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Arc At Bradley

650 North Kinzie Ave, Bradley, IL 60915 · For profit - Corporation · 120 certified beds · (815) 933-1666 Medicare & Medicaid certified

Call the home — (815) 933-1666 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited May 20245 actual-harm citations$123,187 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 5 actual-harm citations
  • a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $123,187 in federal fines (most recent 2026-02-19)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
350 N Kinzie Ave · (815) 348-9320 · Call to confirm hours
Pharmacy
2080 No. St. Route 50 · (815) 937-5175 · Call to confirm hours
Grocery
Meijer0.5 mi
Grow 5! Bradley, 954 N Kinzie Ave · (779) 301-8200 · Call to confirm hours
Park
525 Pierce Ave · Typically dawn to dusk
Place of worship
1085 Mulligan Dr · (815) 929-1030

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 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 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 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%13.4%15.4%typical
Long-stay residents who lose too much weight13.9%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%0.9%0.9%typical
Long-stay residents with a urinary tract infection0.6%1.5%2.0%better
Long-stay residents with depressive symptoms72.7%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.3%3.1%3.3%typical
Long-stay residents whose ability to walk worsened19.9%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.7%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine96.3%91.8%95.3%typical
Long-stay residents with pressure ulcers4.6%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control22.4%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.2%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine72.8%63.1%79.4%typical
Short-stay residents rehospitalized after admission28.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit25.5%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.922.021.67worse
Long-stay outpatient ER visits per 1,000 resident days4.012.221.80worse

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.

40.5% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.5%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
0.17U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF40.5%CMS range 27.7–54.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.5–15.010.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting92.9%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 2022–Sep 2024CMS 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

0.63
RN hours/ resident / day
0.27
LPN hours/ resident / day
1.85
Aide hours/ resident / day
2.74
Total nurse hours/ resident / day
0.59
RN hoursweekends
60.3%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 88.9 residents a day — about 74% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.74 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.56 hrs/resident/day on weekends vs 2.82 on weekdays — 9% thinner on weekends. RN hours go from 0.65 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% 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

13
deficiencies at the latest standard inspection (2024-05-17)
10
at the previous standard inspection (2023-04-27)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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

39 citations, most serious first. The 15 most serious are shown; the remaining 24 are one tap away and print in full.

  • Actual harm · Gcited before2026-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly transfer a resident from his bed to the wheelchair. This failure resulted in the resident sustaining an impacted spiral fracture of the left humerus. This applies to 1 of 3 residents (R2) reviewed for injuries in a sample of 3.Findings include:R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. On 5/15/26, R2 was admitted to the hospital for an impacted spiral fracture of the left humerus and discharged on 5/18/26. On 5/27/26 at 11:35 am, R2 left shoulder and upper arm were observed swollen with purple coloring to the skin.On 5/27/26 at 11:50 am, V7 (R2's family member) said that on 5/15/26, she came to visit R2, and when she touched his left shoulder, he jumped and told her that his shoulder hurt. V7 said she reported it to R2's nurse.On 5/27/26 at 2:35 pm, V5 (Nurse) said she was R2's nurse on 5/15/26 and V7…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to supervise a resident's smoking activity and failed to implement interventions to prevent her from sustaining burn injuries. This failure resulted in a resident sustaining blistered (second degree) cigarette burns.This applies to 1 of 4 (R1) residents reviewed for smoking safety in a sample of 5.The findings include:The facility's Reportable Incident form showed that on 4/6/26 at 11:40 AM, R1 was observed with a wound to left side of chest. [R1] was outside on a smoke break and was wearing the smoker's apron. Resident was observed with what appeared to be a cigarette burn on the left side of her chest. Root cause determined to be burn caused by cigarette ash due to windy conditions, smoker's apron flew up while smoking during smoke break.On 04/29/2026 at 1:31 PM, the resident smoking activity was observed. Staff placed a smoking ring (device that holds a cigarette) on R1's left index finger. R1's smoking apron was placed in a manner that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transfer a dependent resident safely by failing to use a mechanical lift with two staff assistance for one of four residents (R1) reviewed for accidents. This failure resulted in R1 sustaining