They didn't change it at all yesterday and still have not changed it today. I don't know what's going on. On 3/19/25 at 1:02 PM, V3 (Regional Nurse Consultant) stated, (R19) actually has a fistula. She has a lot of fluid in her stomach. (R19) has a history of cancer in her colon. We don't have a care plan for the ostomy. We are making it now. On 3/19/25 at 2:24 PM, V2 (DON-Director of Nursing) stated, (R19) has a fistula, but it is an ostomy bag. If it is 1/3 or…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to administer tube feedings and care for enteral tubes as ordered for residents with gastrostomy tubes (g-tubes). This applies to 2 out of 3 (R117 and R5) residents reviewed for gastrostomy tubes in a sample of 32. The findings include: 1. On 3/18/2025 at 3:55 PM, V8 (Registered Nurse/RN) said she reviewed R5's gastrostomy tube (g-tube) feeding order. V8 said she was going to initiate R5's scheduled feeding infusion via a pump as ordered. V8 flushed R5's tube with 30 ml (milliliters) of water and then connected the feeding tubing to R5's g-tube. V8 did not check for placement or residual as ordered. V8 then programmed the feeding pump to infuse at a rate of 100 ml per hour. R5's Order Summary Report dated 3/19/2025 showed an order of Enteral Feed Order one time day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION Enteral feeding: formula Osmolite 1.5 amount 1980 ml rate 110 ml/hr x 18 hours. R5's report also had enteral feed orders of every evening shift PRIOR TO INITATING FEEDING; ASPIRATE GASTRIC CONTENT,…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications as ordered. There were 30 opportunities with 2 errors resulting in a 6.6% error rate. This applies to 2 of 3 (R134, R342) residents observed in the medication pass. Findings include: 1. On 3/20/25 at 8:22 AM, during medication administration, V9 (RN-Registered Nurse) administered Ferrous sulfate 325 mg (milligram) to R134. Review of R134's POS (Physician Order Sheet) and MAR (Medication Administration Record) showed the Ferrous Sulfate tablet 325 mg, one time a day is on hold from 3/14/25 to 4/1/25. 2. On 3/20/25 at 9:10 AM, during medication administration, V13 (LPN-Licensed Practical Nurse) did not administer R342's Amiodarone Hydrochloride 200 mg. Review of R342's MAR and POS shows an order for Amiodarone Hydrochloride 200 mg, give one tablet orally in the morning. On 3/20/25 at 11:47 AM, V2 (Director of Nursing) said while passing medications, she expects nurses to follow physician's orders to make sure the right medication is given to the right person and that the five R's (right…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to serve a resident his prescribed diet. This applies to 1 out of 3 (R71) residents reviewed for diets in a sample of 32. The findings include: On 3/18/2025 at 12:40 PM, R71 was in an upright bed in a slouched position with his hips below the bend of the bed. R71 was not properly positioned in bed. R71 was eating his served lunch meal that had a yellow drink that was thin in consistency. R71's meal ticket indicated he was to receive nectar-thickened liquids. V9 (Agency Registered Nurse/RN) was asked to check R71's served drink and V9 verified R71 was not served the correct consistency of drink. On 3/20/2025 at 12:25 PM, V2 (Director of Nursing/DON) said she expects nursing staff to check residents' meal tray items and tickets prior to serving them their meals to ensure they are receiving their prescribed diet. R71's Order Summary Report dated 3/20/2025 showed his diet was General diet, Regular texture, Nectar consistency initiated on 3/04/2025. R71's care plan said he had a swallowing problem related 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.
- Potential for harm · Dcited before2025-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care to a resident. This applies to 1 of 3 residents (R2) reviewed for timely incontinence care in the sample of 6. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure. R2's MDS (Minimum Data Set) dated December 27, 2024, showed R2 has moderate cognitive impairment. The MDS continued to show R2 was dependent on facility staff for toileting hygiene. R2's incontinence care plan dated December 30, 2024, showed [R2] has bowel incontinence related to weakness, limited mobility, fatigue, pain, activity intolerance. The care plan continued to show multiple interventions dated December 30, 2024, including Check resident frequently and assist with toileting as needed. On February 10, 2025, at 10:00 AM, R2 was lying in bed with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a staff member was skilled to change an indwelling pleural catheter dressing appropriately for a resident with respiratory conditions. This applies to 1 out of 4 residents (R2) reviewed for nursing care services. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, pneumothorax, chronic obstructive pulmonary disease, atrial fibrillation, bradycardia, anemia, pulmonary hypertension, ascites, and congestive heart failure. R2's EMR showed R2 was to be receiving indwelling pleural catheter for the management of his pleural effusions (excess fluid accumulation) in his lungs and shortness of breath related to his chronic respiratory conditions. On 8/01/2024 at 8:35 AM, V6 (Wound Care Registered Nurse/WC RN) said on 7/25/2024 at 10:30 AM during R2's wound care he was observed agitated and having…
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.
