Bria Of River Oaks

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

33.3% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 8.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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.

Staffing

How full it usually is: this home is certified for 309 beds and averages 264.5 residents a day — about 86% occupied, or roughly 44 beds typically open. It runs fairly full. 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 2.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.47 hrs/resident/day on weekends vs 3.02 on weekdays — 18% thinner on weekends. RN hours go from 0.50 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

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.

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

38 citations, most serious first. The 23 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-01-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its abuse policy by not reporting an observed incident of abuse to the Abuse Coordinator immediately, and failed to prevent a resident (R5) from being sexually assaulted by another resident (R6), for one out of three residents reviewed for abuse in a total sample of eight. This failure resulted in V11 (CNA) observing R5 facedown in the bed crying with R5's naked buttocks exposed, and R6 directly behind R5 in a bed, while R6's pants were around R6's knees. The Immediate Jeopardy began on 12/12/23 when the sexual assault was witnessed. V1 (Administrator) was notified on 12/21/23 at 11:45 AM of the Immediate Jeopardy. The surveyor confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 12/22/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R5 is a [AGE] year old with the following…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to protect the resident's right to be free from physical assault/abuse for a resident R9 by the V10 (Activity Aide/CNA). V10 grabbed R9 by the arms, took R9 down to the floor, landed on his back, and held R9 down. This failure resulted in R9 subsequently complaining of pain, He was sent to the hospital and diagnosed with acute bilateral lower back pain and elbow and thumb pain; R9 said he was scared this would happen again. This affects one of three residents (R9) reviewed for physical assault/abuse. Findings include: R9 face sheet shows R9 has muscle wasting and atrophy, anxiety, and right ankle contracture. MDS dated [DATE] section show other behaviors symptoms not directed towards others. On 4/4/25 at 10:11am R9 was observed to be alert to person, place, time and situation. R9 said V10 hit him and slammed him to the floor. R9 said this happened by the fire extinguisher near the Nurses station, R9 escorted surveyor to the area. R9 identified V10 as…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-24 · 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 interview and record review, the facility failed to conduct a comprehensive assessment for a resident with a new onset of left leg pain. This affected one out of three residents (R1) reviewed for nursing assessments in a total sample of seven. This failure resulted in R1 being delayed treatment and not sent to the hospital for a fractured left hip for four days. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, Todd's paralysis, dementia, and chronic kidney disease. The Hospital Records dated 2/22/25 document R1 was admitted to the hospital for left hip fracture post fall. R1 reported falling while trying to get in the wheelchair two days ago. R1 is unable to move the left lower extremity and reported achy and tenderness. R1 is guarded and rated the pain a ten out of ten. R1 reported taking pain medication with minimal relief. R1 was admitted for further evaluation. Upon exam, R1 had extremity pain, limited range of motion, and joint swelling to the left hip. The admitting…