an acute nondisplaced proximal tib (tibia)-fib (fibula) fracture. Findings include: The facility's 2/24/2025 Report to the State Survey Agency showed R1 .was observed on his right side Stat Xray done .Upon investigation that included review of clinical records, assessment, hospital documentation, and statements of staff on duty; it was found that resident is a 2 transfer assist This serves as final report. On 03/02/25 at 9:42 AM, R1 stated her fall occurred when the CNA (Certified Nursing Assistant) was trying to put her in the shower chair. R1 stated there was only one CNA assisting her to transfer. R1 stated she fell, and her left leg was hurting. R1 stated the CNA told her Your leg is fine. R1 stated her left leg is broken in two places. On 03/02/25 at 1:33…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-02-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement pressure ulcer prevention interventions including completing and documenting physician ordered weekly skin assessments and failed to identify and treat a facility-acquired pressure ulcer for one of three residents (R1) reviewed for skin concerns on a sample list of eight. These failures caused R1 to develop a sacral pressure ulcer that was discovered and noted to be unstageable, upon assessment by a wound physician. Findings include: R1's Face Sheet showed his diagnoses included type 2 diabetes, adult failure to thrive, hypertension, blindness in one eye unspecified, left side hemiplegia and hemiparesis, chronic kidney disease, and acquired absence of left leg below the knee. R1's 1/5/2025 MDS (Minimum Data Set) showed he was cognitively intact and he did not have a behavior of rejecting care. R1 was identified as being at risk for developing pressure ulcer / injury. R1 utilized a manual wheelchair for mobility and was occasionally incontinent of urine and stool. R1 did not have any documented MASD (Moisture…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility neglected to monitor a resident's change in condition, follow the orders to monitor a resident's vital signs and blood pressure as ordered and failed to notify the advanced practice nurse of signs and symptoms of a stroke. This failure resulted in a delay of treatment for R1 and causing a hemorrhagic stroke and right-sided weakness. This applies to 1 of 3 residents (R1) reviewed for facility response to change in condition and treatment in a sample of 3. The findings include: R1 is a [AGE] year-old male admitted on [DATE] having a mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 11/07/23 at 10:15 AM, V8 (Hospital Registered Nurse) stated, On 10/31/23, R1 said to multiple staff at multiple times to send him to ER (Emergency Room) as he was experiencing right side numbness and tingling. But they don't let him for whatever reason. R1 said he began to tell people to send him to the hospital on [DATE] at around 9-10 AM. He was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 received timely incontinence care.This failure applies to 1 of 3 residents (R1) reviewed for incontinence care.Findings include:R1's health record shows he is a [AGE] year-old male with diagnoses including dystonia (neurological movement disorder), type 1 diabetes, hydrocephalus (brain fluid disorder), muscle wasting and atrophy, and cognitive communication deficit who was admitted to the facility April 17, 2026.On June 08, 2026 at 1:13 PM, V9 (Friend) said approximately 3 weeks ago, R1 was in the dining room during dinner. V9 said R1 had wet through his pants, his chair cushion, and the urine had leaked onto the floor. R1 was wearing double incontinence briefs and leaked through it all. A team leader was called to dining room to see and clean up the urine. V9 said approximately a week or week and a half ago, R1 triggered his call light to be changed, a staff responded by coming into the room, turning the call light off,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintain residents' rooms and bathroom areas in a safe, clean and homelike condition. This failure applies to 5 of 7 residents (R1, R3, R4, R5, and R6) reviewed for environment.Findings include:1. R5 was a [AGE] year-old male with diagnoses that included a history of brain aneurysm, recurrent major depressive disorder, and presence of vascular implants and grafts who was admitted to the facility March 29, 2022. On May 13, 2026 at 9:35 AM, in R5's bathroom, there was a heavy presence of rust on the ceiling vent and shower tile, a heavy presence of a thick dark substance and stains throughout the floor, cracked and peeling ceiling paint, a loose handle bar, visible rust stains on another handle bar, and on the frame of a toilet commode. R5 said he would like the maintenance issues addressed when maintenance is available to get to it, there is only one maintenance staff. 2. R1 is a [AGE] year-old female with a diagnoses history of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observation, interview and record review the facility failed to provide bathing assistance to residents dependent for assistance. This applies to 2 of 4 (R2, R3) residents reviewed for bathing in a sample of 4 residents. Findings include: On 6/17/25 at 11:25 AM, R3 stated she had missed getting showers. R3 stated she was supposed to be switched to evening shift for baths. Last week no one could tell her who the shower aid was. R3 stated was then told she was not on the list for her Tuesday showers. During the interview R3 was noted with an unpleasant odor. On 6/17/25 at 11:36 AM, R2 stated she had not gotten her bed bath on Wednesday the prior week. R2 stated she prefers bed baths to showers. R2 stated there is a regular occurrence that she misses her bed