- Potential for harm · Dcited before2024-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document the assessment of a resident (R2) who had a change in condition and required a transfer to the hospital for abnormal vital signs. This applies to 1 out of 4 residents (R2) reviewed for nursing care services. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, pneumothorax, chronic obstructive pulmonary disease, atrial fibrillation, bradycardia, anemia, pulmonary hypertension, ascites, and congestive heart failure. R2's EMR continued to show R2 was transferred to the hospital on 7/25/2024 for abnormal vital signs. On 8/01/2024 at 8:35 AM, V6 (Wound Care Registered Nurse/WC RN) said on 7/25/2024 at 10:30 AM during wound care R2 was observed agitated and having difficulty breathing. V6 said she alerted V5 (RN) to assess R2. V6 said R2's vital signs were unstable, his blood pressure was 56/46…
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.
- Potential for harm · D2024-07-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a care plan conference that included the resident, resident representative and interdisciplinary team was performed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 3 residents (R1 and R3) reviewed for comprehensive care plans in the sample of 4. The findings include: 1. R1's Face Sheet shows that she admitted to the facility on [DATE] with the diagnoses of cellulitis of the left lower limb, atrial fibrillation, resistance to vancomycin, methicillin resistant staphylococcus aureus infection, end stage renal disease, diabetes mellitus, morbid obesity, anemia, dependence on renal dialysis, weakness, pressure ulcer of left hip-stage 4, pressure ulcer sacral, unsteadiness of feet, chronic osteomyelitis, acute kidney failure, thrombocytopenia, venous insufficiency and hypothyroidism. R1's Comprehensive Assessment was completed on 5/21/24. R1's Nursing Notes show that she was discharged 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.
- Potential for harm · Dcited before2024-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needs extensive assistance getting to the toilet was brought to the toilet in a timely manner for 1 of 4 residents (R2) reviewed for activities of daily living (ADLs) in the sample of 4. The findings include: R2's Face Sheet shows she admitted to the facility on [DATE]. R2's Physical Therapy evaluation dated 7/25/24 shows that she needs substantial/maximal assistance for transfers. On 7/26/24 at 10:01 AM, V3 (Certified Nursing Assistant/CNA) responded to R2's call light that was going off. R2 asked to get up to go to the bathroom. V3 told R2 that she could not get her up until she was seen by therapy. At 10:05 AM, R2 put her call light back on and was heard from the hallway yelling for help. R2 said that she put her call light on earlier because she had to go to the bathroom and have a bowel movement, but the CNA told her that she could not bring her until after she sees physical therapy. R2 stated, Please help me. R2…
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.
- Potential for harm · Dcited before2024-07-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, interview, and record review that facility failed to ensure pressure ulcer treatment interventions were in place for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 4. The findings include: 1. The facility provided Wound Report printed on 7/26/24 shows that R2 has a stage 3 sacral pressure wound measuring 1 centimeter (cm) x 1.5 cm x 0.4 cm. On 7/26/24 at 11:01 AM, V3 and V4 (Certified Nursing Assistants/CNAs) provided incontinence care to R2. R2 had an open wound on her sacrum. Every time V3 wiped R2's buttocks, she said, Ouch. There was no dressing on R2's sacrum or in her incontinence brief that was taken off. On 7/26/24 at 12:21 PM, V11 (Wound Registered Nurse) said that she just did R2's dressing change about 5 minutes ago. V11 said that R2 did not have a dressing in place when she went and did the dressing change. V11 said that R2 has a stage 3 pressure wound on her sacrum that has orders for a dressing. V11 said that if a CNA notices that a wound does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide supervision and safe eating interventions for residents with swallowing and eating disorders. This applies to 2 of 4 residents (R1, R2) reviewed for weight loss and nutrition. Findings include: 1. R1 is an [AGE] year-old male readmitted to the facility on [DATE], with the following diagnosis: anorexia, repeated falls, hernia, dysphagia, hypertension, and anxiety. R1's POS (physician order sheet) documents mechanical soft diet with thin liquids with upright position during and 30 minutes after meals with supervision. Small/single bites, single sips, alternating food, and liquids with double swallow. R1's speech therapy evaluation and plan of treatment dated July 2, 2024, documents as part of R1's treatment plan, upright position during and 30min (30 minutes) after meals, small/single bites, single sips, alt food/liquids double swallow. R1's assessment showed prolonged mastication and pocketing of food. R1 was observed on July 5,…
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.
