Atrium Health Care Center
1425 West Estes Avenue, Chicago, IL 60626 · For profit - Limited Liability company · 160 certified beds · (773) 973-4780 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (56) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $163,637 in federal fines (most recent 2024-03-18)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 23% of its spending goes to commonly-owned related companies
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 improved from 2 to 3 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 | 7.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 99.0% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.7% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.9% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 44.3% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 56.6% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.3% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.55 | 2.02 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.61 | 2.22 | 1.80 | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 7.3–17.2 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.3% | 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 | 0.0% | 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 | 0.0% | 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 | 9.2%CMS range 5.4–14.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 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 160 beds and averages 150.0 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.54 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.60 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 2.12 hrs/resident/day on weekends vs 2.71 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.44 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
56 citations, most serious first. The 18 most serious are shown; the remaining 38 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-10-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor a cognitively impaired resident (R1), who was assessed to be at high risk for elopement and who had an electronic monitoring safety device on the right ankle; the facility staff failed to respond to alarms which may have sounded as R1 exited the building; and the facility failed to follow their elopement risk policy and procedures to prevent elopement. These failures affected R2, who speaks predominately Mandarin Chinese with limited understanding of English, who eloped from the facility on 9/12/23 without staff knowledge or supervision, has not returned to the facility and has not been located by the local police department which places R1 at a potential risk for harm when reviewed for improper nursing care in the sample of 16 elopement risk residents (R1, R3, R4, R6, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19 and R20). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 9/12/23 at 1:00 pm when…
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 before2024-07-05 · 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 interviews and record reviews, the facility failed to keep two (R8, R10) of six residents free from abuse. This failure resulted in R8 and R10 sustaining a swollen and bruised eye. Findings include: 1. R10's clinical record document in part the following: R10 is a fifty-year-old with the medical diagnosis of schizophrenia, hypertensive heart disease with heart failure, acute ischemic heart disease, abnormalities of gait and mobility, and essential hypertension. R10's minimum data set brief interview of mental status dated 5/1/24 scored [8], indicates cognition is mildly impaired. R10's care plan: -2/5/24: R10 has a diagnosis of mental illness, impaired decision making, inability to understand course of treatment. -5/15/24: R10 has not been the perpetrator of abuse, and he will remain safe, free from abuse and mistreatment. R10's After Visit Summary from emergency room dated 5/12/24: -R10 was seen for assault, injury to head/eye -Apply timolol maleate 0.5% solution to left eye -Acetaminophen to decrease…
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 before2024-07-05 · 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 safe practices when turning a resident in bed during resident care for 1 (R7) of three residents reviewed for falls. The facility also failed to ensure fall preventions were added to the care plan after R7's fall. This failure resulted in R7 falling out of bed and sustaining a laceration to the scalp. Findings Include: R7 has diagnosis not limited to Quadriplegia, Osteomyelitis, Hyperlipidemia, Muscle Spasm, Constipation, Postherpetic Polyneuropathy, Type 2 Diabetes Mellitus, Angina, Anxiety Disorder, Thiamine Deficiency, Vitamin D Deficiency, Bipolar Disorder, Schizophrenia, Chronic Pain, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock, Stage 4 and Essential (Primary) Hypertension. R7's MDS (Minimum Data Set) Section C - Cognitive Pattern BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Section GG - Functional Abilities and Goals: Functional Limitations in Range of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-06-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to provide safe and adequate care for a resident (R1) of 3 residents reviewed for incontinence care and bed mobility, who requires two person-assist for incontinence care and bed mobility. This failure resulted in R1 falling out of bed, hitting his head on the bedside dresser, being transferred to the hospital on 2 different occasions post fall, and being diagnosed with post-concussion syndrome. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Quadriplegia, chronic embolism and thrombosis of deep veins lateral upper extremity, schizo-affective disorder, cocaine abuse, iron deficiency anemia, pain, unspecified, low back pain, essential (primary) hypertension, constipation, nasal congestion, allergy, unspecified, changes in skin texture, pain in left shoulder. MDS section C (dated 03/08/2024) documents that R1 has a BIMS score of 15, indicating that R1's cognition is intact. MDS section…
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 before2024-05-02 · 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 the right of resident to be free of abuse for two (R4, R8) of six residents reviewed for abuse in the sample. This failure resulted in R4 being hit in the mouth sustaining facial trauma and R8 being hit in the nose resulting in bleeding and pain. Findings include: 1) R4 is a [AGE] year old male resident with a diagnosis including Schizophrenia, Deaf non speaking and Restlessness and agitation. R4 has a unscorable BIMS (Brief Interview for Mental Status). R4 is care planned for behavior symptoms concerning inappropriate personal boundaries due to diagnosis of Schizophrenia active 6/1/21. Symptoms are manifested by inappropriate touching. R4 will sneak up behind others and tap or grab them at the shoulders or back. R4 will also in attempt to joke with others steal their hats and run away from them. R4 requires ongoing supervision, cueing, and prompting from staff to remain on task and behave in a respectful and appropriate manner. R5 is a [AGE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-03-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to that ensure that a resident was free from physical abuse. These failures affected R2 who was physically scratched in the face by R1 and affected R6 who was physically kicked and scratched on the neck by R7 when reviewed for resident to resident physical assault, for four (R1, R2, R6, R7) of six residents reviewed in the sample of 6. Findings include: On 3/12/24 at 2:49 pm, R2 stated that on 2/16/24 in the evening, R2 had turned the overhead lights on in the room to write. R2 stated that R2's former roommate, R1, walked and turned off their room lights. R2 stated that R2 went back to turn on the overhead lights (by switch on the wall in their room), and R1 attached me (R2) and tried to scratch my eyes out. R2 said that there were scratches from R1 on R2's right cheek and face. R2 said that the door was open and that both R1 and R2 were standing in room. R2 stated that R1 didn't say any words to R2 prior to scratching R2, and that it happened so quickly.…