bath. She brought the issue up in the last resident council meeting and had spoken to the social worker about her missed bed baths. R2 stated she never refuses a bed baths because she only gets them twice per week and she wants them done. During the interview R2 was noted with an unpleasant body odor. On 6/17/25 at 11:47…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 ensure a resident was able to get into bed to use his urinal. This applies to 1 of 4 residents (R3) reviewed for incontinence care. Findings include: On 03/04/25 at 1:20 PM, R3 stated on Friday 02/28/25 he had been sitting up in his wheelchair since 11:00 AM. R3 stated at 2:30 PM he was still in the wheelchair in his room. He stated his bed was not working. R3 stated the staff knew his bed was not working before he got out of bed. He stated the staff told him a work order was in place to repair his bed. R3 stated at 2:30 PM he pressed his call light to let his CNA (Certified Nursing Assistant) know that he needed to urinate. His bed still was not working. He stated maintenance came in and tried to repair the bed, but it still did not work. R3 stated the facility called the other maintenance person who was at home. R3 stated he still needed to urinate. R3 stated he was wearing and incontinence brief, but he urinates a lot. R3 stated he wanted to use the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 provide call light access. This applies to 2 of 7 residents (R2, R3) reviewed for call light accessibility in a sample of 8. Findings include: 1.R2 has diagnoses that includes quadriplegia, type 2 diabetes and epilepsy. R2's current care plan interventions include ensure call light is within reach and answer promptly. On 2/19/25 at 4:02 PM, R2 was sitting up in his motorized wheelchair. R2's call light that is activated when he blows into it was located on the left side of his bed near the wall and not in reach of his mouth. R2 stated the call light is never left near him when he is up in his wheelchair. R2 stated he must go out in the hall and look for assistance if he needs anything. On 2/20/25 at 1:17 PM, V7 CNA (Certified Nursing Assistant) stated all residents should have a call light available to them to notify staff if they need assistance. 2. R3 has diagnoses that includes hemiplegia and hemiparesis following cerebral infarction, carcinoma in situ of anus and anal canal, hypertension and dysphagia. R3'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 shower assistance to a resident. This applies to 1 of 3 (R1) residents reviewed for shower assistance in the sample of 11. Findings include: R1 was admitted to the facility on [DATE]. R1's admission MDS (minimum data set) dated January 30, 2025 showed that the resident was cognitively intact and required total assistance from the staff with shower. The facility's care plan task report showed that R1 was scheduled to receive shower/bathing on Tuesdays and Fridays during the morning. The facility presented only one shower sheet dated January 27, 2025 signed by V10 (CNA/certified Nursing Assistant). On February 4, 2025 at 3:30 PM, V10 stated that she did not provide a shower to R1 on January 27, 2025 but instead provided a bed bath. On February 4, 2025 at 12:22 PM, R1 was in bed, alert and oriented. In the presence of V2 (Director of Nursing), R1 stated that she had not received any shower since admission at the facility. During this…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 routine shower/bed bath care for residents who require extensive assistance for activities of daily living (ADL) care. This applies to 2 of 3 residents (R1, R2) reviewed for ADL care in the sample of 3. The findings include: 1. Face sheet shows R1 has multiple medical diagnoses which include acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic kidney disease, chronic diastolic (congestive) heart failure, morbid (severe) obesity with alveolar hypoventilation, encounter for attention for tracheostomy, atelectasis, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications, other asthma, need for assistance with personal care, other lack of coordination, other reduced mobility, abnormal posture, chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE], shows R1 is alert and oriented and requires substantial/maximal assistance for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 provide a dignified dining experience to residents who require feeding assistance. The facility also failed to provide dignity in wound care by not closing windows during wound care. This applies to 5 of 8 residents (R5, R17, R18, R22, and R24) reviewed for dignified resident care in a sample of 25. The Findings include: 1. R299 is a [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R299 requires partial/moderate assistance with eating. 2. R18 is a [AGE] year-old male with cognition intact as per the MDS dated [DATE] and requiring substantial/maximal assistance for eating. 3. R22 is a [AGE] year-old male with severely impaired cognition as per the MDS dated [DATE] and with an admitting diagnosis, including hemiplegia affecting the right dominant side secondary to cerebral infarction. 4. R24 is a [AGE] year-old female with severely impaired cognition as per…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide activities for 4 residents (R17, R29, R50 & R44) based on their care plans in a sample of 25. 1. on [DATE] at 11:44 AM, R17 was observed in her room. V15 (R17's son) was present at the time. V15 said that the facility does not provide activities for his mother. V15 said Someone used to come around and spend time with her, but she died. Now no one comes by. V15 said that he is at the facility everyday A review of R17's electronic health records showed no 1:1 activity for the last 30 days. R17's [DATE] care plan showed activities care need with interventions including, express satisfaction with level and type of involvement in leisure activities during one on one visits 3-4xweekly. 