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 2025Q4 — more than 6% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 14% — 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 2.43 hrs/resident/day on weekends vs 2.92 on weekdays — 17% thinner on weekends. RN hours go from 0.50 to 0.24 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 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.

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.

39 citations, most serious first. The 22 most serious are shown; the remaining 17 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
• 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 · F2025-08-28 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  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 an emergency food supply was in stock and available for dietary services in the facility as documented in the facility assessment. This failure has the potential to affect all 257 residents who receive oral meals from the facility's kitchen during an emergency.Findings include:On 8/26/25 at 10:02 AM, during the review of the kitchen dry storage area there are no emergency food supplies in stock. V9 was inquired. V9 said, We don't have any emergency food in stock, our food supplier is supposed to bring it if we need it. I can give you the policy they gave us.On 8/25/25 at 11:40 AM, V9 District Manager provided a copy of the food service order of emergency food. V9 said, I spoke to the manager, and they put in a order for emergency food today, it should be here by Wednesday.On 8/27/25 at 1:22 PM, V1 Administrator was inquired of the expectation regarding the facility's emergency food availability. V1 said, My expectation is to have food in stock to last 72 hours that is easily accessible in case of an…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-28 · 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

  Based on observation interview and record review, the facility failed to ensure the resident's right to dignity. This failure affects 4 residents (R5, R9, R15, R113) in a sample of 84 residents reviewed for dignity. Findings include:R15's minimum data set (7/25/2025) documents in part that R15 is dependent on staff for eating assistance.R9's minimum data set (7/1/2025) documents in part that R9 requires substantial/maximum assistance from staff for eating assistance.R113's minimum data set (5/30/2025) documents in part that R15 is dependent on staff for eating assistance.R5's minimum data set (6/27/2025) documents in part that R5 requires partial/moderate assistance from staff for eating assistance. On 8/25/2025 at 12:35 PM, observed sign in the 1st floor north dining room that lists R5, R9, R15 and R113 as Feeders indicating that these residents require feeding assistance. The sign was placed in a high visibly area without cover that would allow for any passerby to see the residents listed as feeders and discloses their personal level of care needs.On 8/26/2025 at 1:00 PM, V1…

  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 before2025-08-28 · 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 ensure the resident's right to a safe, comfortable, home-like environment, as evidenced by failing to repair damaged walls, failing to have an adequate door for closets, failing to repair broken beds/room furniture, failing to repair overbed lights, and failing to repair windows. These failures affect 15 residents (R236, R75, R103, R194, R244, R183, R63, R118, R120, R81, R147, R143, R101, R94, and R39) in a sample of 84 residents reviewed for environment. Findings include:On 8/25/2025 at 10:38 AM, R153 explained that the facility is not kept up well, furniture is broken, and resident rights are not respected. R153 stated that this makes R153 want to leave the facility and be discharged elsewhere. On 8/25/2025 at 12:34 PM, R258 expressed concerns that the facility is in disrepair, that the staff are aware and choose to not fix any of the issues. R258 explained that furniture is broken, lights are broken, and nothing gets fixed. R258…