- Potential for harm · Dcited before2024-07-08 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for residents with weight loss and nutritional needs. This applies to 2 of 4 residents (R2, R8) reviewed for nutrition and weight loss. Findings include: 1. R2 is a [AGE] year-old female with the following diagnosis: protein calorie malnutrition, anxiety, hypertension, and psychotic disorder with delusions. R2 has an order for general puree diet, (nutritional supplement drink) and (nutritional supplement dessert) with lunch and dinner. R2 is underweight at 104 pounds. R2 has a care plan focus dated October 16, 2023, that documents R2 has a chewing problem related to dysphagia and malnutrition. R2 also has listed as a care plan intervention to, eat in an upright position, to eat slowly and chew each bite thoroughly. R2 was observed in the second-floor dining room on July 5, 2024 at 12:23PM. R2 was scooping her food with her fingers and consuming food rapidly. V5 and V7 (Certified Nursing…
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.
- Potential for harm · Dcited before2024-06-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to utilize a gait belt when transferring a resident and failed to revise R1's plan of care after an earlier fall incident. This applies to 1 of 3 residents (R1) reviewed for fall and injuries. The findings include: The EMR (Electronic Medical Record) shows R1, was a [AGE] year-old, admitted to the facility on [DATE]. The EMR also shows R1's diagnosis that included heart failure, other disorders of psychological development, cardiomyopathy, restlessness and agitation, encounter for palliative care, underweight, personal history of Covid-19, osteoarthritis, fracture right femur (5/10/2024), and mild protein calorie malnutrition. The most recent MDS dated [DATE] showed R1's ADL's (Activities of Daily Living) regarding functional level. The MDS showed that R1 required extensive assistance for bed mobility, transfer, dressing and toileting. R1 was also assessed as severely impaired with decision making. The Fall assessment dated [DATE] showed that R1 scored 20…
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.
- Potential for harm · F2024-04-18 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a designated certified IP (Infection Preventionist) who was responsible for the facility's Infection Control Prevention Program. This applies to all 130 residents residing at the facility. Findings include: The facility's document titled Resident Listing Report dated 4/16/2024, showed the facility's census of 130 residents. On 4/16/2024 at 9:00 AM, V2 (Director of Nursing/DON) said she was the IP for the facility. V2 said she took the IP role in October 2023. V2 said she started an infection preventionist training course approximately six years ago but never completed the certification exam and never received a certification. On 4/17/2024 at 11:15 AM, V1 (Administrator) and V3 (Regional Nurse Consultant) said V2 (DON) was the IP for the facility and believed V2 had completed the IP training required and was certified. They said the IP role required specialized infection training certification. The facility's Infection Preventionist policy with a reviewed date of 6/01/2023 showed Policy Statement: The Infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-18 · tag F0880 — failed to prevent and control infections — patternProvide 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 interview and record review, the facility failed to implement its Infection Prevention and Control Program when it failed to provide surveillance data to the Local Health Department that identified other residents at risk for Legionnaire's disease after a confirmed case of Legionnaires' disease was associated with the facility. The facility also failed to identify R1's Legionnaire's diagnosis when he returned from the hospital and failed to notify R1's care team of the diagnosis. This applies to 8 of 8 residents (R1-R8) reviewed for communicable disease of Legionnaire's. The findings include: 1. The EMR (Electronic Medical Record) showed R1 admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. R1's EMR showed multiple diagnoses including pneumonia unspecified organism, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with exacerbation, obstructive sleep apnea, dependence on supplemental oxygen, and history of COVID-19. On [DATE] at 10:00 AM V2…
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.