2. During tours of the facility on [DATE], [DATE] & [DATE], R29 was never observed in any 1:1 activity. A review of R29's last 30 days of 1:1 activity program showed, No documentation. R29's [DATE] Care plan showed a care need for activities 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to identify environmental hazards that poses risks for potential accidents. This applies to 6 of 6 residents (R6, R8, R28, R33, R39, and R61) reviewed for accidents/hazards in the sample of 25. The findings include: 1. On 05/14/24 at 12:20 PM R39 was not in the room. A portable oxygen tank (cylinder) was stored in R39's closet without a cart or stand. On 05/15/24 at 3:11 PM the portable oxygen tank (cylinder) was still in the closet without a storage cart or stand. On 05/16/24 at 10:44 AM the portable oxygen tank continued to be stored in R39's closet without a storage cart or stand. On 05/14/24 at 2:55 PM R39 said he does not use oxygen and does not know why the oxygen is stored in his closet. On 05/16/24 at 11:51 AM V5 (Assistant Director of Nursing) said the portable oxygen (cylinder) tanks are stored in the front oxygen room. The portable oxygen is stored in a crate that is individualized for each tank. No oxygen should be stored in a closet without being secured. V5 said secured means that the oxygen is in a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 24 citations
  • Potential for harm · E2024-05-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to contain, replace, and date respiratory equipment. This applies to 4 of 4 residents (R5, R11, R15, R38) reviewed for respiratory equipment in a sample of 25. The findings include: 1. On 5/15/24 at 10:45 AM, during initial tour, surveyor went to R11's room. R11 was not in his room. On R11's end table, his face mask to his AVAPS (Average Volume Assured Pressure Support) machine was not dated or contained in a plastic bag. R11's POS (Physician Order Sheet) shows the following order: AVAPS: When sleeping maximum pressure 30 PS Min/Max 10/15 EPAP Min/Max 10/15 Rate: 20 Tidal Volume: 600 Insp. Time 0.88 2 liters oxygen. 2. On 5/15/24 at 11:15 AM, R15 was not in his room. His concentrator was left on. R15's oxygen tubing was not dated. R15's nasal cannula was uncontained and left on his recliner. R15's POS shows the following order: Oxygen per Nasal Cannula at 2 Liters/Minute continuous every shift related to unspecified chronic bronchitis. 3. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance in Activities of Daily Living, a dignified dining experience and answering of call lights. This applies to 11 residents (R5, R9, R16, R18, R22, R24, R29, R32, R38, R46, R51) reviewed for staffing concerns in a sample of 25. Findings include: On 5/14/24 at 9:45 AM, a strong stench of urine was noted upon entry into the facility. On 5/15/24 at 02:08 PM, during the Resident council meeting 1. R51 stated there are only four C.N.As (Certified Nursing Assistant) for the entire facility at nights. R51 stated staffing for the facility is terrible nights and weekends. R51 stated they hear residents calling out for help every night and weekends. 2. R38 stated there are only four C.N.A at nights and on weekends and two nurses at night. R38 stated staffing is short on weekends. R38 stated staff see her at the end of the shift…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: wear appropriate PPE (Personal Protective Equipment) when going into an isolation room, monitor and track residents who were on isolation, obtain physician orders for isolation, develop care plans for isolation, and perform hand hygiene during wound care. This applies to 4 of 4 residents (R17, R21, R31, R62) reviewed for infections in a sample of 25. The findings include: On 5/15/24 at 11:24 AM, V5 (Registered Nurse/Assistant Director of Nursing/Infection Preventionist) stated, I work full time here. I started in August in 2023. The facility's last annual survey was in April 2023. I don't have a separate logbook of residents who were on isolation since then. I didn't know we were supposed to log those. Surveyor asked V5 who was on isolation currently. She stated that R62 was the only resident on isolation. When asked who were the residents that were on isolation for the past couple of months, V5 could only remember two other residents-R21 and R31 because she never created any logs for residents were 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotics prescribed to residents. This applies to 6 of 6 residents (R11, R25, R38, R47, R58, R60) reviewed for antibiotics in sample of 25. The findings include: 1. R11's POS (Physician Order Sheet) shows Amoxcillin-Potassium Clavulanate Tablet 875-125 MG (Milligrams): 1 tablet by mouth every 12 hours for infection for 7 days with an order date of 8/3/23. The August Monthly Infection Log shows the following for R11: Infection site: skin (ssti) left lower leg; Onsite date of 7/27/23; Signs/Symptoms: Left lower leg swelling erythema (+) drainage. Lab/Diagnostic Results Wound Culture/ MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin Resistant Enterococci). R11 did not have a McGeer's criteria form in the infection control binder or uploaded into his electronic medical record. 2. R25's POS shows Ciprofloxacin HCL 500 MG: Give one tablet by mouth every 12 hours for UTI (Urinary Tract Infection) for 5 days with an order date of 9/7/23. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observation, interview and Record review the facility failed to provide a comfortable wheelchair for one (R65) resident reviewed for mobility in a sample of 25 residents. Findings include: R65 was admitted to the facility on [DATE]. R65's MDS (Minimum Data Set) dated 3/11/24 shows he is cognitively intact with a BIMS ((Brief Interview for Mental Status) score of 15. R65's MDS shows the use of a wheelchair for mobility. R65's diagnoses include morbid obesity, abnormal posture, lack of coordination, reduced mobility, osteoarthritis, and chronic gout. R65's physician orders include may participate in outings. R65's current care plan includes ADL (Activities of Daily Living) / mobility performance deficit that may fluctuate with activity throughout the day related to limited mobility, musculoskeletal impairment, abnormal posture and lack of coordination. No documentation found in R65's EMR (Electronic Medical Record) the reason for his refusal to use the facility provided wheelchair. Review of R65's EMR…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 that 1 resident (R50) was free from physical restraints imposed for staff's convenience in a sample of 25. Findings include: On 05/15/24 at 9:13 AM, R50 was not in his room. V4 (nurse) said that R50 was not in his room because he tries to stand up all the time, so we bring him to the nurses' station. At 9:15 AM V50 was observed at the nurses' station and no staff were present at the time. R50 was observed sitting at a table and his chair was pushed up against the table with the wheels locked. R50 was observed rocking in his chair attempting to stand up. V4 said that the table is in front of R50 to keep him from standing up. V4 said that R50 always tries to get up and the table keeps him from getting up. V4 said R50 can actually walk but he will wonder in the hallway, and he is wobbly and unstable, and this is why we keep him at the table. V4 said they usually put R50 at the nurse's station to keep him from standing up and wandering. On 05/16/24 at 11:14 AM V1 (Administrator) said that the staff should…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary care and services to maintain their ability to carry out the activities of daily living with regards to communication for 2 Spanish speaking only residents (R45 & R77) in a sample of 25. Findings include: On 05/14/24 at 1:30 PM R45 and R77 were observed in their shared room. V14 (Certified Nurse's Assistant) said that R45 and R77 are Spanish speaking, and she can't communicate with them because she does not know Spanish. R45 was asked if she needed anything and R45 replied in Spanish. V14 said I can't communicate with her. Sometimes I don't know what she is saying. V14 then asked R77 if she needed anything and R77 replied in Spanish. V14 then said, I don't know what she says. I don't know if they need anything right now and I don't know what to do. R77 continued speaking and V14 just left the room without even acknowledging her. 1. R45 electronic health record review showed that R45 is a Spanish speaking only [AGE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 ADL (Activities of Daily Living) to 3 dependent residents (R9, R29 & R32) in a sample of 25. 1. On 05/14/24 at 12:41 PM, R29 was observed with long jagged nails and facial hair on her chin, about 1/2 inch long. On 05/15/24 at 12:14 PM R29 was observed with long jagged nails and facial hairs on her chin. R29's 5/21/24 care plan showed R29 had an ADL self-care/mobility performance deficit that may fluctuate with activity throughout the day. R29's 3/20/24 MDS (minimum data set) section GG showed under personal hygiene that R29 was dependent for personal hygiene. On 05/16/24 at 10:44 AM V1 (Administrator) said that R29 should not have had facial hair and her nails should have been maintained for dignity, hygiene and self-feeling good and safety. V1 said R29's jagged nails could cause her to scratch herself or someone else. 2. On 05/14/24 01:45 PM R32 was observed with facial hair on both sides of her mouth up to 2 inches in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide wound care as physician ordered. This applies to 1 of 6 residents (R74) reviewed for pressure ulcers. Findings include: R74 has diagnoses that include metabolic encephalopathy, lack of coordination, reduced mobility, malignant neoplasm of prostate and hypertension. R74's has a physician order to cleanse area to coccyx with wound cleanser, pat dry, apply calcium alginate and secure with border gauze daily. R74's current care plan states the R74 has an actual skin impairment of pressure ulcer to sacrum related to fragile skin with interventions that include treatment as ordered. On 5/16/24 at 10:54 AM R74 stated there is a wound on his backside. R74 stated he did not know how he developed the wound. R74 stated his dressing had only been changed once during the week. R74 did not remember what day it was changed. On 5/16/24 at 12:01 PM, V5 ADON (Assistant Director of Nursing) stated she did wound rounds on 5/14/24 for R74. V5 ADON stated a small opening was discovered on R74's sacrum on 5/12/24. V5 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 a restorative range of motion program to a resident with limited range of motion. This applies to 1 of 1 resident (R33) reviewed for limited range of motion in a sample of 25. The findings include: On 05/14/24 at 02:23 PM R33 was in bed, awake, alert, and oriented x 1-2. R33's left leg was contracted. R33 complained of pain to his left thigh. On 05/16/24 at 12:14 PM V17 (Certified Occupational Therapy Aide/Director of Rehab) said R33 received occupational therapy and physical therapy beginning on 04/16/24. V17 said occupational