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 before2023-03-10 · 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 monitor, supervise, and assist one resident (R109) with history of multiple falls with injuries resulting in left arm fracture, acute nasal fracture, and acute intracranial hemorrhage with a hematoma; the facility also failed to provide 2-person assistance during bedside care for 1 resident (R129) who required total assist. This failure resulted in R109 falling off the bed during bedside care. These failures apply to 2 out of 4 residents (R109 and R129) from a total sample of 30 residents reviewed for accidents and supervision. R109 was hospitalized and treated for injuries. Findings include: 1. R109 was [AGE] years old, initially admitted on [DATE]. R109's medical diagnoses include pain in joint, history of falling, physical fracture of lower end of ulna, left arm and fracture of nasal bones. R109's Brief Interview for Mental Status (BIMS) scored dated 11/24/2022 was 12, indicating moderate cognitive impairment. On 03/07/2023 at 11:15 AM.…
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 · G2023-03-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow its policy related to unintended weight loss and failed to follow care plan interventions for weight loss. The facility also failed to follow its policy for providing resident with double portion during meals for 1 (R60) out of 11 residents reviewed for nutrition status. These failures resulted in (R60) having continuous significant weight loss. Findings include: R60 was [AGE] years old, initially admitted on [DATE]. R60's medical diagnoses include Dysphagia and Dementia. R60's Brief Interview for Mental Status dated 01/18/2023 scored '99 indicating that R60 was not able to be interviewed due to rarely or never understood. On 03/07/2023 at 11:36 AM. Food carts that contained trays for lunch from the kitchen arrived on the floor. Facility staff were distributing trays. R60 received his tray between 11:36 AM to 11:46 AM. At 11:56 AM R60 was seen wheeling his wheelchair going out of the dining room to his room. None of the staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect residents from physical abuse when resident-to-resident altercations occurred, resulting in R2 slapping R1 in the face; and R4 slapping R3 in the face. This failure affected four out of six residents reviewed for abuse. Findings include: 1. R3's Brief Interview for Mental Status (BIMS) dated 3/6/26 shows a score of 4 which indicated that R3 has some cognitive impaired. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, developmental disorder of speech and language, nicotine dependance, chronic obstructive pulmonary disease and hypertensive heart disease. R4's Brief Interview for Mental Status (BIMS) dated 3/12/26 shows a score of 15 which indicated that R3 is cognitively intact. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar type, primary insomnia, and hypertensive heart disease. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-22 · 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 ensure timely assessment, treatment, monitoring, and physician follow-up for a resident with a persistent lice infestation. This failure resulted in the resident (R5) experiencing ongoing symptoms, including scratching, and placed the resident and other residents at risk for continued infestation. This failure affected one out four residents reviewed for resident assessment, treatment, skin conditions, and infestations. Findings include:R5's Brief Interview for Mental Status (BIMS) dated 4/7/26 shows a score of 11 which indicated that R5 has some cognitive impairments. R5's face sheet shows that R5 has a diagnosis which includes but not limited to pediculosis due to pediculous humanus capitis, rash, and other nonspecific skin eruption.On 6/15/26 at 12:30 pm, Surveyor observed R5 in bed awake, alert, noted repeatedly scratching multiple areas of the body, including the chest, back bilateral arms, and legs. Multiple scabbed lesions of varying sizes were observed on the resident's skin in the locations being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure adequate supervision and monitoring of residents during a scheduled smoking break. This failure affected one resident (R3) resulting in resident-to-resident altercation occurring (R4 slapped R3) and has the potential to affect all 37 residents who smoke on the patio area in the facility. Findings include: R3's Brief Interview for Mental Status (BIMS) dated 3/6/26 shows a score of 4 which indicated that R3 has some cognitive impaired. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, developmental disorder of speech and language, nicotine dependance, chronic obstructive pulmonary disease and hypertensive heart disease. R4's Brief Interview for Mental Status (BIMS) dated 3/12/26 shows a score of 15 which indicated that R3 is cognitively intact. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar type, primary insomnia, and hypertensive heart disease. On 6/15/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-02 · 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
Based on interview and record review the facility failed to ensure that one resident (R1) was free from physical abuse when R2 struck R1 during an altercation in their shared room. This affected two of three residents (R1/R2) reviewed for abuse. Findings include: The facility initial reportable incident to the local state agency dated 2/12/26 at 9:54 pm, documents, in part: 2/12 2026 at approximately 804 PM it was reported that R1 and R2 displayed physical aggression in their room period staff overheard yelling and responded to residents' room as they are roommates. Resident immediately separated and both residents placed on one-to-one staff monitoring. Skin assessment completed for both residents. R1 noted with bump on right side of forehead in superficial scratch. R2 noted without injury redness swelling or bruising. Police made aware positions made aware with order to send both residents to the local hospital for an evaluation. Order noted and carried out. R1 to be sent to the local hospital and R2 to be sent to the local psychiatric hospital. To both residents being sent for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow a care plan and provide a safe environment for a resident at risk for falls by failing to ensure items were away from a residents bed/space for one (R1) of three residents reviewed for falls. Findings include:R1's history includes but is not limited to heart disease, paranoid schizophrenia, hypertension, chronic pain, and history of falling.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, for Section C. Brief Interview for Mental Status (BIMS) score is a 7 which indicates R1 has severe cognitive impairment. Section GG. Mobility: D. Sit to Stand is coded as a 3 which indicates partial/moderate assistance. I. Walk 10 feet is coded with a 3 which indicates partial/moderate assistance.On 4/10/26 at 12:10 pm, R1 noted in room lying in bed. R1's right upper eye lid is noted to be black with no swelling. R1's bed was noted in the lowest position with one floor mat on the right side. There was no floor mat on the left side 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 · Dcited before2025-10-23 · 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
Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse by a resident. This failure affected two (R1 & R2) residents out of 13 residents reviewed for abuse. Findings include:On 10/22/2025 at 3:44pm, R8 stated she was in her room adjacent to his (R2)'s room when she heard someone yelling 'nurse' 'nurse'. She drew the curtain and saw (R1) on the floor and a wheelchair turned on its side and (R2) punching (R1). She could not see where the punches landed on (R1). On 10/22/2025 at 3:58pm, V10 (Certified Nursing Assistant) stated he saw (R1) on the floor and the wheelchair beside him and (R2) was hitting (R1)'s back with his (R2) hand on a fist.On 10/21/2025 at 12:33pm, V3 (Licensed Practice Nurse) stated that particular day (10/14/2025). He (R1) went to the room to ask for (R3- R2's roommate), and he (R2) said (R3) was not in the room. On his (R1) way out, he calls him a b*h. He (R2) stated he comes out of his room, and he starts to hit him (R1). On 10/21/2025 at 2;21pm, V4 (Psychiatric Rehabilitation Services Assistant) stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-12 · 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 interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse. This failure has affected one of four residents reviewed for abuse. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, heart failure and carcinoma of oral cavity. R2's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. On 6/10/2025 at 11:30 AM, R2 stated that R3 walked up to her (R2) and begun to choke her for no reason. She stated that she was not afraid of (R3), and that she felt safe in the facility and had no additional concerns. On 6/10/2025 at 11:30 AM, R10 and R11 both stated that they witnessed R3 grabbing R2 around the neck. On 6/11/2025 at 10:38 AM, V2 (DON/ Director of Nursing) stated that she was informed that on 4/25/2025, R3 had an altercation with R2 because she (R2) was looking at him (R3). R3 was discharged from the facility after…
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 before2025-05-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) food items were stored according to manufacturer recommendations, c.) discard expired food based on use by date and guidelines, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 150 residents receiving food prepared in the facility's kitchen. Findings include: On 04/30/25 at 9:10 AM, during initial kitchen tour V5 (Dietary Supervisor) stated when items are delivered, they are labeled with a delivery date. When items are opened or prepared, they should be labeled with opened and/or preparation date and with a use by date. V5 stated all items should be used within seven days with day one being the preparation date, day seven being the use by date. At the end of day seven items should be discarded. V5 stated it is important for items to be labeled with a delivery date, opened date, and use by date so the kitchen staff knows when to discard items, so they are not served to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-02 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly date opened multi-dose inhaler for 1 (R27) resident, ensure that multi-dose insulins and antibiotic medication were stored properly at appropriate temperature for 4 (R12, R33, R57, R205) residents and discard expired multi-dose vial injection reviewed for medication storage and labeling. The findings include: On [DATE] at 9:34 AM Surveyor inspected 3B medication cart with V6 (Licensed Practical Nurse / LPN) and found the following medications inside the medication cart: - R205's Penicillin G 4ml (milliliter) injection with Pharmacy label indicated keep in refrigerator do not freeze. Medication was found inside the medication cart and was not refrigerated. - R27's opened multi-dose Ventolin HFA inhaler with no open date label. V6 said once inhaler is opened it should be dated to know when to discard. On [DATE] at 9:41am 3rd floor medication room inspected with V6 and found the following inside the refrigerator with temperature…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-02 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare pureed food in appropriate diet consistency form based on recipe and spreadsheet. This failure has the potential to affect four residents on pureed diets (R9, R15, R68, R75) prepared in the facility kitchen. Findings Include: On 04/30/25 at 11:06 PM, observed lunch tray line in progress. Desserts were already portioned out and on resident's meal trays. Observed regularly prepared gelatin without canned fruit on R9, R15, R68, R75's lunch trays. The regularly prepared gelatin without canned fruit was not pureed and the gelatin appeared firm and stiff, holding its shape in large, spooned portions in the bowl. On 04/30/25 at 11:10 AM, V5 (Dietary Manager) stated the regular diets are receiving prepared gelatin mixed diced pears for dessert and the pureed diets are receiving regularly prepared gelatin but without the diced pears. On 04/30/25 at 11:11 AM, V27 (Cook) stated he prepared regular gelatin with diced pears for the regular…
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 38 citations
- Potential for harm · Ecited before2025-05-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure staff wear proper PPE (Personal Protective Equipment) during high contact resident care activities for 1 (R1) resident on Enhanced Barrier Precautions (EBP) reviewed for infection control on the total sample of 61. Findings include: On 4/29/25 at 1:05 PM Surveyor conducted medication administration observation with V10 (LPN) and stated R1 is NPO (nothing by mouth) and has G-tube (Gastrostomy Tube). Observed R1 lying in bed, on moderate high back rest with G-tube feeding Nepro at 60ml (milliliter) flush 100ml every 8hrs (hours) infusing via pump. V10 prepared Valproic acid 250mg (milligrams) 5ml and administered medication via G-tube wearing gloves. Observed EBP (Enhanced Barrier Precautions) signage posted on the wall over R1's head part. V10 wore gloves during medication administration via G-tube but she did not wear gown. On 4/30/25 At 10:28am V2 (DON / Director of Nursing) stated she has been working in the facility for a year. She said staff should observe EBP when resident has indwelling medical…
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 · D2025-05-02 · 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
Based on observation, interview, and record review the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times for two residents (R7, R41) reviewed for dignity in the total sample of 61. Findings include: On 04/29/25 at 11:28 AM during the dining observation in the third-floor dining room there were seven tables that seated two -four residents for dining. V19 (Certified Nurse Assistant) was observed passing out the meal trays to the residents at multiple tables without completing the service of the meals at one table before serving a meal tray to another table. R7 was served his (R7) meal tray at 11:42 AM. R7 waited 7 minutes to be served after the first residents meal tray was served at the same table that seated four residents. V19 served multiple meal trays at different tables and two resident rooms before serving R7. R41 was seated across from R7. At 11:44 AM R41 asked about her meal tray. On 04/29/25 at 12:02 PM When surveyor asked V19 (Certified Nurse Assistant) why the residents…
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 · D2025-05-02 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide podiatry services for one (R355) of six residents reviewed for foot care in a sample of 61. Findings include: On 04/29/25 at 10:57 AM, observed R335 lying in bed without socks on. R335's toenails were long, extending far past his toes and were jagged. R335 said, my toenails are really long and when I put on my socks my long toenails get snagged on them, so I have to be really careful when I put them on. R355 stated he's been living here since February 2025, and no one has cut his toenails since his been living at the facility. R355 stated the last time he remembers a podiatrist cutting his nails was in October 2024. R355 said, that is why they are so long! and no one has asked me if I'd like my toenails cut or offered to cut them for me since I've been here. I'd like for someone to cut them because they are too long and need to be cut. On 04/29/25 at 12:06 PM, V13 (Licensed Practical Nurse) stated the CNAs only cut fingernails,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-02 · 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