- Potential for harm · Fcited before2024-02-08 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure facility had provided sufficient staffing to meet the care needs of residents of the facility. This has the potential to affect all 131 residents residing in the facility. The findings include: 1. On 2/5/24 at 1:14 PM, R97 stated that on a Sunday night shift (1/28/24) going to Monday morning a week ago, that she woke up at 2 AM with a bowel movement. R97 stated that she pushed the call light at 2:15 AM to ask staff to clean her. V8 (Nurse) came in and V8 told R97 that she would tell the CNA (Certified Nursing Assistant) staff that R97 needed assistance. R97 added that nobody came to clean her up and R97 turned the call light on again and waited. R97 could not remember how long she was waiting the same nurse (V8) came. From the doorway V8 informed her that a CNA was coming and told her to turn off the call light. R97 felt tired, she was awake the entire time. R97 couldn't go back to sleep because she was sitting on her feces, it was very uncomfortable. R97 turned her call light again at 7 AM, and at 7:30…
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.
- Potential for harm · Fcited before2024-02-08 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide palatable meals to facility residents. This applies to all 128 residents receiving oral diets in the facility. The findings include: Facility Resident Listing Report, dated 2/5/24, shows the facility resident census was 131 residents. Facility Diet Type Report, dated 2/6/24, shows the facility had 3 residents with physician orders for NPO (Nothing by Mouth) and one resident who had a physician order for NPO in addition to may have pleasure feeds with trained staff. On 2/5/24, the following residents expressed concerns regarding the palatability of the food served at the facility: - At 11:18, R98 stated, Yuck! R98 stated the food was Not good! It's terrible! They give small portions for old folks and has no taste. The food comes cold. R98 stated he was usually served his meals last and received food cold. - At 12:01 PM, R46 stated, Food is always served cold. I have to go to the dining room if I want to receive hot food. - At 12:25…
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.
- Potential for harm · Fcited before2024-02-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to sanitize pots/pans utilizing a sanitizing solution at a concentration per manufacturer instructions, failed to change gloves and wash hands after touching soiled surfaces during food preparation., and failed to store resident food per facility policy. This applies to all 128 residents residing in the facility receiving oral diets. The findings include: Facility Resident Listing Report, dated 2/5/24, shows a facility census of 131 residents. Facility Diet Type Report, dated 2/6/24, shows the facility had 3 residents with physician orders for NPO (Nothing by Mouth) and one resident who had a physician order for NPO in addition to may have pleasure feeds with trained staff. 1. On 2/05/24 at 10:40 AM during initial tour of the kitchen, V3 (Cook) stated he was utilizing the 3 compartment sink to wash and sanitize dishes. There was a pan soaking in the third compartment sanitizing sink which had a clear, pink solution in the sink. There were soiled dishes in the rinse sink which had no water in the sink. V3 stated…
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.
- Potential for harm · Ecited before2024-02-08 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide grooming and timely toileting hygiene for residents who require assistance with activities of daily living (ADL) care. This applies to 12 of 13 residents (R115, R222, R29, R38, R70, R77, R1, R324, R328, R98, R97, and R122) reviewed for ADL (Activities of Daily Living) in the sample of 29. The findings include: 1. Face sheet shows that R115 is 80 years-old who has multiple medical diagnoses which include lack of coordination, adult failure to thrive, need for assistance with personal care, and reduced mobility. MDS dated [DATE] shows that R115 is alert and oriented and is totally dependent to staff for toileting hygiene. On 2/05/24 at 11:46 AM, R115 asked if someone could clean her and change her incontinence brief. R115 stated that she was last changed around 4 AM. On 2/05/24, at 11:48 AM, V11 (Certified Nursing Assistant/CNA) provided personal care to R115. R115 was noted to be heavily saturated with urine and a bowel movement.…
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.
- Potential for harm · Ecited before2024-02-08 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to serve the facility menu as planned. This applies to 10 of 10 residents (R25, R46, R52, R91, R100, R106, R323, R325, R326, R327) reviewed for menus not followed in a sample of 29. The findings include: Facility menu, dated 2/6/24, shows the residents were to be served yellow cake with frosting for dessert. On 2/6/24 at 12:22 PM, V20 (Cook) began serving lunch in the first-floor main dining room. V17 (Certified Nursing Assistant) began placing blueberry yogurt instead of cake on several lunch trays stacked on a cart. V17 stated, They're out of dessert. Each of the residents (R25, R46, R52, R91, R100, R106, R323, R325, R326, R327) had lunch menu tickets on their trays showing they were to have been served cake for desert on the menu and no blueberry yogurt. On 2/6/24 at 12:29 PM, R46 was served her lunch tray with blueberry yogurt and no cake. R46 stated I did not request yogurt. At 12:30 PM, R52 was served his lunch tray with blueberry yogurt and no cake. On 2/6/24 at 12:37 PM, V19 (Food Service Consultant) 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.