therapy ended 05/02/04 and physical therapy ended 05/06/24. V17 said when R33 was discharged from therapy, the therapy department referred him to restorative nursing for lower extremity range of motion. On 05/16/24 at 01:39 PM V5 (Assistant Director of Nursing) said during the facility's morning meeting, therapy discusses who is coming off therapy. V5 said the facility does not have a restorative nurse, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-14 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 sinks in working order for resident's use. This applies to 5 of 6 residents (R1-R5) reviewed for physical environment in the sample of 9. The findings include: R1-R3 shared a room. On October 13, 2023, at 11:40 AM, R1's room had a sink with signage above the sink read Don't use. The sink had standing water in it and a bucket under the sink to catch drips. R1 stated, I don't use the sink. We can't wash up or brush our teeth. Even the CNAs can't use it when cleaning up my roommate (R3). I have been in this room since September 16 (2023). We can't even wash our hands. R1 added no room change was offered to her. R1's admission MDS (Minimum Data Set) dated September 16, 2023, showed R1 was cognitively intact. On October 13, 2023, at 12:52 PM, R2 (R1's roommate) stated You can't brush your teeth or wash your face if the sink does not drain. It's been probably like for a month at least. I have asked the maintenance on several occasions.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-27 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 privacy during provisions of care and failed to ensure that the catheter is covered in a privacy bag. This applies to 5 of 20 residents (R7, R16, R17, R48, R49) observed for privacy during provision of care in the sample of 20. The findings include: 1. Per electronic medical record (EMR), R7 is 76 years-old with multiple medical diagnoses which include muscle wasting and atrophy on multiple sites, osteoporosis without current pathological fracture, and reduced mobility. On 4/25/23 at 9:58 AM, V10 (Certified Nursing Assistants/CNA) was attempting to reposition R7 on his right side. The door was wide open, the privacy curtain was not drawn, and the window shade was not closed. R7 was wearing a hospital gown, the hem of the gown was up to his lower trunk, with his thighs and incontinence brief expose which can be viewed from the hallway. On 4/25/23 at 10:34 AM, V11 (CNA) came in to assist V10 for incontinence care of R7. V11 closed the door behind her, however, the window blinds remained open, and the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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 incontinence care and failed to ensure that the urinary catheter drainage bag and tubing was positioned in a manner that would prevent further infection and maintain hygiene. This applies to 4 of 4 residents (R7, R16, R49 and R55) reviewed for incontinence care and urinary catheter care in the sample of 20. The findings include: 1. R55 has multiple diagnoses which includes sepsis, paraplegia, morbid (severe) obesity due to excess calories, ESRD (end stage renal disease), dependence on renal dialysis, neuromuscular dysfunction of the bladder and UTI (urinary tract infection), based on the face sheet. R55's MDS (minimum data set) dated March 14, 2023, shows that the resident is cognitively intact and requires extensive assistance from the staff with most his ADLs (activities of daily living), including toilet use (management of catheter). The same MDS shows that R55 has an indwelling urinary catheter. R55's progress notes dated April 8, 2023, showed that the resident was sent to the hospital for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that medication with shortened expiration dates were labeled upon opening of its container. This applies to 13 residents (R4, R12, R15, R19, R22, R44, R53, R75, R83, R86, R87, R141, R341) reviewed for medication storage and labeling. On 4/25/23 from 4:54 PM through 5:27 PM, 3 of the 5 medication carts of the facility were checked with V4, V7, and V8 (All Nurses). The following insulins and inhalers were observed: 1. R44's Lantus Solostar was open and not dated. 2. R12's Novolog Flex Pen, open and not dated 3. R75's Insulin Lispro Kwik Pen, pen and not dated, Symbicort 160/4.5 open and not dated. 4. R341's Levemir Insulin 1000 units/ml- unopened but not refrigerated 5. R53's Fluticasone Propionate and Salmeterol 100/50 was open and not dated. 6. R87 has two Lantus Solostars and 2 Humalog Kwik Pens that were open and not dated. 7. R23's Breo Ellipta 200-25 mcg/inh, open and not dated. 8. R15's Lantus 100 units/ml open and not dated. 9. R86's Humalog Kwik Pen - open and not dated. 10. R19's Lantus…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-27 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 store resident's foods in a safe and sanitary manner in the unit refrigerator. This applies to 4 of 4 residents (R4, R35, R52, R87) observed for food's brought from outside in the sample of 20. The findings include: On 04/25/23 at 02:55 PM, the unit refrigerator for resident food storage for unit 1, 2 and 3 was checked in the presence of V7 (Licensed Practical Nurse). There were multiple food items wrapped in plastic bags which were packed to the ceiling of the refrigerator, allowing no air circulation and causing the refrigerator door to be barely closed. The bags that were closest to the door were checked and had names of the resident or room numbers on the bag or the food containers but did not have a date. Some of the food items had a strong stale odor. The thermometer placed inside the refrigerator showed 45 degrees Fahrenheit and the visible food items near the door were noted to have condensation on them. V7 stated that these food items belonged to the residents and the nursing staff place these items…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care. This applies to the 4 residents (R7, R16, R17, R49) observed for hand hygiene and gloving during incontinence care. The findings include: 1. R7 is 76 years-old with multiple medical diagnoses which include Bacteremia. On 4/25/23 at 10:34 AM, V10 and V11 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R7 who was saturated with urine and had a bowel movement. V10 wiped R7's feces, some of the feces contacted to her gloves. After V10 cleaned R7's back peri-area, she applied a clean incontinence brief, and repositioned R7 without changing her gloves and without hand hygiene in between task. 2. 