  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 · G2025-03-24 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and identify the underlying cause of a resident's (R1) new onset of pain in the left leg, and failed to inform the primary care provider of continued pain after being adminstered tramadol 50mg. This affected one out of three (R1) residents reviewed for pain management in a total sample of seven. This failure resulted in R1 having increased pain levels for four days before R1 was sent to the hospital for treatment of a left hip fracture. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, Todd's paralysis, dementia, and chronic kidney disease. The Hospital Records dated 2/22/25 document R1 was admitted to the hospital for left hip fracture post fall. R1 reported falling while trying to get in the wheelchair two days ago. R1 is unable to move the left lower extremity and reported achy and tenderness. R1 is guarded and rated the pain a ten out of ten. R1 reported taking pain medication with minimal relief. R1 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
• Actual harm · Gcited before2024-12-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policies and procedures for abuse prevention and behavior management by not calling for assistance or physically intervening during a resident-to-resident verbal and physical altercation; the facility also failed to identify an incident of abuse. This failure applied to two (R2, R3) of two residents reviewed for abuse and resulted in R2 sustaining a compression fracture of the spine, developing anxiety, and feeling unsafe in the facility after an altercation with another resident. Findings include: R2 is a [AGE] year-old male with a diagnoses history of Bipolar Disorder, Depression, Muscle Wasting, and Atrophy who was admitted to the facility on [DATE]. On 11/25/2024 at 12:11 PM, R2 stated that last Thursday (11/21/2024) morning at around 6 AM, the nurse came to his room and, cut on the light and advised she wouldn't leave it on for too long. R2 stated he responded that it was ok because he didn't get sleep anyway. R2 stated the nurse…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-10 · 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 ensure staff was aware of a high risk falls resident required supervision and monitoring and failed to prevent a resident from falling from the wheelchair while on 1:1 monitoring by staff. This affected two of three residents (R1, R2) reviewed for supervision. This failure resulted in R1 suffering a left arm fracture after falling while walking in the hallway unsupervised or without monitoring, and R2 from falling from the wheelchair and sustaining a laceration to the right ear. Findings Include: 1. R1 is a [AGE] year-old with the following diagnosis: dementia, schizophrenia, unsteadiness on feet, and displaced fracture of the left humerus. A Nursing note dated 9/22/24 at 8:30 PM documents that the nurse was notified by staff that R1 was observed getting off the floor in the annex (hallway on the first floor). As the nurse was waiting for the elevator to go downstairs, R1 came off the elevator and ambulated to R1's room. The nurse immediately followed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-01 · 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 interview and record review, the facility failed to 1) identify emergency care was needed for two residents who exhibited a change in physical and mental status. These failures applied to two (R1, R2) of four residents reviewed for nursing care and resulted in R1 experiencing a delay in care of two hours before emergency services were called, after being assessed with high blood pressure and mental status change; R1 was admitted to the hospital with a critical change in neurological condition; this failure also resulted in R2 going into cardiac arrest approximately two hours after the nurse assessed R2 with low blood sugar. Findings include: R1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included history of cerebral infarction, type II diabetes and Dementia. According to the Minimum Data Set, R1 demonstrated mild cognitive impairment, but was able to make needs known to staff. Per nurses notes effective 7/18/24 at 5:14pm, R1 was found in his room vomiting. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-07-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer; failed to timely identify, assess, and treat skin breakdown; failed to provide a plan of care to prevent skin breakdown; failed to provide preventative low air loss mattress; and failed to educate staff on pressure ulcer prevention and treatment. This deficiency applies to 1 resident R77 out of 28 reviewed for pressures in the sample of 28. This failure resulted in R77 sustaining 1 facility-acquired stage 3 sacrum pressure ulcer. Findings include: R77 is [AGE] year-old female admitted to the facility 3/23/23, with diagnoses including but not limited to End Stage Renal Disease, anxiety, and schizoaffective disorder. MDS (Minimum Data Set), dated 3/26/24, showed R77 with no pressure ulcers and at risk for pressure ulcer development, with only a pressure reducing device for chair, but no other pressure ulcer preventative treatments were provided. Care plan, dated 3/24/23, reads, (R77)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse. This applies to 3 of 15 residents (R6, R3 and R1) reviewed for abuse in the sample of 15. This failure resulted in R5 hitting R6 in the face. R6 was sent out to the local hospital and sustained a displaced right maxillary sinus fracture and displaced fracture of the right zygomatic arch. The findings include: 1. The facility's Abuse Final Report, dated 2/9/24, documents on 2/3/24, R6's interview statement: he was in the hallway when R5 approached him saying things that were not making sense .the next thing, he got hit in the face by R5. R5's interview statement he thought R6 hit him in the foot and got mad and hit R6. Interviews of witness: two staff members verbalized they were present with residents, as they observed them having a verbal disagreement .R5 abruptly swung at R6 R6 was sent out to the local hospital for further medical evaluation. CT scan conducted there was a mildly displaced…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-03 · 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 interview and record review, the facility failed to ensure the prescribed treatment order was performed for a resident with a diabatic foot wound. This failure resulted in R1's diabetic foot wound showing signs and symptoms of an infection and requiring hospitalization. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 19. The findings include: R2's face sheet shows R2 is a [AGE] year-old male admitted to the facility on [DATE], with diagnosis including type 1 diabetes, weakness, schizophrenia, anxiety, hypertension, and alcohol abuse. R2's Wound Progress note, dated 8/28/23, documents a diabetic right plantar full thickness foot wound measuring 1.9cm (centimeters) x 1.5cm x 0.5cm with moderate serous drainage. The treatment includes to apply Iodsorb gel, alginate calcium and gauze dressing daily. R2's Wound Progress Note, dated 9/4/23 and 9/12/23, documents R2's visit has been rescheduled as patient is stable per facility staff. R2's Skin/Wound Evaluation, dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the development and worsening of wound, failed to implement pressure ulcer interventions, and failed to maintain the appropriate amount of linens for incontinence management. These failures affected one (R93), of four residents in the sample of 66, and resulted in R93 re-developing a Stage 4 pressure ulcer to left ischium. Findings include: R93 is a [AGE] year-old, female, admitted in the facility on 02/05/2018, with diagnoses of Vascular Dementia, Unspecified Severity, with Agitation and Pressure Ulcer of Other site, Stage 4 (04/29/19). Per facility's list of residents with pressure ulcers - facility acquired, R93 is on the list. R93 has a Stage 4 pressure ulcer on the left ischium. R93's POS, dated 12/14/19, documented: Daily skin assessment everyday shift for standard care. R93's current POS (Physician Order Sheet) documented: 07/24/23 - Cleanse left ischium with normal saline, skin prep the periwound apply Alginate AG (silver)…