- Potential for harm · E2024-02-08 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare pureed diets as per facility policy. This applies to 10 of 10 residents (R8, R22, R23, R28, R33, R34, R41, R72, R91, and R110) reviewed for pureed diets. The findings include: Facility Diet Type Report, dated 2/6/24, shows the facility had pureed diet physician orders for 10 residents (R8, R22, R23, R28, R33, R34, R41, R72, R 91, R110). On 2/05/24 at 10:40 AM, V3 (Cook) was preparing pureed meatloaf in the kitchen for lunch service. V3 began removing pureed meatloaf product from the blender and placing in a pan. V3 stated he was finished pureeing the meatloaf and was putting it in warmer for service. There were solid pieces of meatloaf visible in the pureed meatloaf product. The pureed meatloaf looked lumpy and not smooth. V3 stated the pureed meatloaf should have no chunks and almost pudding like. V3 tasted the pureed meatloaf and stated I'll do it again. They just don't want huge chunks. On 2/6/24 at 12:37 PM V18 (Food Service Manager) also stated he saw the pureed meatloaf at lunch on 2/5/23 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.
- Potential for harm · Ecited before2024-02-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable standards for infection control by not implementing hand hygiene, and use of PPE (personal protective equipment) during direct resident care. The facility also failed to ensure that an indwelling catheter drainage bag was stored in a manner to prevent urine infection. This applies to 6 of 7 residents (R43, R63, R70, R97, R122 and R222) in a sample of 29. The findings include: 1. The EMR (Electronic Medical Record) showed that R122 was admitted to the facility on [DATE]. R122, a [AGE] year-old with diagnoses that included cerebral palsy, pulmonary embolism, unspecified psychosis, depression, dysphagia, severe protein-calorie malnutrition, gastrostomy status, and iron deficiency anemia. On 2/05/2024 at 10:07 AM, R122 was observed lying in bed. R122's was non-verbal. R122 had an indwelling catheter that was noted with a cloudy urine output. V33 (Registered Nurse) was present during this observation. On 2/06/24 at 1:00 PM,…
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.
- Potential for harm · D2024-02-08 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to honor resident religious food preferences. This applies to 2 of 4 residents (R323 and R325) reviewed for religious food preferences in a sample of 29. The findings include: 1. admission progress note, dated 1/24/24, shows, Resident arrived at facility 1608 Resident is on a diabetic diet and does not consume pork or gelatin per her religion On 2/05/24 at 11:05 AM with V45 (Family) interpreting, R323 stated she was receiving pork and beef products despite informing the facility she did not eat pork or beef due to religious preferences. V45 stated, They are giving her bacon and beef in spite of they know she does not eat it. They tell her 'I know you don't eat it, but it is on the menu.' Progress note, dated 2/2/24, shows, Resident's son requested resident get only boiled egg and a piece of bread for breakfast daily. This writer left a message for dietary manager. Dietary Profile Form, signed 1/31/24, shows R323 was identified as having a religious practice of no pork/gelatin and no likes/dislikes were identified other than…
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.
- Potential for harm · D2024-02-08 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide restorative rehabilitation services to a resident as recommended by physical therapy recommendations. This applies to 1 of 1 resident (R46) reviewed for restorative services in a sample of 29. The findings include: MDS, dated [DATE], shows R46 was cognitively intact. On 2/05/24 at 12:01 PM, R46 stated she had been asking for staff to perform her restorative therapy program exercises however was receiving no assistance. R46 stated she had no consistent restorative therapy since she was discharged from physical therapy at the facility. Therapy Recommendation for Restorative Programs, dated 12/18/23, shows therapy recommended Active Range of Motion (AROM) to R46's BLE (bilateral lower extremities), minimum assistance/supervision for transfers, and walking with supervision with rolling walker. On 2/6/24, V51 (Restorative Nurse) provided the electronic clinical documentation of R46's restorative program dated 1/1/24 to 2/6/24. The documentation…
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.
- Potential for harm · Dcited before2024-02-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and provide adaptive device to residents, to prevent further reduction in ROM (range of motion). This applies to 3 of 4 residents (R14, R41 and R122) reviewed for range of motion in the sample of 29. The findings include: 1. R14 had multiple diagnoses including cerebrovascular disease and hemiplegia affecting left nondominant side, based on the face sheet. R14's annual MDS (minimum data set) dated 1/3/24 showed that the resident was moderately impaired with cognitive skills for daily decision making. R14's MDS showed that the resident had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed that R14 required moderate to total assistance from the staff with her ADLs (activities of daily living). On 2/5/24 at 12:03 PM, R14 was sitting in her wheelchair inside the second floor main dining room. R14 was unable to move her left arm and her left hand was contracted. R14 cannot open her left hand…
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.