49 is 44 years-old who has multiple medical diagnoses which include quadriplegia, acute kidney failure, chronic kidney failure, and long-term (current) use of antibiotic. On 4/25/23 at 10:46 AM, V10 (CNA) rendered incontinence care to R49 who was wet with urine and had a bowel…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 assistance with showers and personal hygiene/grooming for residents who require extensive assistance for the same. This applies 3 of 5 residents (R12, R17, R24) observed for activities of daily living in the sample of 20. The findings include: 1. R12's diagnoses in EMR (Electronic Medical Records) included Parkinson's disease, other lack of coordination, unsteadiness on feet, unspecified dementia, unspecified severity, without behavioral disturbance, enterocolitis due to clostridium difficile, recurrent, other reduced mobility. R12's quarterly MDS (Minimum Data Set) dated 2/20/23 showed that R12 was moderately impaired in cognition and required extensive two person assistance with personal hygiene. On 04/24/23 at 11:34 AM, R12 was lying in bed with V9 (R12's husband) at her bedside. V9 stated, Look at her nails. There is all black underneath her nails and I told them to clean it and they haven't. They all need to be cut too. R12'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to addressed residents' positioning needs during provisions of care based on their assessments and care plans. This applies to 3 of 4 residents (R7, R17, R49) observed for turning/positioning in the sample of 20 The findings include: 1. Per electronic medical record (EMR), R7 is 76 years-old with multiple medical diagnoses which include muscle wasting and atrophy on multiple sites, osteoporosis without current pathological fracture, and reduced mobility. On 4/25/23 at 9:58 AM, R7 was lying in bed on his back, while his bilateral lower extremities (thighs and legs) were bent. V10 (Certified Nursing Assistants/CNA) was observed attempting to reposition R7 by pushing R7's left knee and thigh so R7 could turn on his right side. V10 did not attempt to support R7's upper trunk. R7 is cognitively impaired, he was groaning during this process, but was unable to verbalized how he felt. R7's admitting minimum data sheet (MDS) dated [DATE] showed that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 equipment and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 3 residents (R33 and R141) reviewed for mobility and range of motion in the sample of 20. The findings include: 1. R33 has multiple diagnoses which includes quadriplegia and complete lesion at C3 (cervical 3) level of the cervical spinal cord, based on the face sheet. R33's quarterly MDS (minimum data set) dated April 17, 2023, shows that the resident is cognitively intact and requires extensive assistance from the staff with most of his ADLs (activities of daily living). On April 24, 2023, at 11:54 AM, R33 was sitting in his motorized reclined wheelchair inside his room. R33 was alert, oriented and verbally responsive. R33's both hands and fingers were extended, and the resident could not flex or move them. R33 had a splint on his right hand but no adaptive equipment/device on his left…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 medication opportunities with 2 errors, resulting in an 8% medication error rate. This applies to 1 of 6 residents (R80) reviewed during medication pass in the sample of 20. The findings include: On 4/24/23 at 5:33 PM, V12 (Assistant Director of Nursing/ADON) administered medications to R80 via gastrostomy tube (g-tube). R80 has multiple scheduled medications which include Pantoprazole Sodium Oral Packet 40 milligrams (mg) and Levetiracetam 100 mg/ml (milliliter), with order to give 15 ml via g-tube. There was no available Pantoprazole Sodium Oral Packet in the medication cart. V12 took a Pantoprazole 40 mg tablet DR (Delayed Release) from their floor stock. V12 crushed this medication and administered it to R80 via g-tube. V12 also administered Levetiracetam 100 mg/ml (milliliter). There was a 15 ml Levetiracetam solution in the cup. However, V12 did not administer the full amount of the medication to R80. There was about 1-1.5 ml left in the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure 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 provide nutrition supplement as ordered by Physician. This applies to 2 of 2 residents (R38, R70) observed for dining in the sample of 20. The findings include: 1. On 04/25/23 at 12:54 PM, R38 received a lunch meal tray with 4 oz/ounce thickened water and 4 oz thickened juice. R38' meal ticket showed house supplement with meal tray but R38 did not receive the same. This was relayed to V5 (Certified Nursing Assistant) who was in the vicinity. V5 stated that she was unaware why R38 did not receive the supplement as she did not pass the