Based on observation, interview and record review, the facility failed to follow their policy to ensure controlled medication that require refrigeration are stored within a locked box within the refrigerator to decrease the possibility of loss or diversion for 1 (R68) resident reviewed for medication storage and labeling in a sample of 61. Findings include: On 4/29/25 09:55 AM Surveyor inspected 2nd floor medication room with V7 (RN / Registered Nurse) and found R68's Lorazepam solution kept inside unlock refrigerator. Lorazepam was not kept / stored inside a lock box. R68's face sheet showed last admission date on 7/26/2024 with diagnoses not limited to Cerebral infarction due to thrombus, Hypothyroidism, Seizure, Heart failure, Hypertensive heart disease with heart failure, Vascular dementia, Dysphagia. MDS (Minimum Data Set) dated 1/28/2025 showed R68's cognition was impaired. R68's physician orders dated 4/29/25 showed order not limited to Lorazepam 2 mg/mL oral concentrate, give 0.25 milliliter (0.5 mg) by oral route every 2 hours for 14 days as needed. On 4/30/25 At 10:28am V2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-02 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for 3 (R73, R125, R149) of 9 residents observed during medication administration. Surveyor observed 4 errors during 28 medication administration opportunities. This resulted in a medication error rate of 12.49%. The findings include: On 4/29/25 at 9:20AM Surveyor conducted medication administration observation with V8 (Licensed Practical Nurse / LPN) and she prepared the following medications for R73: 1. Celecoxib 200mg (milligram) 1 capsule. 2. Docusate sodium 100mg 1 capsule. 3. Vitamin C 500mg 1 tablet 4. Allopurinol 100mg 2 tablets 5. Acetaminophen 500mg 2 tablets 6. Folic Acid 100mg 1 tablet 7. Imbruvica 420mg 1 capsule 8. Vitamin D3 25mcg (micrograms) 1000iu (unit) 1 tablet 9. Iron tablet fe so4 (iron) 325mg 1 tablet 10. Miralax powder 17gm (gram) mixed with 1 cup water. 11. Fluticason Ellipta 100cmg/25mcg. R73 inhaled / puffed once. 12. Aspirin 81mg 1 tablet On 4/29/25 09:28 AM V8 administered prepared meds to R73 and taken orally. V8 handed Fluticason…
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 · D2025-04-16 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to follow their policy of requesting a fingerprint-based background check within 72 hours of receiving the residents' name based criminal history background check for two of two residents (R9, R10) reviewed for Abuse Prevention. Findings include: On 04/14/2025 at 12:05pm during the Identified Offender Program review with V9 (Business Office Manager) observed R9's (03/26/2025) name based Criminal History Report's result: HIT and R10's (04/03/2025) name based Criminal History Report's result: HIT. This surveyor requested to see R9's and R10's fingerprinting consent, schedule, receipt, result and risk assessment. V9 stated (V3 - Social Service Director) is responsible for scheduling the fingerprinting of the residents. On 04/14/2025 at 1:24pm, V3 presented this surveyor R9's and R10's unsigned and undated 'Nursing Home Resident Applicant Fingerprinting Consent Forms'. V3 stated when I get the CHIRP result with HIT that is the only time we order for fingerprinting of our residents. I inform (Fingerprint Service Provider) via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 ensure that staff are aware of the requirements for involuntary (psychiatric) admission, failed to provide resident a petition for involuntary admission and failed to explain the rights of admittee for one of four residents (R1) reviewed for transfer/discharge. Findings include: R1's (2/5/25) petition for involuntary/judicial admission states resident was in an alleged physical altercation with co-peer, both patients were separated however he continues to attempt to become physical. Resident had to be removed from the area to a lower floor but would not comply to separate from co-peer therefore MD (physician) was made aware with order to send to hospital to prevent provoking and harm to others. [Page 3 was endorsed by V7/Social Service Director]. Page 4 states Within 12 hours of admission to the facility under this status and/or completion of a new petition, I gave the respondent a copy of this petition (IL462-2005). I have explained the Rights of admitted to the respondent and have provided him or her with a copy of it. I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · 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 follow policy procedures, failed to ensure that osteomyelitis was included in diagnoses, failed to schedule medication as directed, and failed to administer medications as ordered for one of four residents (R3) reviewed for medication administration. Findings include: R3 was admitted to the facility on [DATE] with diagnosis of local infection (due to central venous catheter) and discharged AMA (Against Medical Advice) on 2/16/25. R3's (2/14/25) progress notes state at 3:05pm, resident was admitted into the facility with diagnosis of acute osteomyelitis (bone infection) - which was excluded from the diagnoses. Medications verified with medical doctor with order to continue with hospital medications. R3's (2/14/25) POS (Physician Order Sheets) include the following antibiotics: Cefepime 1 gram IV every 8 hours for 1 month [Start Date/Time: 2/15/25 12:00am] and Vancomycin 750 milligrams IV every 8 hours for 1 month [Start Date/Time: 2/15/25 12:00am]. 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.
- Potential for harm · D2025-03-19 · 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 interview and record review the facility failed to follow policy procedures, failed to assess/document skin integrity impairments, failed to ensure that the facility wound report was accurate, failed to obtain descriptive treatment orders (including wound locations/medication/type of dressing), and failed to follow physician orders for one of four residents (R3) reviewed for pressure ulcers. Findings include: R3 was admitted to the facility on [DATE] and discharged AMA (Against Medical Advice) on 2/16/25. R3's (2/14/25) progress note [entered 2/18/25 - 4 days later] states at 3:05pm, resident was admitted into the facility with diagnosis of acute osteomyelitis and discharge diagnosis of pressure injury of right hip (stage 4) complicated by deep penetrating ulcer on the left buttock with osteomyelitis of ischial tuberosity and inferior [NAME] of left ischium. Resident's wound was debrided on 2/3/25 and is on wound vac for the stage 4 wounds with continuous pressure of 125/125. Dressing dry and intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-23 · 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 that two (R1, R2) residents were free from abuse. This failure resulted in R1 and R2 verbally and physically abusing each other in a total sample of four residents reviewed for abuse. Findings include: R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to schizoaffective disorder, bipolar type, bipolar disorder, current episode manic without psychotic features, unspecified. R1's MDS (Minimum Data Set) section C dated 01/15/2025 documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive function. R2 is a [AGE] year-old individual with medical diagnosis that include but not limited to Chronic pain syndrome, Poisoning by heroin, undetermined, initial encounter, Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus. R2 MDS (Minimum Data Set) section C dated 12/02/2024, documents R2's Brief Interview for Mental Status (BIMS) as 15/15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · 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 document review the facility failed to ensure the residents right to be free of abuse in for two (R1 and R4) out of five residents included in the resident sample of 9. Findings include: 1: R1 is a [AGE] year old female with a diagnosis including Burns involving 30-39% of body surface with 9% third degree burns, Panic disorder, Schizophrenia, and chronic pain due to trauma. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) score of 15/15. R1 ambulates by wheelchair. On 1/22/25 at 11:10AM R1 stated I reported to the Social Service Director that my roommate's sister (V5) was verbally inappropriate to me when she was in my room to visit. I said good morning to her (V5). The sister (V5) responded by saying don't say good morning to me. She (V5) said you are a f*g b*h liar. Have a nice life. I reported this to V4 (Social Service Director). V4 came to my room and looked into this. V4 told me that the visitor (sister) was not allowed up on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the initial reportable for the allegation of sexual assault was sent to the State Agency within the mandated timeframe for one (R2) resident reviewed for abuse in the total sample of 6 residents. Findings include: V1 (Administrator)'s (12/06/2024) email correspondence with State Agency documented, in part Sent: 12/06/2024 6:15PM. Subject: Facility Reportable R2 vs unknown. R2's (12/06/2024) Preliminary 24-hour Incident Investigation Report documented, in part Date, Time, Location and Circumstance of Alleged incident. On 12/06/2024 at approximately 3:30pm, R2 alleged that she was sexually assaulted on 09/25/2024 by an unidentified male staff member. R2's (12/11/2024) Final Incident report documented, in part Type of Incident: Alleged Sexual Abuse. Date of Alleged Incident: 12/06/2024. Time of Alleged Incident: 3:30pm. On 12/18/2024 at 12:15pm, V1 (Administrator) stated I am the Abuse Coordinator. When I receive allegation of abuse, I do preliminary report and send it to State Agency. The time frame for reporting the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · 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
Based on interview and record review, the facility failed to ensure an allegation of sexual assault was thoroughly investigated. This failure affected 1 (R2) resident reviewed for abuse in the total sample of 6 residents. Findings include: R2's (12/06/2024) Preliminary 24-hour Incident Investigation Report documented, in part Date, Time, Location and Circumstance of Alleged incident. On 12/06/2024 at approximately 3:30pm, R2 alleged that she was sexually assaulted on 09/25/2024 by an unidentified male staff member. On 12/16/2024 at 12:58pm, R2 stated I was sleeping, I don't remember the time. I know it was 3rd shift early morning of 9/25/24. 3rd shift starts at 11PM. The (09/24/2024 and 9/25/2024) daily staffing forms indicated that V17 (Certified Nursing Assistant) worked on second floor on 3rd shift. The (09/24/2024) Unit 2, Shift 11-7 Certified Nursing Assistant Assignment sheet documented that V17 was assigned to R2. V17's (pay period 12/082024-12/21/2024) Time report indicated that V17 worked on 12/09, 12/10, 12/11, 12/14, 12/16. The (12/11/2024) R2's Investigation packet did…
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 before2024-12-19 · 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 F689 Based on interview and record review, the facility failed to uodate a plan of care and provide assistance to one resident (R1) who required supervision assistance when ambulating. This failure affected one resident (R1) in a total sample of three residents reviewed for falls. Findings include: R1's diagnoses include but are not limited to type 2 diabetes, chronic obstructive pulmonary disease, schizoaffective disorder, essential hypertension, history of falling, bilateral primary osteoarthritis of knee. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1's cognition is intact. R1's MDS dated [DATE] section for functional abilities and goals documents in part, GG0115. Functional Limitation in Range of Motion .B. Lower extremity (hip, knee, ankle, foot) 2 .Impairment on both sides .GG0170. Mobility .I. Walk 10 feet: Once standing the ability to walk at least 10 feet in a room, corridor, or similar space .05. Set up or clean-up…
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 before2024-11-22 · 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 and protect residents from resident-to-resident physical abuse. This failure affects one (R1) resident out of eight residents reviewed for abuse. As a result of this failure, R2 pushed R1 to the floor. Findings include: Facility reported incident/FRI dated 07/06/2024, documents that the facility reported an altercation between R1 and R2. FRI documents that R1 reported R2 pushed R1 and R1 fell to the floor. R1's face sheet documents that R1 is a [AGE] year-old female with diagnoses not limited to: schizophrenia, depressive disorder, recurrent, mild, hypothyroidism, essential (primary) hypertension. R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. R2's face sheet documents that R2 is a [AGE] year-old male with diagnoses not limited to: schizophrenia, restlessness and agitation. R2's MDS/Minimum Data Set, dated [DATE] documents that R2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, failed to follow their policy to report any allegation of abuse to the administrator or administrator's designee and to Illinois Department of Public Health for one resident (R5) out of three residents reviewed for abuse. Findings include: On 10/08/2024, at 11:00 AM, surveyor observed R5 in his room. R5 stated that sometimes nurses and CNAs hit him. R5 stated that one time they took his walker and hit himself with it. R5 stated that he spoke to social worker about this issue. R5 is not sure who the CNA or nurse was that hit him. On 10/08/2024 at 12:31 PM, V5 (Social Worker) stated that R5 informed her that he was hit by a CNA and was verbally aggressive towards him. V5 stated that she notified V1 (Administrator) and V4 (Social Worker Director). V5 stated that R5 have given her written statements about how CNAs and nurses have hit him. On 10/08/2024 at 12:35 PM, V5 showed surveyor the written statements given to her by R5. V5 stated that R5 has made these allegations in the past couple months. On 10/08/2024 at 1:45 PM, V1 (Administrator) stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-11 · 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
Based on interview and record review, failed to follow their policy to investigate allegations of abuse by the administrator or administrator's designee for one resident (R5) out of three residents reviewed for abuse. Findings include: On 10/08/2024 at 11:00 AM, surveyor observed R5 in his room. R5 stated that sometimes nurses and CNAs hit him. R5 stated that one time they took his walker and hit himself with it. R5 stated that he spoke to social worker about this issue. R5 is not sure who the CNA or nurse was that hit him. On 10/08/2024 at 12:31 PM, V5 (Social Worker) stated that R5 informed her that he was hit by a CNA and was verbally aggressive towards him. V5 stated that she notified V1 (Administrator) and V4 (Social Worker Director). V5 stated that R5 have given her written statements about how CNAs and nurses have hit him. On 10/08/2024 at 12:35 PM, V5 showed surveyor the written statements given to her by R5. V5 stated that R5 has made these allegations in the past couple months. On 10/08/2024 at 1:45 PM, V1 (Administrator) stated that she is familiar with R5. V1 stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affects all 149 residents in the facility. Findings include: On 04/01/24 at 10:00 AM during initial tour of the dietary area the reach in refrigerator was observed with 3 sleeves of opened bologna on top of sliced bologna in a flat pan, which were undated and unlabeled. Ground beef in 6 inch deep flat pan was observed with ripped aluminum cover exposing contents and was undated and unlabeled. Walk in refrigerator was observed with a large tray of pre made meat sandwiches were undated and unlabeled. A large tray of pineapple/strawberry desert in small bowls were undated and unlabeled. A large 6 inch deep pan of pineapple/strawberry desert was undated and unlabeled. The dry food storage room was observed with an open package of oatmeal cookies open and uncovered. The floor was observed with the broken glass from a 4 ft fluorescent lightbulb on the floor. This light was above 6-30 gallon bulk food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-04 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to maintain an effective pest control program so that the facility is free of insect pests in the dietary area. This has the potential to affect all 149 residents in the facility. Findings include: On 4/1/24 at 10:30AM two live nymph stage roaches were observed on the floor in the food service area next to the food service janitors closet. On 4/2/24 at 11:30AM two live adult roaches were observed under the dishwasher on the floor. On 4/3/24 at 11:30AM one dead roach was observed inside a box of opened plastic medicine cups in the dry food storage area. On 4/3/24 at 11:40PM V20 (Interim Dietary Manager) stated I was not aware of roaches in the dietary area. I know the pest control company sprays in the kitchen. Facility policy titled Pest Control includes statement: Purpose 1.To ensure that the facility is free from refuse, litter, insect and rodent breeding areas. 