  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 before2023-08-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly monitor two cognitively impaired residents (R190, R224) to prevent harm or injury; failed to identify, evaluate, and follow their facility's policy for an injury investigation by not initiating an investigation or assessment of R190's hematoma to her left elbow; and failed to provide adequate supervision for a resident (R224) with gait/and balance impairment. These failures applies to two of five residents (R190, R224) reviewed for falls and/or injury and resulted in R190 sustaining a hematoma to the left elbow, and R224 sustaining bruises to both knees. Findings include: 1. R190's medical record indicates she has a past medical history not limited to: dementia, conversion disorder with seizures or convulsions, schizophrenia, weakness, unsteadiness on feet, overactive bladder, extrapyramidal and movement disorder. R190's Minimum Data Set Section C-Cognitive Patterns that showed resident's Brief Interview for Mental Status score,…

  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 before2023-08-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affected one resident (R180) who was physically abused by (R215). As a result of this failure, R180 was taken to the hospital where he was treated for a right temporal sulcal subarachnoid hemorrhage and right temporal hemorrhagic contusion, and was admitted to neuro ICU for further evaluation. Findings include: R180 is a [AGE] year-old male, who has resided at the facility since 2020, with past medical history of weakness, unsteadiness on feet, difficulty walking, Schizophrenia, type 2 diabetes, and anemia. R215's Minimum Data Assessment (MDS), dated [DATE], section G (functional) assessed R215 as requiring supervision for all Activities of daily Living (ADL), including walking in room and corridor. R215's Behavior assessment, dated 5/25/2023, documented behavioral symptoms of physical aggression towards self and others, wondering that affects others. R180'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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-23 · tag F0880 — failed to prevent and control infections — isolated
  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 and interview the facility failed to ensure appropriate infection control practices in Personal Protective Equipment (PPE) availability. The facility also failed to ensure proper hand hygiene/handwashing is performed after glove usage. This deficiency affects the 1st floor and 2nd floor reviewed for Infection control.Findings include:On 5/23/26 at 10:03AM, observed 1st floor and 2nd floor isolation bins without appropriate PPE in place.On 5/23/26 at 10:17AM, V8 (Certified Nurse Aide) observed wearing gloves in the hallway, removed gloves and no hand hygiene performed. On 5/23/26 at 10:17AM, V8 said that she is not supposed to wear gloves in the hallway and perform hand hygiene, before and after glove usage. V8 said she did not perform hand hygiene after glove removal.On 5/23/26 at 10:35AM, V2 (Director of Nursing) said that staff is not to wear gloves in the hallway for infection control purposes. V2 said staff should perform hand hygiene before and after glove usage. V2 said that PPE should be stocked in isolation bins and accessible to staff.5/23/26 at…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-24 · 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 provide comfortable and safe temperature levels of 71-81 degrees for residents at the facility. This failure affected 8 residents R1 through R8, who were reviewed for a safe, comfortable environment. Findings Include: On June 23, 2025, between 11:20 a.m. and 11:45 a.m., with V3 (Maintenance Director), several randomly selected rooms were observed to ensure comfortable temperatures. Temperatures in the selected rooms on the second floor where R1, R2, R7, and R8 reside are as follows: room [ROOM NUMBER]-82 degrees; 208-87 degrees; 209-83 degrees; 223-81 degrees; 228-82 degrees. R1 was in bed in the room and stated It's too hot here R1 added that it's been hot for a while. R2 was in the room and stated he was hot, and that the air conditioner had been leaking water, and staff put a blanket underneath it and promised to fix it. R7 was in bed and nodded that she was not comfortable. R8 stated that it's