trays. V5 brought two 4 oz cartons of strawberry house supplement to R38. R38 only drank the supplements and did not want the meal. On 04/25/23 at 01:04 PM, V6 (Cook) stated that the nursing staff provides the house supplements and health shake to those eating in the dining room. On 04/25/23 at 3:18 PM, V4 (Licensed Practical Nurse) stated she usually gives the house supplements with medications and that she doesn't remember if she gave R38 her supplement during medication…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow PPE (personal protective equipment) guidance during the provision of daily meals. This applies to all 56 residents that received meals from the facility kitchen. The findings include: Facility Resident Census and Condition of Residents dated 1/10/22 showed that the census was 56 with no tube feedings in the facility. Facility Diet Type Report dated 1/10/22 included that all 56 residents received oral diets. On 01/10/22 at 12:05 PM, V4 (cook) who was wearing a black colored personal cloth mask that was under her nose was seen preparing desserts, washing dishes and assist with putting salad into bowls for the residents. When asked if she received any guidance for usage of PPE at the facility, V4 gave a look of annoyance. When V4 was told that she had her facial covering below her nose, she continued to stare without moving an inch. V4 then without changing or correcting her mask, proceeded to wheel carts that contained drinks for the residents to hallways (100, 300 and 400) where resident rooms were…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident received an inhaler treatment as ordered by the physician, per plan of care and per manufacture's guidelines. This applies to 1 of 1 resident reviewed for self-administration of medication in the sample of 19. The findings include: R49 has multiple diagnoses which included COPD (chronic obstructive pulmonary disease), malignant neoplasm of the larynx, secondary malignant neoplasm of the left and right lungs and acute respiratory failure with hypoxia, based on the face sheet. R49's quarterly MDS (minimum data set) dated 12/24/21 shows that the resident is cognitively intact and would require supervision to limited assistance from the staff with his ADL (activities of daily living). On 1/10/22 at 11:44 AM, R49 was sitting on the edge of his bed, alert and verbally responsive. On top of R49's overbed table was a metered-dose inhaler named, Symbicort AER (aerosol) 160/4.5. There was no label to indicate the name of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 devices to maintain and prevent further reduction in ROM (range of motion) for a resident. This applies to 1 of 1 resident (R20) reviewed for ROM in the sample of 19. The findings include: R20 has multiple diagnoses which included chronic diastolic (congestive) heart failure, contracture of the left-hand muscle, muscle wasting and atrophy of the left shoulder and left hand, based on the face sheet. R20's quarterly MDS (minimum data set) dated 11/17/21 shows that the resident is cognitively intact and would require extensive assistance from the staff with most of her ADL (activities of daily living). On 1/10/22 at 12:01 PM, R20 was inside her room, sitting in her wheelchair. R20 was alert and verbally responsive. R20 has contracture on her bilateral hand/fingers and the resident does not have any device in place. R20 was unable to open or extend to open some of the fingers on both her hands, especially on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$123,187 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $98,565 — penalty dated 2026-02-19
  • $10,358 — penalty dated 2025-02-21
  • $14,264 — penalty dated 2023-11-08
  • Medicare payment denial — starting 2026-03-19 for 90 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 ARCADIA CARE — 25 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 →

RatingThis homeChain avg
Overall 1 of 51.3-0.3 vs chain
Health inspection 2 of 51.7+0.3 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 2 of 53.1-1.1 vs chain
The other 24 homes this chain runs (chain average 1.3★, 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 / managerTypeRoleSince
CEBALLOS, MARIEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
GRONSKY, AMANDAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 05/01/2024
MCCLURE, MICHELLEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
SEITLER, DOVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
SPECTOR, JENNIFERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
ARCADIA CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
ISHOLA, HAMEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
NAGUBADI, SANDHYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
TUROFSKY, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
WILHELM, NAFTALIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
BERKOWITZ, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/02/2025
MEYSTEL, YOSEFIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/01/2025
CURIS SERVICES LLCOrganizationADP OF THE SNFsince 05/01/2024

CMS files one row per role, so the 27 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$8.4M
Net patient revenuemost recent cost report
-13.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 15%Medicare 6%Other / private 79%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$313per resident / day
operating cost
$9,514per month
≈ monthly operating cost
$276per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 146112. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-17, 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.

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