2. Building and grounds shall be kept free of possible infestations of insects and rodents by eliminating sites of breeding and harborage inside and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to properly disinfect multi-use equipment used on 4 residents (R58, R61, R92 and R135). The failures affected R58, R61, R92 and R135 reviewed for infection control in the sample of 60. Findings include: On 4/2/2024 at 9:18am, V19 (Licensed Practical Nurse/LPN) removed the handheld portable blood pressure machine which was in the medication cart. V19 then took the blood pressure machine into R92's room, who was observed lying in bed on his back, and applies the blood pressure cuff on R92's upper left arm without sanitizing the blood pressure cuff. R92's face sheet documents, in part, R92's diagnoses including but not limited to: irritable bowel syndrome with constipation, hypertension, nausea and vomiting, schizophrenia and major depressive disorder. R92's Brief Interview for Mental Status (BIMS), dated 03/08/24, documents R92 with a score of 15 which indicates that R92 is cognitively intact. On 4/2/2024 at 9:31am, V19, LPN, removed the handheld portable blood pressure machine which was in the medication cart and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the first floor shower room was clean and sanitary. This has the potential to affect the 45 residents residing on the first floor. Findings include: On 04/01/2024 at 10:49am surveyor observed two pieces of human feces on the shower floor of the first-floor shower room. On 04/01/2024 at 10:51am surveyor observed V8 (CNA/Certified Nursing Assistant) direct a resident into the first-floor shower room to take a shower. V8 did not step into the shower room to check the shower room for cleanliness. On 04/01/2024 at 11:14am surveyor observed resident leaving from the first-floor shower room. Surveyor returned to the shower room to observe the same two pieces of human feces on the first-floor shower room floor. On 04/01/2024 at 11:16am surveyor interviewed V8 (CNA/Certified Nursing Assistant) regarding the cleanliness of the first-floor shower room floor. V8 stated housekeeping staff is responsible for cleaning the shower room floor. V8 stated I usually check the shower room for cleanliness after the 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 before2024-04-04 · 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 empty one resident's (R59) urinal located on the resident's (R59) bedside dresser and failed to ensure that the call light was within reach for one resident (R133). This failure had the potential to affect 2 residents out of a sample of 60 residents. Findings include: On 4/1/24 at 10:53am, R59 was observed laying on his left side with a urinal filled with 300ml of clear amber urine on the bedside dresser. On 4/1/24 at 11:31am, R59's urinal was again observed filled with 300ml of a clear amber urine on the bedside dresser. R59's admission Record, documents, in part, diagnosis of acquired absence of left leg above knee, acquired absence of right leg above knee, peripheral vascular disease, essential (primary) hypertension, major depressive disorder, epilepsy, and schizoaffective disorder. R59's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Investigation of Mental Status (BIMS) score of 99 which indicates that R59 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 · D2024-04-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 update the advance directive status in the medical records for one resident (R77) reviewed for advance directives in a sample of 60. Findings include: R77's admission diagnoses documents in part, sepsis, diabetes, hypertension, encephalopathy, chronic hepatitis C, and chronic obstructive pulmonary disease. R77's Brief Interview for Mental Status (BIMS) score is 5. R77 has severe cognitive impairment. R77's POLST (Practitioner Order for Life-Sustaining Treatment) Form dated [DATE], documents in part, Section A: No CPR (Cardiopulmonary resuscitation) Do Not Attempt Resuscitation (DNAR). R77's Face sheet (printed on [DATE]) documents in part, Advance Directives Full Code. R77's Physician's Orders (printed on [DATE]) documents in part, Advance Directives: Full Code. R77's ([DATE]) progress note documented in part, admitted to hospice. R77's ([DATE]) care plan documents in part, Focus: Advance Directive DNR (Do Not Resuscitate); R77 is and will remain a DNR…
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 · D2024-04-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 document that a medication was not received by one resident (R92) and failed to follow a physician's order to take a blood pressure prior to administering medication to one resident (R119). This failure had the potential to affect 2 residents out of a sample of 60 residents. Findings include: On 4/2/2024 at 9:18am, V19 (Licensed Practical Nurse/LPN) asked R92 if R92 wanted the scheduled dose of the medication, polyethylene glycol, the physician ordered. R92 replied, No, I do not want the polyethylene glycol. This surveyor asked V19 if R92 is refusing the polyethylene glycol and V19 stated, yes. Upon review of R92's Medication Administration Report (MAR) to reconcile the above medication that was ordered and scheduled for administration but refused by R92, R92's MAR documents that polyethylene glycol was administered at 9:00am, on 4/2/24 by V19. However, the preparation or administration of this medication was not observed by surveyor. R92's Physician Order Report, dated 02/29/24, shows that R92 has an order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-04 · 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
Based on observation, interview and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 2 residents (R95 and R147) receiving controlled substances from the third floor, team 1 medication cart. Findings include: On 4/2/24 at 1:10 pm, Surveyor observed the shift change accountability record for controlled substances on the 3rd floor team 1 medication cart had missing signatures for the oncoming and off going nurses on 4/1/24 for the 3rd shift. On 4/2/24 the signature for the oncoming nurse for the 1st shift was missing. This observation was pointed out to V26 (Registered Nurse). V26 stated, I counted with the off going nurse, but forgot to sign the sheet. Surveyor inquired to V26 when does the sheet supposed to be signed? V26 stated, the sheet should be signed after completing the count. R95's diagnosis includes but are not limited to bipolar, depression, anxiety, and hypertensive heart disease. R95 (1/17/24) physician order documents in part,…