  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 · E2025-08-28 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  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 properly qualified staff completed Level I Pre-admission Screening and Resident Reviews (PASARR). This failure affects 5 (R1, R8, R9, R14, and R188) residents reviewed for pre-admission screening in the sample list of 84 residents.Findings include: Record review of R9's PASARR (Pre-admission Screening and Resident Reviews) Level I Screening (8/27/25) indicates that V23 (Office Manager) completed the level I PASSAR screening for R14. Record review of R14's PASARR (Pre-admission Screening and Resident Reviews)Level I Screening (1/23/24) indicates that V23 (Office Manager) completed the level I PASSAR screening for R14. Review of Level I PASARR Attestation and Signature documents in part By checking this box, I attest that I have reviewed all information herein and that I take responsibility for the completeness and accuracy of information reported throughout this submission. I attest that I am a healthcare professional working in a clinical…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-28 · tag F0645 — pattern
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 preadmission screening assessments were completed as required for residents identified that have a mental illness. This failure affects 4 residents (R1, R9, R188, and R260) reviewed for pre-admission screening in the sample list of 84 residents.Findings include: R9's face sheet documents, in part, an admission date of 2/18/2016. R9's face sheet documents R9's diagnoses that include but are not limited to schizoaffective disorder (7/02/2019). Review of R9's health records do not show that a Level I or Level II Pre-admission Screening and Resident Review (PASARR) was completed for R9. On 08/27/2025 at 1:35 PM, V1 (Administrator) brought in a level one preadmission screening and resident review for R9 dated 8/27/25. The level outcome states: refer for level II onsite. Rationale: A PASRR level II evaluation must be conducted. That evaluation will occur as an onsite/face to face evaluation. R260's face sheet documents, in part, an admission date 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-28 · tag F0770 — failed to provide lab services — pattern
  Provide timely, quality laboratory services/tests to meet the needs of residents.
  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 the container of the multi blood glucose test strips were labeled with an open date. These failures have the potential to affect 9 residents (R39, R47, R49, R100, R119, R133, R142, R175, and R184) who receive blood glucose monitoring tests, reviewed for medication storage in storage in the sample of 84 residents.Findings include: On 8/26/25 at 9:24am, with V18 (Registered Nurse/RN), during observation of medication storage, an opened container of the multi blood glucose strips with no open date was observed in the medication cart. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. This observation was pointed out to V18 and V18 said, There should be a date on the container (container of the multi blood glucose strips). I (V18) was going to throw it (container of the multi blood glucose strips) out. They (multi blood glucose strips) are only good for 28 days after opening the container. The results may not be reliable.…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-28 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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's pest control program failed to ensure the facility was free of pests. This failure affects 7 residents (R90, R257, R183, R63, R60, R203, and R243) in a sample of 84 residents reviewed for pest control.Findings include: On 8/25/2025 at 10:13 AM, flying winged insects were observed flying throughout R90 and R257's room. Approximately 25 small, winged insects were observed crawling on R90's water cup. No other sources of hydration were noted for R90 within the room. R90 stated, They (the insects) gnats. That's my water cup, I been drinking out of it.On 8/25/2025 at 10:15 AM, V7 (Registered Nurse) affirmed that there were approximately 30 winged insects crawling on R90's water cup. V7 stated to R90, I will get you a new water cup-I'll be right back. V7 grabbed the water cup, causing the winged insects to fly off the cup and into the room.On 8/27/2025 at 11:46 AM, a tour was conducted with V26 (Maintenance Director). During the tour, winged insects…

  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 · D2025-08-28 · 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 the restorative needs and provide restorative device (hand splints) for a resident with hand contractures to prevent further decline. This failure affected one resident (R235) of three residents, reviewed for restorative care, in a total sample of 84 residents.On 8/25/25 at 10:35 AM, R235 was observed in in the wheelchair with contracted hands and fingers, without any device to prevent further contractures.Again on 8/25/25 at 12:00pm, R235's hands were still in the same position. R235 was asked if staff comes to do exercise for his fingers and hands, but R235 stated that no one has done anything for his hands. At this time, V16 (Restorative Nurse) was notified. V16 stated He(R235) does not have anything ordered for his hand. I will do an assessment and see what he(R235) can get. V16 later came and presented the physician order sheet (POS) dated 8/25/25 for R235 that states Left Hand Splint to be worn at all times except hygiene 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 · Dcited before2025-08-28 · 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 ensure and implement sufficient supervision and interventions to prevent fire hazards for residents assessed as requiring supervised smoking for one (R168) resident who was found with a lighter underneath the bed mattress in the room, and one (R179) resident whose bathroom was observed full of smoke and bedroom garbage can with multiple cigarette butts opened with tobacco wrapped in strips of paper. This failure affects two resident (R168, R1790 all reviewed for safety and monitoring.Findings include:R179 is [AGE] years of age. Current diagnoses include but are not limited to Chronic Obstructive Pulmonary Disease, Nicotine Dependance, Schizoaffective Disorder, Major Depressive Disorder, Bipolar Disorder, and Dementia. R179's comprehensive assessment section C cognitive patterns dated 7/13/2025 documents a brief interview for mental status score of 10 out of 15. R179 has moderate cognitive impairment.On 08/25/2025 at 12:16 PM, during…

  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.

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