been a few weeks, and they did not fix…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-24 · 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 ensure that air conditioners in the second and third floor hallways and in some residents' rooms are in good repair to provide cool, comfortable and functional environment for residents. This failure affected a total of 127 residents (59 residents on the second and 68 residents on the third floor), that were reviewed for functional and comfortable environment. Findings Include: On 6/23/25 at 10:30am after the entrance conference, V2(Director of Nursing) presented the Facility's Census that shows that 59 residents reside on the second floor while 68 residents reside on the third floor. On 6/23/25 between 10:30am and 11:15am during observation with V3(Maintenance Director), the second-floor hallway temperature was 84 Degrees Fahrenheit. Several randomly selected rooms (208, 207, 227, 228, 304, 308, and 310), were observed with air conditioner units that were not functioning properly and blowing warm air. On 6/23/25 between 11:30am 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to follow their behavior management policy and facility practice and document an incident of performing crisis prevention intervention techniques for one of one residents R9 reviewed for behavior management and documentation. Findings include: 4/4/25 at 1:15pm V12 (LPN) said she was R9's nurse on 3/31/25 going into that morning of 4/1/25. V12 said V10 did not inform her that he initiated and performed crisis prevention intervention technique on R9, by grabbing R9 by the wrist bilaterally and taking R9 down to the floor and holding R9 in that position. 4/4/25 at 2:16pm V13 (LPN) said she was R9 Nurse on 4/1/25 during the morning shift and V10 did not report to her that he initiated and performed crisis prevention intervention technique on R9, by grabbing R9 by the wrist bilaterally and taking R9 down to the floor and holding R9 in that position. 4/4/25 at 11:45am during a phone interview with V2 (acting Administrator) V2 said she was not aware that V2 initiated and performed a crisis prevention intervention technique on R9 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-14 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their discharge and change in condition policies and did not notify a family member of a resident's change in condition and needed to be sent out to the hospital. This affectes one out of three residents (R1) reviewed for change in condition policy and procedures. Findings Include: R1 is a [AGE] year old with the following diagnosis: chronic obstructive pulmonary, disease, type 2 diabetes, and left eye glaucoma. A Nurse Practitioner note dated [DATE] documents the nurse practitioner saw R1 for a concern for hyperglycemia and altered mental status. R1 is positive for confusion and hyperglycemia upon assessment. Plan is to transfer to the hospital for medical evaluation. A Nursing note dated [DATE] at 11:42AM documents R1 was sent to the hospital due to altered mental status and uncontrolled hyperglycemia. There is no documentation that a family member was notified of this transfer. A Nursing note dated [DATE] documents R1 admitted to the hospital…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-12-03 · 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 observations and interviews, the facility failed to follow their policy and procedures for housekeeping and maintenance by not keeping residents' room in clean condition, not replacing heavily soiled mattresses when needed, not removing unclean clothes from the room in a timely manner, and not ensuring residents windows were covered or that windows coverings were replaced when needed. This failure applied to nine (R2, R4, R5, R6, R7, R8, R9, R10, R11) of nine residents reviewed for environment. Findings include: On 11/25/2024 at 11:44 AM Observed R4 and R5's window partially covered with torn paper blinds. R4 stated he would prefer his window covers to be replaced. On 11/25/2024 at 12:11 PM R2 stated he was previously living in room R9 and R10's current room. R2 stated housekeeping in that room was bad. R2 stated staff are not responding timely when residents pee and poop and leave a mess behind. R2 stated that one-night last week, there were dirty/soiled linens and briefs left in the shower room,…