- Potential for harm · Dcited before2024-02-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow the physician's order to check for residual feeding before administration of the enteral feeding and failed to check for proper placement of the feeding tube per policy and procedure. The facility also failed to ensure that the head of the resident's bed was elevated while receiving enteral feeding. This applies to 2 of 2 residents (R63 and R122) reviewed for feeding tube in the sample of 29. The findings include: 1. R63 had multiple diagnose including acute respiratory failure, type 2 diabetes mellitus and gastrostomy, based on the face sheet. R63's active order summary report showed an order dated 4/27/23 for NPO (nothing by mouth). The order summary report showed an order dated 6/30/23 for, Enteral feed order one time a day Glucerna 1.5 at 84 ml/hr (milliliters/hour) x 18 hours. On (4:00 PM and off 10:00 AM). The same order summary report showed an order dated 4/26/23 to, Aspirate residual feeding, if more than 60 ml, hold feeding…
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.
- Potential for harm · Dcited before2024-02-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 3 errors, resulting in 12% medication error rate. This applies to 2 of 5 residents (R63 and R99) observed during medication pass in the sample of 29. The findings include: 1. On 2/6/24 at 8:51 AM, V31 (Licensed Practical Nurse) prepared and then administered multiple medications to R99 including two capsules of Gabapentin 300 mg (milligrams). R99's active order summary report showed an order dated 4/19/23 for Gabapentin 400 mg, 1 capsule by mouth three times a day. On 2/7/24 at 9:15 AM, the medications for R99 inside the unit medication cart was reviewed with V31 and V5 (Wound Care Nurse). It was confirmed that there were two blister packs of Gabapentin 300 mg for R99 inside the medication cart. V31 acknowledged in the presence of V5 that she administered the two capsules of Gabapentin 300 mg from the same blister pack to R99 during the 2/6/24 morning medication pass. 2. On 2/06/24 at 4:02 PM, V39 (Registered Nurse) took out…
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.
- Potential for harm · D2023-10-04 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and record review, the facility failed to provide privacy during incontinence care. This applies to 1 of 5 residents (R2) reviewed for privacy. The finding include: The EMR (Electronical Medical Record) showed R2 was admitted to the facility with the diagnoses of respiratory failure, chronic obstructive pulmonary disease, diabetes, hypertension, malaise, heart block, and lack of coordination. The MDS (Minimum Data Set) dated 09/09/2023 showed R2 was cognitively intact and required extensive assistance with one assistance with toilet use. The care plan dated 9/23/2023 showed R2 was incontinent of bowel and bladder. On 10/03/2023 at 9:59 AM, R2 said there was incident that occurred recently. R2 said a female CNA (Certified Nurse Assistant) provided incontinence care in front of female and male visitors. R2 said the visitors were visiting both him (R2) and his wife (R3), who share a room. R2 said the CNA did not fully close the privacy curtain and did not ask the visitors to leave while incontinence care was being provided. R2 said the visitors stayed…
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.
- Potential for harm · Fcited before2023-09-29 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility had provided sufficient staffing to meet the care needs of residents of the facility. This failure resulted in R3's newly open wound to the right upper thigh and R2's active bleeding from skin excoriation from the sacral area. This failure has the potential to affect all 106 residents in the facility. The findings include: The Facility Data Sheet showed that facility had a total resident census of 106. On 9/24/2023 at 12:16 P.M., V19 (Staffing Scheduler) stated the facility census (106-109) had remained stable for the last couple months and any census changes that did occur did not change staffing needs on the facility floors. V19 stated that she was informed by management to schedule staffing as follows: -for the A.M. shift starts 6:30 A.M. through 2:30 P.M. for CNAs (Certified Nurse Assistant); 6:30 A.M. through 3:00 P.M. for nurses; P.M. shift starts for CNAs 2:30 P.M.-10:30 P.M.; Night shift starts 10:30 P.M.-6:30 A.M.…
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.
- Potential for harm · Fcited before2023-09-29 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow the facility's policy for infection control regarding the use of PPE (Personal Protective Equipment), hand hygiene and disinfecting environmental surfaces to contain spread of Covid-19 outbreak. This has the potential to affect all 106 residents in the facility. The Findings include: The Facility Data Sheet showed that facility had a total resident census of 106. 1. On 9/27/2023 at 3:45 P.M., V2 (Director of Nursing) stated that Covid-19 outbreak in the facility started on 9/8/2023 with one resident. V2 also said that there were 25 residents affected with Covid-19 on 9/12/2023, which was the peak number of residents infected as V2 said. V2 also added that as of 9/27/2023, they have 8 residents with an active Covid 19 positive. V2 also stated that regarding staff which mostly involves nursing department, one staff got positive with Covid on 9/10/2023 and on 9/14-15/2023, there were 14 staff that were positive for Covid-19. 2. On 9/23/2023 at 11:45 A.M., together with V6 (CNA/Certified Nurse Assistant)…
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.
- Potential for harm · Ecited before2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received ADL (Activities of Daily Living) assistance per their plan of care. This applies to 11 of 11 residents (R1 through R11) reviewed for ADLs in a sample of 11. The findings include: 1. The EMR (Electronic Medical Record) showed that R3, a [AGE] year-old, with diagnoses that included metabolic encephalopathy, morbid obesity, diabetes mellitus type 2, neuropathy, congestive heart failure, vascular dementia, without behavioral disturbance, psychotic and mood disturbance, anxiety, Alzheimer's disease, hypertension, repeated falls, depression, COPD (chronic obstructive pulmonary disease), lack of coordination, reduce mobility, and Covid-19 positive. The most recent MDS (Minimum Data Set) dated 9/12/2023 shows that R3 was cognitively moderately impaired with BIMS (Brief Interview Mental Status) score of 9/15, required extensive to total assistance from 2-3 staff assist for bed mobility, transfers, dressing, and toilet use.…
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.
- Potential for harm · Fcited before2023-01-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the dishwasher was tested using the correct testing method, failed to ensure cold foods were maintained at or below 41 degrees Fahrenheit prior to serving, and failed to ensure dishes were allowed to air dry according to the facility's policy and procedures. This has the potential to affect all the residents in the facility. The findings include: The Resident Census and Conditions of Residents, CMS form 672, dated 1/11/23, showed there were 95 residents in the building and 3 residents in the facility that received tube feedings. On 1/12/23 at 8:52 AM, V5 (Dietary Manager/DM) and V9 (Regional Dietary Assistant) were asked to provide a list of residents and their diet type/consistency for 1/10/23. The document provided by V5 and V9 titled (facility name) Diet Type Report, printed on 1/12/23, showed R3 and R55 were the only residents that did not receive anything by mouth. On 1/10/23 at 10:55 AM, V5 (Dietary Manager) was asked to have…
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.
- Potential for harm · Ecited before2023-01-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 1/11/23 at 10:13 AM, R68 was lying in bed with the head of the bed elevated, participating in speech therapy. R68 was sipping on a protein shake and replied, I'm ready for a little break from therapy. I came here from the hospital. I ended up in here after I swallowed something sharp. I think it was in my collard greens. It was sharp and it cut me up, so I had to come here after the hospital. They give me a lot of food here that I can't eat. I can't chew a lot of it. I try to do the best I can. The food is too rough though. This protein shake is the best thing. R68 had a thin stature. R68 said I'm losing weight and the food they send me isn't helping. The meat was so tough one time that I couldn't cut it with a knife. Sometimes the CNAs will cut it for me, but if a knife won't cut it, then there isn't much they can do is there. The food is mostly cold. The potatoes are always cold. I eat in my room. If I tell them that my food is cold, then they tell me to eat it anyway. Once they bring you food, you eat…
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.
- Potential for harm · Dcited before2023-01-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, interview, and record review the facility failed to prevent the development of a facility acquired pressure ulcer, failed to identify a new pressure ulcer, failed to provide treatments as ordered, failed to complete weekly wound assessments, and failed to implement pressure reducing interventions for 3 of 7 residents (R19, R20, R24) reviewed for pressure ulcers in the sample of 22. The findings include: 1. On 1/11/23 at 9:58 AM, R20 was not in his room. There was a heel boot sitting in the seat of one of the chairs in R20's room. At 10:06 AM, R20 was lying in a recliner in the dialysis unit. R20 had his legs crossed at the ankles, with his left heel resting on the footrest of the recliner. R20 did not have a heel boot on his left foot. At 12:49 PM, R20 was sitting in a recliner in his room, eating his lunch. R20's left heel was resting on the footrest of the recliner. R20 did not have the heel boot in place, nor did he have a pillow under his legs. R20 denied refusing the heel boots. R20…
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.