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 · D2024-04-04 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide thermometers for resident's personal refrigerators for 2 residents (R84 and R133), failed to properly log refrigerator temperatures for 2 residents (R60 and R133) and failed to discard expired food from 1 resident's personal refrigerator (R133). These failures have the potential to affect all 3 residents reviewed for safety of personal food items, in a total sample of 60 residents. Findings include: 1. On 4/1/24 at 10:58am, during observation of R133's personal refrigerator the following were observed: The refrigerator was without a temperature thermometer. The refrigerator was without a temperature log. 3-236ml (milliliter) milk cartons located in the refrigerator had an expiration date of 3/29/24. On 4/1/24 at 10:58am, this surveyor inquired about R133's refrigerator and R133 stated, That's my personal fridge. Staff never come and check the temperature or check for expired food. R133's admission Record documents, in part, diagnosis of type 2 diabetes mellitus with hyperglycemia, depression, phlebitis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-22 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly secure and protect the resident's money for six (R2, R4, R5, R6, R7, R8) out of eight residents reviewed for resident's rights. Findings include: On 03/19/2024 at 11:45AM, V4 (LPN-Licensed Practical Nurse) states the day R2 went to the hospital, V6 (CNA- Certified Nursing Assistant) came to the third floor nurses' station and showed him an envelope. V4 states the envelope was a yellow envelope. V4 states V6 took money out of the envelope and was waving the money saying, I want you to see R2's money. V4 states V6 then put R2's money back into the envelope. V4 states he and V6 did not count R2's money. V4 states the envelope was not sealed and V4 folded the envelope in half and placed it inside of the narcotic lock box located inside of the medication cart. V4 states he was not familiar with the protocol to follow for storing R2's belongings because he never had to keep money for residents at previous facilities V4 has worked for.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-22 · 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
Based on observation, interview and record review the facility failed to accommodate a resident's preference to aid in providing a comfortable and homelike setting for one (R1) resident out of eight residents reviewed for resident's rights. Findings include: On 03/19/24 at 10:00 AM observed R1 sitting up on her bed, in her room, alert and responsive. Surveyor did not observe any fan in R1's room. R1's clinical record documents admission date of 03/11/2024. Diagnoses included but were not limited to other specified depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, other muscle spasm, and diabetes. On 03/19/24 at 10:00 AM R1 said that last week R1 requested a fan from the social worker (identified as V7), and the social worker responded that she would check to see if she had one in her office, but she never brought a fan to her. R1 stated that she met with social worker yesterday and social worker did not mention anything about the fan. R1 said that the room feels warm and there is an air conditioner but is on the window side and R1's bed is closer…
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 · D2024-03-22 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 affirm the right of the resident to be free from misappropriation of resident property. This failure affects one (R2) out of three residents reviewed for misappropriation of resident property. Findings include: R2's MDS/Minimum Data Set, dated [DATE] documents that R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R2 is cognitively intact. On 03/19/2024 at 10:06AM, R2 states she was sent out to the hospital approximately 1 month ago. R2 states her transfer to the hospital happened so quickly that R2 had to make the decision to give her money to her roommate (identified as R3) because R2 did not want to have her money stolen while R2 was hospitalized . R2 states the social worker was not in the facility during R2's transfer to the hospital and this is why R2 gave her money to R3. R2 states she gave R3 $385 in cash and R2 was hospitalized for approximately two weeks. R2 states when she returned from the hospital, V7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-22 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report and investigate misappropriation of property for one (R2) of three residents reviewed for misappropriation of resident property. Findings include: On 03/19/2024 at 10:06AM, R2 states she was sent out to the hospital approximately 1 month ago. R2 states her transfer to the hospital happened so quickly that R2 had to make the decision to give her money to her roommate (identified as R3) because R2 did not want to have her money stolen while R2 was hospitalized . R2 states the social worker was not in the facility during R2's transfer to the hospital and this is why R2 gave her money to R3. R2 states she gave R3 $385 in cash and R2 was hospitalized for approximately two weeks. R2 states when she returned from the hospital, V7 (APRSD/Assistant Psychiatric Rehabilitation Service Director) only returned $185 dollars in cash to R2. R2 states V7 returned her money in a brown paper bag that was not sealed. R2 states she has the bag in her possession and shows it to surveyor. Surveyor observes a small brown paper bag with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-22 · 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 acquire a physician ordered medication and accurately document the administration of medication for one (R1) of three residents reviewed for medication administration. Findings include: R1's clinical record documents admission date of 03/11/2024. Diagnoses included but were not limited to other specified depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, other muscle spasm, and diabetes. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that R1 is cognitively intact. R1's after visit hospital summary dated 03/11/24 documents in part Take these medications Venlafaxine 150mg Capsule ER 24 HR take 1 cap by mouth once per day. Nurse's note dated 03/11/2024 9:29 PM documents that doctor was notified of discharge orders and gave orders to continue with discharge orders. R1's physician order sheet/POS documents 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 · Dcited before2024-03-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise residents in the facility day room which affected two residents (R6 and R7) involved in a physical assault, resident to resident, in the sample of 6 residents reviewed. Findings include: On 3/12/24 at 2:42 pm, R6 stated that on 2/24/24 around 2:00 pm, after lunch in the day room (dining room), R7 kicked me (R6) and pushed me down and called me names. R6 stated that R6 was standing in the day room and that R7 was sitting in a chair. R6 stated that R6 was walking by R7 in the day room, and R7 kicked me (R6) in the leg and pushed me down to the floor with (R7's) hands and scratched my neck. R6 said that R6 didn't say anything to R7 beforehand and was simply walking by R7. R6 said, No staff was there in the day room on 2/24/24 when R7 assaulted R6. R6 stated that R6 got away from R7 in the day room and went to the nurse's station and told V4 (Licensed Practical Nurse, LPN) that R7 attached me. R6's admission Record, documents, in part, diagnoses…
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 before2024-01-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep one resident free from physical abuse. This failure affected one (R3) out of the three residents reviewed for physical abuse. This failure resulted in R2 physically assaulting R3, who experienced an abrasion to the right cheek. Findings include: R2's admission Record documents, in part, that R2 is a [AGE] year-old with the following diagnosis of moderate protein calorie malnutrition, other specified depressive episodes, essential hypertension, ascorbic acid deficiency, constipation, vitamin B deficiency, pain, unspecified, iron deficiency anemia, functional dyspepsia, restlessness and agitation, hypo-osmolality and hyponatremia, muscle wasting and atrophy and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 11, which indicates R2's cognition is moderately impaired. R3's admission Record documents, in part, that R3 is a [AGE] year-old with the following diagnosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0576 — isolatedEnsure residents have reasonable access to and privacy in their use of communication methods.