  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 before2024-10-10 · 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 the interview and record review, the facility failed to follow the hospital discharge instructions by not scheduling a follow-up appointment to evaluate an ear laceration. This affected one of three residents (R2) reviewed for follow-up appointments. Findings Include: R2 is a [AGE] year-old with the following diagnosis: hemiplegia to the right side following cerebrovascular disease, epilepsy, aphasia, and vascular dementia. A Nursing note dated 9/1/24 documents the CNA made the nurse aware that during meal time, R2 was observed sliding out of the wheelchair. To prevent a fall, the CNA slid R2 from the chair to the floor, where R2 rested on R2's buttocks. A skin tear was noted on the right ear. The physician was made aware, and an order was placed to send R2 to the hospital for evaluation. R2 returned from the emergency department with a treatment order for the laceration. There was also a referral to see an outside physician in three days. The primary physician and family were notified. A Nurse…

  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 · F2024-09-14 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve an portion of food that meets the needs and preferences of the residents. This failure applies to all 238 residents receiving meals from the facility. Findings include: R1 is a [AGE] year-old female, with a diagnoses history of Psychosis, Auditory Hallucinations, Bipolar Disorder, Post Traumatic Stress Disorder, Schizoaffective Disorder, Recurrent Major Depressive Disorder, Non-Toxic Multi Nodular Goiter, and Abnormal Results of Thyroid Function, who was admitted to the facility 3/22/2023. R3 is a [AGE] year-old female, with a diagnoses history of Dementia, Schizophrenia, COPD, Dysphagia, Extrapyramidal Movement Disorder, and Hypothyroid Disorder, who was admitted to the facility 01/27/2021. On 09/13/2024 at 9:50 AM, V6 (Certified Nursing Assistant) stated, (R1) and (R3) could eat all day. The food portions are too small. (R1) eats pureed meals and they provide a scoop of pureed foods which doesn't seem adequate. The meal portions…

  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 · E2024-08-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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, facility staff failed to 1) identify emergency care was needed for two residents (R1 and R2) who exhibited a change in physical and mental status; 2) failed to monitor blood sugar levels for two residents (R5 and R6) who received diabetic medications daily; 3) failed to accurately demonstrate insulin preparation and 4) failed to ensure availability of resident specific diabetes medications used for emergencies. Findings include: R1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included history of cerebral infarction, type II diabetes and Dementia. According to the Minimum Data Set, R1 demonstrated mild cognitive impairment, but was able to make needs known to staff. Per nurses notes effective 7/18/24 at 5:14pm, R1 was found in his room vomiting. The nurse on duty (V4 Registered Nurse) assessed vital signs which included abnormal blood pressure (177/94) and decreased oxygen saturation (87%) on room air. V4 administered…

  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 · Dcited before2024-06-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse to 1 of 4 residents (R2) reviewed for physical abuse in the sample of 15. The findings include: The Facility Reported Incident (FRI) as final, dated 4/5/24 (date of incident 3/30/24), documents, Allegation Type: Physical. The FRI show (R2), BIMS (Brief Interview for Mental Status) of 14, alert and oriented with diagnoses of schizophrenia, depression and weakness. (R1) BIMS of 14, alert and oriented x 3 with diagnoses of hypertension, schizophrenia and chronic kidney disease. (R1) was aggressive towards (R2). (R1) stated he heard some sounds and when he opened his eyes, he could see (R2) going through his pants pocket he had out by his dresser. (R1) said he yelled at (R2) for him to stop but (R2) did not (stop) so he got up and hit (R2). Staff overheard a verbal disagreement and in the process (R1) hit (R2) in the face. They were both separated. (R1) was sent to the hospital for psych eval and (R2) was sent to a local hospital for further medical evaluation. R2'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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$219,662 in federal fines across 7 penalties. 1 Medicare payment denial on record.

• $22,984 — penalty dated 2025-03-14
• $25,604 — penalty dated 2024-12-03
• $14,050 — penalty dated 2024-10-10
• $30,550 — penalty dated 2024-07-13
• $30,602 — penalty dated 2024-05-31
• $82,833 — penalty dated 2024-01-09
• $13,039 — penalty dated 2023-11-03
• Medicare payment denial — starting 2024-06-20 for 2 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 BRIA HEALTH SERVICES — 10 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 →

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

CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 96% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.9M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL