La Bella of Caseyville
601 West Lincoln Avenue, Caseyville, IL 62232 · For profit - Limited Liability company · 150 certified beds · (618) 345-3072 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 7 actual-harm citations
- a high number of inspection citations overall (40) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $222,663 in federal fines (most recent 2026-02-19)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.6% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.7% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 31.2% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 19.4% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.8% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.9% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 36.9% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.8% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 22.6% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.24 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.24 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
32.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.9% 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 56 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 32.4%CMS range 19.8–54.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.3–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 10.5%CMS range 6.6–16.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 150 beds and averages 109.1 residents a day — about 73% occupied, or roughly 41 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.03 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 3.21 on weekdays — 19% thinner on weekends. RN hours go from 0.34 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
40 citations, most serious first. The 17 most serious are shown; the remaining 23 are one tap away and print in full.
- Actual harm · Gcited before2026-02-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess 1 (R5) of 3 residents that had a change in condition. This failure resulted in R5 being transferred to the emergency room after not eating or coming out of her room for over 2 days. R5 was admitted to the hospital and diagnosed with RSV (Respiratory Syncytial Virus.)Findings Include:R5's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pneumonia, nasal congestion and postnasal drip. R5's Minimum Data Set (MDS), dated [DATE] documents she was alert, performed activities of daily living (ADLs) with supervision or touching assistance from staff for eating, toileting, personal hygiene and transfers. Mobility device: wheelchair. Frequently incontinent of bowel and bladder. R5's Physician's Order Sheet (POS) dated 1/2026 and 2/2026 documented the following physician's order dated 7/3/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-06-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff implemented existing accident prevention interventions and failed to review and revise interventions after changes in resident's condition in 3 of 4 residents reviewed for falls in the sample of 37. These failures resulted in R5 suffering multiple falls and right ankle fracture. 1. R5's Face sheet documents an admission date of 3/29/2021. Diagnosis include Displaced Comminuted Fracture of Shaft of Right Tibia, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Chronic Kidney Disease. R5's Minimum Data Set, MDS, dated [DATE] R5 is moderately cognitively impaired. MDS dated [DATE] documents R5 requires partial to moderate assist with lying to sitting and sitting to standing. R5's care plan dated updated 6/19/2025 documents R5 is at risk for falls related to diagnosis of Chronic Obstructive Pulmonary Disease, Heart Failure, repeated infections, Weakness, Gout, Respiratory Failure, Pain, Obesity,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-02-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse in 2 of 8 residents (R4, R5) reviewed for abuse in the sample of 8. This failure resulted in R5 being scared and not feeling safe in the facility. Findings include: 1. On 2/14/25 at 8:25 AM, R5 stated recently R6 grabbed her by the arm and left bruises as she was walking by him. R5 stated staff didn't intervene right away but did come when she yelled out. R5 stated R6 resides on the same hall as her, she's scared and doesn't feel safe in the facility because of him (R6). R5 stated she wants to be moved off that hallway to get away from R6. R5 stated there haven't been any further incidents with R6 but she doesn't go near him. On 2/14/25 at 12:55 PM, V1, Administrator, stated R5 and R6 either bumped into one another or grabbed ones arm. V1 stated she watched the camera footage and didn't see R6 grab R5's arm, they were just passing one another in the hallway. V1 stated R6 does have behaviors every day, yells/screams out and it gets on 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.
- Actual harm · G2024-01-02 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to pass as needed (PRN) pain medications in a timely manner and failed to provide prescribed medications as ordered to 1 of 10 residents (R2) reviewed for medications in a sample of 30. The failure resulted in R2 experiencing continued pain and the inability to sleep. Findings include: R2's Face Sheet, dated 12/14/23, documents R2 has diagnoses of fracture if unspecified part of neck of left femur and other acute postprocedural pain. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with repositioning, dependent with transfer, personal hygiene, dressing, bathing, toilet use, and has an indwelling catheter and is occasionally incontinent of bowel. R2's Care plan, with admission date of 11/30/23, documents R2 has acute/chronic pain. Fracture to left hip. The goal is R2's pain will be minimized with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-01-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 scheduled medications as ordered for 7 of 10 residents (R1, R2, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. Findings include: 1. R1's Face Sheet, dated 12/19/23, documents R1 has diagnoses of pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/or touching assistance with oral hygiene, personal hygiene, eating, dependent with toileting hygiene, toilet transfer, tub/shower transfer, and substantial/maximal assistance with shower/bathe. He is always incontinent of bowel and bladder. R1's Physician's orders, were reviewed on 12/11/23, and documents R1 is to get the following medications at 6:00 AM, Protonix 40 milligrams (mg), Gabapentin 100mg, Sevelamer 800mg, Calcium Carbonate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-11-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to perform and monitor proper catheter care and monitor a penile wound for 1 of 3 (R3) residents reviewed for catheter care in a sample of 3. This failure resulted in R3 having a preventable penile injury resulting in a surgical intervention. Findings include: R3's Care Plan, dated 3/11/22, documents R3 is at risk for skin breakdown and/or pressure ulcer formation d/t (due to) dx (diagnosis) hemiplegia, anemia, multiple sclerosis, muscle weakness, contractures, Vit D deficiency et (and) DMII (Diabetes). R3 is total care for ADL's (activities of daily living). Incont (incontinent) of bowel. Has foley catheter. Currently has reddened area to penis - (Barrier) q (every) shift. No open areas noted. Apply (barrier) protect to reddened area on penis as ordered. Skin checks weekly. 3/16/22 documents (R3) has indwelling 16FR foley catheter r/t (related to) dx neurogenic bladder, hemiplegia et (and) multiple sclerosis. 6/21/23 (R3) has: Condom/Intermittent/Indwelling/ Suprapubic) Catheter: CATHETER: Position (R3's)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-11-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to position R2 in bed, in a safe position to prevent a fall in 1 of 1 resident (R2) in the sample of 3. R2 was sent to emergency room with a detection of acute cerebral ischemia and a small left frontal scalp hematoma. Findings Include: R2's Face Sheet documents an admission date of 1/14/2021. Diagnosis' include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery. Aphasia, Dysphasia. R2's Minimum Data Set, MDS, dated [DATE] documents, R2 is severely cognitively impaired and is totally dependent on staff for bed mobility and transfers. R2's MDS dated [DATE] documents, R2 has had no falls since admission. R2's care plan updated 6/12/2023 documents, R2 is at risk for falls related to diagnosis of Dementia, Cerebral Vascular Accident, Hemiplegia, Hemiparesis, Muscle Weakness, Lack of Coordination. Transfers requires…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain a resident's right to refuse a vaccination for 1 of 5 residents (R2) reviewed for resident rights in the sample of 5.The findings include:R2's admission Record, dated 5/4/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Metabolic Encephalopathy, Type 2 Diabetes Mellitus (DM), Cerebrovascular accident (CVA), Hemiplegia, Hemiparesis, Dysphagia, Aphasia, Dementia, Epilepsy, Congestive Heart Failure (CHF), Cardiomyopathy, Hypertension (HTN), Arteriosclerotic Heart Disease (ASHD).R2's Care Plan, dated 8/4/25, documents R2 requires assist with daily care needs related to some impaired mobility, cognitive impairment and diagnosis: CVA. R2 has impaired communication related to diagnosis: Aphagia and CVA. R2 is incontinent of bowel and bladder.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and requires partial/moderate assistance for Activities of Daily Living…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 a clean/comfortable/homelike environment for 1 of 4 residents (R4) reviewed for environment in a sample of 5. Findings Include: On 05/04/2026 at 10:02 AM, R4's mattress had an area on the head and side of the mattress that was sticky to touch and looked like something had been splattered on the mattress. There was also a white pasty-like substance seen under where the splatter area was. R4's Face Sheet, admission date of 11/7/25, documents she has diagnoses of but not limited to Parkinson's Disease with dyskinesia, morbid (sever) obesity, and hypertension (HTN). R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15, she requires assistance with her activities of daily living (ADLs), and she is incontinent of bowel and bladder. On 05/04/26 at 10:02 AM, R4 said the day before yesterday (05/02/26) at about 10:00 PM she had asked staff to open one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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, observation, and record review, the facility failed to assure that medication orders were processed accurately through the stages of ordering and administering medications by placing an order for a vaccination and then administering the vaccination when the resident's Power of Attorney (POA) had refused it for 1 of 5 residents (R2) reviewed for pharmaceutical services in the sample of 5. The findings include:R2's admission Record, dated 5/4/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Metabolic Encephalopathy, Type 2 Diabetes Mellitus (DM), Cerebrovascular accident (CVA), Hemiplegia, Hemiparesis, Dysphagia, Aphasia, Dementia, Epilepsy, Congestive Heart Failure (CHF), Cardiomyopathy, Hypertension (HTN), Arteriosclerotic Heart Disease (ASHD).R2's Care Plan, dated 8/4/25, documents R2 requires assist with daily care needs related to some impaired mobility, cognitive impairment and diagnosis: CVA. R2 has impaired communication related to diagnosis: Aphagia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-27 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide an RN (Registered Nurse) for at least eight hours per day when reviewed for staffing. This failure has the potential to affect all 108 residents residing in the facility. Findings Include: On 6/24/25, there were 4 LPNs (Licensed Practical Nurses), 9 CNAs (Certified Nursing Assistants), and V3, RN/ADON (Assistant Director of Nurses)/ICP (Infection Control Preventionist) working in the ADON/ICP role. The Daily Nursing Shift Assignment Sheets were reviewed and on 6/12/25, 6/14/25, 6/15/25, 6/17/25, 6/18/25, 6/19/25, 6/20/25, 6/21/25, and 6/22/25, there was not a designated RN working for at least 8 hours. On 6/24/25 at 11:50 AM, V1, Administrator, stated even with V3, ADON/IPC, they don't have enough RNs. The Daily Staffing Summary, dated 6/3/23, documents it is the goal of the facility to meet or exceed nursing staff levels required to provide quality care to the residents. The CMS (Centers for Medicare & Medicaid Services) for 671, dated 6/24/25, documents there are 108 residents residing in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide an ABN (Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) form to notify a resident or their responsible party that they no longer required daily skilled services in 3 of 3 residents (R5, R25, R77) when reviewed for Medicare Coverage Notices in the sample of 37. Findings Include: 1. R5's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, documents R5 began Medicare A skilled services on 3/5/25 and the last covered Medicare A service date was 4/3/25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. R5's NOMNC, dated, 5/19/25, documents the notification was not provided prior to the end date of 4/3/25. 2. R25's SNF Beneficiary Protection Notification Review, documents R25 began Medicare A skilled services on 4/18/25 and the last covered Medicare A service date was 6/1//25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. The NOMNC was not provided due to Social Worker was not aware…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer oxygen therapy as prescribed and provide signage on doors where oxygen is in use for residents receiving oxygen therapy for 2 of 3 residents (R2, R3) reviewed for respiratory care in the sample of 11. Findings include: 1. R2's Face Sheet dated 8/28/2024 documents R2 has diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Respiratory Failure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's Order Audit Report dated 1/11/2024 documents, Oxygen continuous at 2 Liters/Minute per nasal cannula every shift for chest pain/SOB (shortness of breath). On 8/27/2024 at 10:20 AM, there was no oxygen in use signage located in R2's room or on R2's door regarding oxygen being utilize in this room. R2 stated she takes her portable oxygen tank to the dining room for lunch and the nurse must fill it with oxygen. On 8/27/2024 at 12:05 PM, R2 was in her room and stated she had no oxygen in her portable tank…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure coordination of care with residents' community-based physician including preventative care to maintain the highest practicable physical well-being for 1 of 6 residents (R3) reviewed of quality of care in the sample of 6. Findings include: R3's admission Record, not dated, documents R3 was admitted [DATE]. R3's Brief Interview for Mental Status, dated 5/3/2024, documents R3 is cognitively intact. R3's Progress Note, effective date 6/11/2024 at 12:30 PM, documents created dated 6/14/2024 at 11:57 AM Late Entry: Note Text: Resident was concerned over his Cologuard being sent out and asked what time the mail ran. I informed him they picked up at around 2pm and he had time to get it ready. He then stated he did not need to go now, and he would have to wait until Wednesday. On 6/12/2024 at 9:40 AM R3 stated he was admitted to the facility on [DATE]nd. R3 stated shortly after he went to his primary physician which is outside of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 88 residents living in the facility. Findings Include: The facility Infection Control Log was requested for the entire year since the last survey. On 5/28/2024 at 9:02 AM, An infection control log was provided but did not have any dates or organisms listed or documented. On 5/28/2024 at 10:43 AM, V3, Assistant Director of Nursing (DON) stated, I just recently was hired and took over as the infection control preventionist in March. I have completed this course and got my certificate. All of the surveillance, everything should be in the book. I am new to this position, and I just have not gotten the surveillance/infection control where it needs to be at. I know there are no organism listed. The infection control book provided by V3 on 5/28/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-31 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure call lights were being answered in a timely manner for 5 of 7 residents (R32, R36, R70, R77, R82) reviewed for call lights in the sample of 54. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting; R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with the call lights not being answered in a timely manner on all shifts. They stated the average wait time is probably 30 minutes with some times even longer depending on what is going in in the facility. R32's Minimum Data Set (MDS), dated [DATE], documented that R32 was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 8:52 AM, R32 stated, We have been having issues with call lights and we have talked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 resident clothes were being maintained, cleaned, and returned in a timely manner for 5 out of 7 residents (R32, R36, R70, R77, R82) reviewed for laundry in the sample of 42. Findings include: On 5/28/2024 at 8:45 AM, V7, Activity Director, was asked to bring 4-5 residents to a group meeting that were able to answer questions and were interviewable. The following residents were brought to the meeting R32, R36, R70, R77 and R82. During the group meeting on 5/29/2024 at 8:45 AM, R32, R36, R70, R77 and R82 all stated they were having issues with missing laundry and the facility was not doing anything about it. 1.R36's Minimum Data Set (MDS), dated [DATE], documented that she was cognitively intact for decision making of activities of daily living. On 5/29/2024 at 9:01 AM, R36 stated, We have issues with laundry too and things go missing and they never find it or replace it. It's not right! 2.R72's MDS, dated [DATE], documented that R72…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 23 citations
- Potential for harm · Dcited before2024-05-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure abuse did not occur for 4 of 5 residents (R40, R49, R74, R75) reviewed for abuse in the sample of 42. Findings include: 1. R49's Physician Order Sheet for May 2024, documented a diagnosis of anxiety disorder, dementia in other diseases classified elsewhere, moderate with agitation, alcohol abuse with other alcohol induced disorder, alcoholic hepatitis without ascites, cocaine abuse with cocaine induced disorder. R49's Minimum Data Set (MDS), dated [DATE], documented R49 was severely impaired for cognition of activities of daily living. Partial/moderate assist for most activities of daily living and he is in a wheelchair. R49's Care Plan, undated, documented, (R49) has impaired cognitive function related to his Dementia. R49's Care Plan does not address abuse. R49's Progress Notes, dated 3/3/2024 at 9:03 PM, documented, Note Text: 10:00 PM resident involved in resident to resident altercation. This resident observed standing over another resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-31 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 2 of 4 residents (R40, and R74, ) viewed for antibiotic stewardship in the sample of 42. Findings include: 1. R40 was documented on the April 2024 Infection Control Log for a urinary tract infection. The log documented, Cephalexin Oral Tablets 500 milligrams give 500 mg (milligrams) by mouth two times a day for UTI (urinary tract infection) for 10 days. R40's Progress Notes, dated 4/16/2024 at 11:51 AM, documented, ABT (antibiotic) ordered and awaiting delivery for UTI (urinary tract infection). R40's Physician Order Sheet (POS) for April 2024, documented, Cephalexin Oral tablet 500 MG (milligrams) (cephalexin) give 500 mg by mouth two times a day for UTI for 10 days. Order date 4/17/2024, end date 4/27/2024. R40's Medication Administration Record (MAR), dated 4/1/2024 to 4/30/2024 documented, Cephalexin oral tablet 500 MG (cephalexin) give 500 mg by mouth two times a day for UTI for 10 days. Start date 4/17/2024. On 5/29/2024 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.
- Potential for harm · Fcited before2024-01-19 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide services of a Registered Nurse (RN) for at least 8 hours daily 7 days per week. This has the potential to affect all 83 residents living in the Facility. Findings include: On 1/19/24 at 1:00 PM, Nurse Staffing Schedules for the past 90 days were requested from V1, Administrator. On 1/19/24 at 2:00 PM, V1, Administrator, provided available documentation and stated she was unable to locate Nurse Staffing Schedules for 10/25/23 through 11/21/23. The Facility's Nurse Staffing Schedules for 9/27/23-10/24/23, 11/22/23-12/19/23, and 12/20/23-1/16/24 were reviewed. There was no RN coverage for 8 hours a day on the following dates: 9/27/23, 9/28/23, 10/2/23-10/5/23, 10/9/23-10/10/23, 10/12/23, 10/16/23, 10/19/23-10/24/23, 11/22/23-11/23/23, 11/27/23-11/30/23, 12/4/23-12/7/23, 12/11/23-12/14/23, 12/18/23-12/19/23, 12/20/23-12/21/23, 12/25/23-12/28/23, 1/1/24-1/4/24, 1/8/23-1/11/23, and 1/15/23-1/16/23. On 1/19/24 at 2:00 PM, V1, Administrator, stated the facility does not have a RN staffing policy, but she expects to follow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-02 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was sufficient nursing staff resulting in 6:00 AM medications not being passed for 6 of 10 residents (R1, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. This failure has the potential to affect all 83 residents residing in the facility. Findings include: 1. R1's Face Sheet, dated 12/19/23, documents R1 has diagnoses of pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires supervision/or touching assistance with oral hygiene, personal hygiene, eating, dependent with toileting hygiene, toilet transfer, tub/shower transfer, and substantial/maximal assistance with shower/bathe. R1 is always incontinent of bowel and bladder. R1's Physician's orders reviewed on 12/11/23, documents R1 is to get 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.
- Potential for harm · Fcited before2024-01-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff maintained an infection prevention and control program to help prevent the development and transmission of a communicable disease by staff not donning appropriate personal protective equipment (PPE) before entering a COVID positive resident's room, failed to have the correct signage in place for residents who were COVID positive, failed to provide bio-hazard receptacles in resident's rooms close to the door for proper discarding of PPE, failed to properly sanitize blood glucose monitors and failed to adhere to proper hand hygiene practices. This failure has the potential to affect all 83 residents residing at the facility. Findings include: On 12/13/23 at 8:35 AM, R7's and R10's room which is a COVID-19 isolation room was observed and there was an isolation sign on the door that documented droplet isolation (keep door closed), the door was observed open at this time, and there were no bio-hazard bins observed in the room at this time. On 12/13/23 at 8:37 AM, R8's room, a COVID-19 room, 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.
- Potential for harm · Dcited before2024-01-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to immediately report bruises of unknown origin to the administrator/or designee for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30. Findings include: 1. On 12/27/23 at 10:06 AM, V20 Certified Nursing Assistant (CNA) and V21 CNA provided incontinent care for R20 who had been incontinent of urine and feces. They unfastened R20's adult diaper and V21 used disposable wipes to wash away feces from R20's labia, groin and inner thighs. After feces was removed, there were two curved deep purple lines on her inner thighs where the diaper's elastic had been. It was bruised and did not fade after diaper removed. They then rolled R20 onto her right side and V21 cleansed the feces from her buttocks and rectum. After feces was removed there were two more easily visible dark purple linear bruises on R20's right and left lower buttocks where the elastic from the diaper was. These were bruises and did not fade after diaper removed. V21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to operationalize their abuse policy and thoroughly investigate bruises of unknown origin for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30. Findings include: 1. On 12/27/23 at 10:06 AM, V20 Certified Nursing Assistant (CNA) and V21 CNA provided incontinent care for R20 who had been incontinent of urine and feces. They unfastened R20's adult diaper and V21 used disposable wipes to wash away feces from R20's labia, groin and inner thighs. After feces was removed, there were two curved deep purple lines on her inner thighs where the diaper's elastic had been. It was bruised and did not fade after diaper removed. They then rolled R20 onto her right side and V21 cleansed the feces from her buttocks and rectum. After feces was removed there were two more easily visible dark purple linear bruises on R20's right and left lower buttocks where the elastic from the diaper was. These were bruises and did not fade after diaper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-05 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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 appropriate use of Antibiotics to treat a Urinary Tract Infection, (UTI), for four (R5, R6, R8 and R20) of five residents reviewed for unnecessary medication use in the sample of 18. Findings include: The undated, Facility Antibiotic Audit Log documents, the orders for Antibiotics for Urinary Tract Infections from 5/31/23 to 8/8/23. 30 residents were documented, as having a UTI, however, 5 did not have Organisms documented on the Antibiotic Audit log. According to the facility's Antibiotic Audit Log, R5 was placed on the Antibiotic, Ceftriaxone for a UTI on 7/12/23. No Organisms were documented. R5s Face Sheet undated documents, diagnosis as Chronic Obstructive Disorder, chronic embolism and Thrombosis of Unspecified Vein, Hyperlipidemia, Unspecified, Congenital Mitral Insufficiency, Pleural Effusion not elsewhere classified, Essential (primary) Hypertension. R5's Minimum Data Set, (MDS), dated [DATE] documents, Cognitive Skills for Daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy on the reporting of the allegation of injuries of unknown origins for resident (R2). This failure had the potential to affect one resident (R2) one in a sample of one. Findings include: R2's Face Sheet undated documents, medical diagnosis as Altered Mental Status, Amnestic Disorder due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. A skin Incident report dated 8/18/23 9:12 AM documents, a CNA noticed bruising and cuts on the right and left forearm of R2. Areas are dry no bleeding,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide evidence, that the allegation of injuries of unknown origin was investigated. This failure affected 1 resident (R2) in a sample of 1. This failure exposed (R2) to potential harm and further injury. Findings include: R2's Face Sheet undated documents, medical diagnosis as Altered Mental Status, Amnestic Disorder due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. A skin Incident report dated 8/18/23 9:12 AM documents, a CNA noticed bruising and cuts on the right and left forearm of R2. Areas are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-05 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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/or develop, a baseline Care Plan to furnish to attain or maintain residents' highest practicable physical, mental and psychosocial well-being for 1 of 1 resident (R2) Findings include: R2's Face Sheet undated documents, R2 was admitted on [DATE] with medical diagnosis of Altered Mental Status, Amnestic Disorder, due to Known Physiological Condition, Encephalopathy, Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with /Routine Healing, Alcohol Use Unspecified with Withdrawal Delirium. R2's Minimum Data Set, (MDS), dated [DATE] documents, R2's Cognitive Skills for Daily Decision-Making Skills is severely impaired. R2 is totally dependent for bed mobility, transfer, locomotion on and off unit, dressing, eating, personal hygiene and bathing. R2 is incontinent of bowel and bladder. R2's Nurses' Progress Notes dated 8/20/23 documents, that R2 was sent to the emergency room of a local hospital on 8/20/23 and 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.
- Potential for harm · Dcited before2023-08-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a treatment in place as ordered for a pressure ulcer for 1 of 3 residents (R4) reviewed for pressure ulcers in the sample of 13. Findings include: On 8/11/23 at 1:42 PM V14 (Licensed Practical Nurse/LPN) was standing next to R4's bed and stated she was going to have to put a dressing on R4's left hip per his treatment order. V14 lifted R4's sheet off of him and he had a hand towel draped across his peri area that was saturated with brown colored urine. V14 rolled R4 towards his right side and a small dime size open area with a pink base was observed to his mid-outer left thigh. There was no dressing on the stage 2 pressure ulcer. V14 stated she does not know where the dressing is and that it must have fallen off when he was incontinent. V14 donned gloves and pushed R4 onto his right side and cleansed the pressure ulcer with wound cleanser, then applied a new bordered foam dressing over the area. On 8/11/23 at 1:55 PM, V15 (Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinent care for a dependent resident for 1 of 3 residents (R4) reviewed for incontinence in the sample of 13. Findings include: On 8/11/23 at 1:42 PM, V14 (Licensed Practical Nurse/LPN) was standing next to R4's bed and stated she was going to have to put a dressing on R4's left hip per his treatment order. V14 lifted R4's sheet off of him and he had a hand towel draped across his peri area that was saturated with brown colored urine. On 8/11/23 at 1:55 PM, V15 (Certified Nursing Assistant/CNA) stated she had been called in at 10:00 AM so she does not know who last changed R4 or performed incontinent care. She stated he is in her section, and this is the first R4 will have been changed since she got here. V15 stated, We could not change him at 12:00 PM because it was lunch time. V15 stated, Whoever changed him before I got here must have put the towel over his peri-area. I don't know why they did that. V27 (CNA) walked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-03 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to staff a Registered Nurse (RN) 8 hours a day, 7 days a week. This failure affects all 86 residents living in the facility. Findings include: On 7/28/23 1:30 PM, V1 (Administrator) stated, We had RN coverage for every day except for the regular days off of our RN staff. On 7/28/23 at 1:35 PM, V2 (Director of Nurses/DON) stated, I think our staffing has been pretty good. The Facility's Nurse's Schedule from 7/5/23-8/1/23 had no documentation there was RN coverage on July 8th and July 9th of 2023. The facility's Resident Matrix provided on 7/26/23, documented there were 86 residents residing in the facility.
- Potential for harm · Ecited before2023-08-03 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respond to call lights to meet residents' needs for 4 of 5 residents (R8, R10, R11, R16) reviewed for residents' rights and dignity in the sample of 14. Findings include: 1. R16's Physician Order Summary (POS) undated documents R16's diagnoses as Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with routine healing, Unspecified; Fracture of Upper End of Left Humerus Subsequent Encounter for Fracture with routine healing; Muscle Weakness (Generalized); History of Falling and Primary Osteoarthritis Unspecified site. R16's Minimum Data Set (MDS) dated [DATE] documents R16 has moderate cognitive impairment and is totally dependent for dressing and toilet use. The MDS documents R16 is occasionally incontinent of bowel and bladder. On 7/27/23 at 4:00 PM, the call light in R16's room was activated. V16 (Certified Nursing Aide/CNA) responded to call light within a minute, went into the room, turned off…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that call lights are accessible to residents for 1 of 5 residents (R8) reviewed for accommodations of needs in a sample of 14. Findings include: R8's Physician Order Summary (POS) undated documents R8's diagnoses as Need for Assistance with Personal Care and Unspecified Lack of Coordination. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has severe cognitive impairment, requires extensive assistance in bed mobility, toilet use, transfer, locomotion on and off toilet, dressing, eating (set up only) and personal hygiene. R8's MDS documents R8's balance during transitions and walking are not steady, only able to stabilize with staff assistance in seated to standing position, moving on and off toilet and surface to surface transfer. On 7/26/23 at 1:21 PM, R8 stated you call push the call light, but they won't show up. R8's call light was noted to be wedged between the wall and bed and not accessible to R8. It took moving the bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-11 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility on 3/23/2024 for 8 consecutive hours and that there was a full time Director of Nursing (DON). This failure has the potential to affect all 87 residents living in the facility. Findings include: On 4/4/2023 at 8:02 AM, there was no Director of Nursing (DON) working at the facility. On 4/5/2023 at 10:02 AM, V1 (Administrator) stated that DON was not working in the facility and was off today. On 4/5/2023 at 1:32 PM, V5 (Corporate Nurse) stated, Our DON is not returning and has officially given her notice. On 4/7/2023 at 10:01 AM, V1 (Administrator) stated, I am not aware of any issues with not having a Registered Nurse (RN) working seven days a week for 8 consecutive hours every day. We are good and have not had any issues. Staffing schedules were reviewed from 3/22/2023 to 4/4/2023 and document that there was no RN coverage for 8 consecutive hours on 3/23/2023. On 4/6/2023 at 4:30 PM, V5 (Corporate RN) stated, We have RNs working on 3/23/2023 that were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-11 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 interview and record review, the facility failed to answer call lights in a timely manner for 7 of 23 residents (R4, R10, R31, R37, R42, R52, R62) reviewed for call lights in the sample of 33. Findings include: On 4/4/2023 at 12:45PM, V19 (Ombudsman) stated, Call lights continue to be a major issue at the facility, and I am still getting complaints about the call lights not being answered in a timely fashion. On 4/6/2023 at 2:00 PM, R37 stated the problem is the nights because it takes too long a time for staff to answer call lights. R37 also stated weekends are the worst. On 4/4/2023 at 9:30AM, R42 stated she has waited over an hour for her call light to be answered on the night shift. On 4/5/2023 at 3:00 PM during the group meeting, R4, R10, and R31, all stated call lights take a long time and they had complained to the facility but nights and weekends waiting for the call lights can take an hour or more for someone to come and help you. They stated they had complained to the facility, but the call lights are still slow on nights and weekends. The facility Grievance dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation, interview, and record review, the facility failed to provide adequate linens to provide a homelike environment for 7 of 23 residents (R4, R10, R28, R31, R43, R52 and R62) reviewed for homelike environment in the sample of 33. Findings include: On 4/5/2023 at 3:00, PM, during group meeting R4, R10, R28, R31 and R43, all stated the facility does not provide enough towels and washcloths when they need them. These residents stated the facility has run out of towels, washcloths, and bed pads on multiple occasions. On 4/7/2023 at 12:00, PM, V5 (Corporate Registered Nurse/ Corporate RN) We have been having some issues with the linen. We think what happened is some of the CNAs (Certified Nursing Assistants) and some of the residents were hoarding the towels and washcloths in the residents' rooms. If the linens are being hoarded, then we would have enough of them when staff need them. On 4/4/23 at 4:10 PM through 4:15 PM, the linen carts on the 100 hall, 300-hall, 200-hall, and 600-hall did not have washcloths, towels, and cloth incontinent pads. On 4/5/2023 at 8:49 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 ensure treatments were administered for the care of pressure ulcers for 5 of 6 residents (R9, R52, R65, R85, and R190) reviewed for pressure ulcers in the sample of 33. Findings include: 1. R85's face sheet, undated, documents R85 has diagnoses of Adult Failure to Thrive, Anemia and COVID. R85's Minimum Data Set (MDS), dated [DATE], documents R85 is cognitively intact. R85's Care Plan, dated 2/11/23, documents R85 has an actual impairment to skin integrity and was admitted with a stage 3 pressure ulcer to the coccyx with an intervention to monitor/document location, size, and treatment of skin impairment. R85's Wound Care Note, dated 4/4/23, documents R85 has a stage 4 pressure ulcer to the coccyx measuring 4.3 centimeters (cm) x 3cm x 0.7cm with undermining at 12 o'clock at 3.9cm. Bone is exposed. Moderate amount of serosanguineous drainage. Wound bed has 76-100% bright red granulation, no slough, no eschar, and no epithelialization…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-11 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a nourishing snack to residents when there were more than 14 hours between a substantial evening meal and breakfast for 5 of 23 residents (R4, R10, R31, R52 and R62) reviewed for frequency of meals and snacks in the sample of 33. Findings include: On 4/4/2023 at 7:51 AM, V30 (Dietary Manager) stated, We serve breakfast at 7 AM, Lunch is at 11 AM and Dinner is at 4 PM. We will make up the HS (bedtime) snacks ahead of time and will send them out on trays that are at the nurse's station. It is the responsibility of the CNAs (Certified Nurse's Aides) to make sure the residents get those snacks. They are supposed to pass them out at 7 PM. I have gotten some complaints about the snacks not being passed out, but the kitchen staff is making those snacks. If there is a problem with snacks it is coming from the nursing staff not passing out the snacks because we make them up every day. We make up peanut butter sandwiches, pudding, orange juice, milk, and cookies. The mealtimes posted by the facility documents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-11 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the family of a change in the resident's condition in 1 of 33 residents (R190), reviewed for notification of changes in condition in the sample of 33. Findings include: R190's Face Sheet, undated, documents R190 has a diagnosis of Stage 3 Pressure Ulcer of the Sacral Region. R190's Minimum Data Set, dated [DATE], documents R190 has moderate cognitive impairment with daily decision making. R190's Wound Care Note, dated 11/10/22, documents the following: Coccyx is an acute unstageable pressure injury. Measurements are 0.5 centimeters (cm) x 0.2cm x 0.1cm. There is a moderate amount of drainage noted. Wound bed has 76-100% bright red granulation, no slough, no eschar, and no epithelialization present. R190's Wound Care Note, dated 11/17/22 documents the following: Coccyx is an acute unstageable pressure injury. Measurements are 0.9cm x 0.5cm x 0.2cm. There is a moderate amount of drainage noted. Wound bed has 76-100% slough, no granulation, no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 27 residents (R39) reviewed for significant medication errors in the sample of 33. Findings include: R39's Physician Order Sheet (POS) for February 2023 documents diagnoses of acute osteomyelitis, left ankle and foot, cellulitis, and diabetes mellitus without complications. R39's February 2023 POS has an order for Ceftriaxone Sodium (an antibiotic) intravenous (IV) solution reconstituted 2 GM (ceftriaxone Sodium), use 2 grams intravenously one time a day for cellulitis and osteomyelitis for 33 days. Start dated 2/3/2023 and end dated 2/10/2023. R39's POS for February 2023 also has and order for Daptomycin Intravenous Solution Reconstituted (Daptomycin). Use 574 milligrams intravenously one time a day for Cellulitis and Osteomyelitis for 34 days. Start Date 2/3/2023 to 2/10/2023. R39's POS documents PICC Line (Peripherally Inserted Central Catheter) Insertion by (Company Name) Vascular Access Company, start dated 2/7/2023; end date 2/10/2023. R39's POS also…
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.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$222,663 in federal fines across 3 penalties. 2 Medicare payment denials on record.
- $48,620 — penalty dated 2026-02-19
- $108,640 — penalty dated 2025-06-27
- $65,403 — penalty dated 2023-11-02
- Medicare payment denial — starting 2025-07-18 for 32 days
- Medicare payment denial — starting 2023-11-24 for 68 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 JENMAX GROUP — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 2.9 | -1.9 vs chain |
The other 6 homes this chain runs (chain average 1.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KLEIN, MIRIAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 10/18/2011 |
| KLEIN, RONNIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 10/21/2011 |
| MILSTEIN, ALBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 26% | since 06/01/1994 |
| WOLFE, SHELDON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | 24% | since 06/01/1994 |
| SW MANAGEMENT | Organization | ADP OF THE SNF | — | since 12/31/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 90% 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 $564K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145585. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.