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 that a resident's mail was delivered unopened which affected one (R2) of six residents (R2, R3, R4, R5, R6 and R8) reviewed for resident rights. Findings include: On 9/21/23 at 11:37 am, R2 stated, I (R2) got mail from them (facility staff) that was open. It was in my room already opened on my bed. When asked who the opened mail was from, R2 said, it was from the state agency department of human services. R2 stated, it looked like it was opened cleanly with a sharp edged, letter opener. On 9/26/23 at 10:58 am, R2 observed in R2's room. When asked if R2 has the copy of the letter that was opened from facility staff, R2 said, No, I (R2) don't have it anymore. But it was a bigger orange envelope, and it was opened. R2's admission Record, documents, in part, diagnoses of hypertension, heart failure, cerebral infarction, dysphagia, and chronic kidney disease stage 3a. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow their policy on safe food handling practices. This failure has the to potential to affect all 53 residents residing on the 3rd floor. Findings include: On 3/7/2023 at 11:30am, on the 3rd floor dining room, V5 (Certified Nurse Assistant) was observed being handed a dirty tray by a resident. V5 put the dirty tray on the clean cart, from which other residents' clean food trays were still being served. On 3/7/2023 at 11:40am, V18 (Registered Nurse) said that dirty trays should not be put in the cart that was holding residents' meals. V18 said, It's an infection control issue because of contamination. On 3/7/2023 at 11:56am, V5 (Certified Nurses' Assistant) said that he did not realize he had put the dirty tray in the clean cart that was still holding other residents' food. V5 further commented that he should not have put the dirty tray in the clean cart with other resident food trays that were still being served because it is an infection control issue. On 03/08/2023 at 2:13pm, V6 (Dietary manager) said…
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 · E2023-03-10 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 in interview and record review, the facility failed to follow their immunization policy for 5 residents (R94, R48, R69, R137, R17) of 8 residents reviewed. Findings include: 1. R94 is a [AGE] year-old individual admitted to the facility on [DATE], last admission documented as 12/26/2022. Medical diagnoses include but are not limited to: schizoaffective disorder, unspecified, Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R94's immunization record documents R94 was offered pneumococcal vaccine on 11/13/2018, Influenza Vaccine on 10/20/2022 and R94 refused vaccine, and verbalized understanding of teaching provided. There was no documentation for type of education R94 was provided. R94's MDS (Minimum Data Set), section C-Cognitive Patterns dated 12/31/2022 document R94's BIMS (Brief Interview for Mental Status) as 10/15, which indicated R94 has some cognitive impairments. 2. R48 is a [AGE] year-old individual admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-10 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility failed to follow their policy to ensure substitute meals were provided for three (R42, R79, R36) out of seven residents reviewed for dining in a sample of 30. Findings include: On 03/07/2023 at 12:00, surveyor observed R42, R79 and R36 not eating their lunch. On 03/07/2023 at 12:32 PM, R42 stated that she did not eat her lunch because she did not receive her substitute meal. R42 stated she requested a cold cut sandwich and did not receive a cold cut sandwich. On 03/07/2023 at 12:02 PM, surveyor observed R79 not eat her lunch. R79 stated she did not receive her cold cut sandwich that she had requested yesterday. On 03/07/2023, at 12:03 PM, R36 stated she also requested a cold cut sandwich, but it never came up. On 03/07/2023 at 12:15 PM, V6 (Dietary Manager) stated, We collect substitute requests the evening before. The activity aide is the one who writes them down on the 'Daily Menu Substitutions' sheet when residents request a substitute. We do have the substitutes sheets for today (3/7/2023) that were collected yesterday.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-03-10 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow the Infection Preventionist (IP) requirement guidelines by failing to have an infection control preventionist certification. This failure has the potential to affect all 150 residents residing at the facility. Findings include: On 3/7/2023 at 12:30pm during infection control review, V3 (Assistant Director of Nursing) said that she does not have infection control certification. V3 said, I am in the process of completing my infection preventionist certification. I started on August 1, 2022 as an infection control nurse. I can have them completed by tomorrow. R3's infection control certification documented completion date as 3/7/2023, which was after the start of the annual survey. On 3/9/2023 at 2:22pm, V2 (Director of Nursing) said the purpose of the Infection Preventionist Certificate is to make sure the Infection Preventionist (IP) nurse has taken courses to make sure she is aware and educated about the infection control process, so that the IP nurse will be able to provide inservice to staff properly,…
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
$163,637 in federal fines across 2 penalties. 2 Medicare payment denials on record.
- $147,782 — penalty dated 2024-03-18
- $15,855 — penalty dated 2023-10-05
- Medicare payment denial — starting 2025-07-16 for 56 days
- Medicare payment denial — starting 2024-04-12 for 105 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 LINEAGE HEALTHCARE — 5 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 | 1.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 4 of 5 | 3.2 | +0.8 vs chain |
The other 4 homes this chain runs (chain average 1.6★, 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 | Since |
|---|---|---|---|
| BRAUNSTEIN, EPHRAIM | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2019 |
| DIENA, AHARON | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2019 |
| WENGROW, HOWARD | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2019 |
| THE ATRIUM HEALTH CARE CENTER LLC | Organization | INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2019 |
| GAUTAM, SAGUN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2019 |
| WILLIAMS, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/08/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 94% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 145479. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-02, 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.