- Potential for harm · Dcited before2023-01-12 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to follow the resident's meal preference and the meal ticket. This applies to 1 of 6 residents (R60) in the sample of 22. The findings include: On 1/10/23 at 11:34 AM, R60 said she is supposed to get 2 chocolate milks on her meal tray with every meal, and she hasn't been getting them because the kitchen staff said, they ran out of chocolate milk. On 1/12/23 at 12:18 PM, V5 (Dietary Manager) said the kitchen has not run out of chocolate milk, and if it's not being given for a resident, it's because the staff is not putting it in the computer. On 1/12/23 at 12:34 PM, the serving area of the 2nd floor dining room had a full crate of chocolate milk. On 1/10/23 at 12:34 PM and 1/11/23 at 12:30 PM, R60 had no chocolate milk on her meal tray. On 1/12/23 at 12:30 PM, V11 (Dietary Aid) said he will plate the food based on the meal ticket and give the plate to the CNA (Certified Nursing Assistants) who will put the beverage on the tray. On 1/12/23 at 12:30 PM, V11 was putting food on plates while looking at the resident's…
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.
- No harm found · C2024-02-08 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post the required information for contacting the State Survey Agency Complaint Hotline to make it available to all residents and their families. This affects all 133 residents residing in the facility. The findings include: On February 7, 2024 at 1:30pm, a meeting was held with Resident Council members, R13, R39, R40, R50, and R58. When asked, none were aware of the posting of a Hotline phone number for the State Survey Agency, but believed the Ombudsman phone was the same thing. On February 6, 2024 at 2:36pm, a search of the common areas accompanied by V1 (Administrator) found no posting of the State Survey Complaint Hotline information. At that time, V1 stated he believed he had seen it, but did not know where. On February 6, 2024 at 2:52pm, V48 (Administrative Assistant) showed the posting of the State Survey Agency Complaint Hotline phone number to be inside a flip folder along with other posters and placed on a shelf at shoulder height out of reach of a resident confined to a wheelchair. Additionally, there was a table…
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.
- No harm found · C2024-02-08 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the required Survey Results folder did not contain the results of the survey of 9/29/2023 and the Survey Results folder was not accessible to all residents in the facility. This affects all 133 residents residing in the facility. The findings include: On 2/6/2024 at 1:48pm, the results of the Complaint Survey of 9/29/2023 were not in the Survey Results folder in the facility. The missing results included citations related to harm to a resident. Additionally, the Survey Results folder was on a shelf at shoulder height and behind a table and chairs, out of reach of a resident confined to a wheelchair. On 26/2024 at 1:48, V1 (Administrator) stated he had no explanation for not placing these results in the folder.
- No harm found · C2024-02-08 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post the facility the required information regarding daily Nurse staffing in the facility. This affects all 133 residents residing in the facility. The findings include: During the 3 days onsite, 2/5/24, 2/6/24, and 2/7/24 there were no required posting of the Nurse and Certified Nurse Assistant staffing. On 2/7/2024 at 3:19pm, V34 (Receptionist) stated, We used to have the staffing posted but we don't have it anymore. On 2/7/2024 at 3:42pm, V37 (Staffing Coordinator) stated we should be posting the staffing, but I have just been too busy to do so for the past several days.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$542,423 in federal fines across 6 penalties. 1 Medicare payment denial on record.
- $277,045 — penalty dated 2026-03-17
- $40,740 — penalty dated 2025-11-21
- $183,450 — penalty dated 2025-09-18
- $12,191 — penalty dated 2025-02-11
- $15,360 — penalty dated 2024-06-02
- $13,637 — penalty dated 2024-02-08
- Medicare payment denial — starting 2025-04-17 for 4 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PEARL HEALTHCARE — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.7 | -1.7 vs chain |
| Health inspection | 1 of 5 | 2.7 | -1.7 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 3 of 5 | 3.7 | -0.7 vs chain |
The other 14 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PHC OVJ LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 99% | since 05/01/2022 |
| KUSHNER FAMILY IDF LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 16% | since 05/01/2022 |
| HERWIG, BRITTANY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/01/2022 |
| ZEFFREN, EITAN | Individual | CORPORATE OFFICER | — | since 05/01/2022 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $721K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145473. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.